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MC-13-1222 Miami Shores Village JUN o 3 2013 Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 BUILDING Permit No. PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: MECHANICAL OWNER:Name(Fee Simple Titleholder): 1 CK Pe-' q F 1 C O Phone#: 3 O S-4 3`1— 0 OG 2 Address: 72— // City: s 47.1/' b �-6 -t State:_ 1 (rte _zip: Tenant/lessee Name: Phone#: Email: JOB ADDRESS: 7 Z IV i n?9 S j 1 I T City: Miami Shores County: Miami Dade Zip: Folio/Parcelt Is the Building Historically Designated: Yes NO X, Flood Zone: APO CONTRACTOR:Company Name: Ally-TK &-,,L an,dL j' 4.2.; Phone#: Address: O'51 W • H-" City:["E?ST PV State: T77'f --C c K Zip: ' Qualifier Name: c 4 -r coo O © y 4F-5 Phone#:7eh((3M?kS State Certification or Registration#: Cad C U S S`/ ')r Certificate of Competency#: Contact Phone#: ;3VS--12>i 3 91 O-0 Email Address: T��-t�S�jQa d� • ca .� _ DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ � �fJ b Square/Llnear Footage of Work: Type of Work: DAddress DAlteration ONew )Mepair/Replace DDemolition �. al • ..a aaw.?4. Descriptiin o�'4Work: Vii►?5✓�A Submittal Fee$ Permit Fee$-. T CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ C TOTAL FEE NOW DUE$ V 1� Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING, SIGNS, WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and AIR CONDITIONERS,ETC.... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection ' ich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not e a pr ved and a inspection fee will be charged. Signature Signature v Owner or Agent Contractor The foregoing instrument was acknowledged before me thi The foregoing instrument was acknowledged before me this., 2 day of_rte,20 13,by\f Q(K.t LTICA- ay of Su vt e- ,201 a,by '2i C'P"r4o O V� who is personally known tome or who has produced who is personally known tome or who has produced___,___"_ As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: `\0\ r Si tP .tpay op4 a i°r Pu i Print: Y Comm.Exp? Dec 19, 14 G r My Commission Expires: -n �, 9�` moo, ': M Gt. Ex��ission, * EE 49103 ---4 :�T '�j/ '�" — ��F Bonded Through National Notar Assn K1 r A 0.0 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Miami Shores Village too Building Department toafo� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel:(305) 795.2204 AIR CONDITIONING REPLACEMENT DATA Fax:(305) 756.8972 PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change-out must be on its own data sheet.Multiple units on single sheets are not acceptable. Job Address(where the work is being done): City: Miami Shores Village County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS ARI(AHRI)DATA SHEET REQUIRED Change Disconnecting means:YES ❑ NO❑ ARHI Sheet Attached:YES❑ NO❑ Contract Attached:YES 0 UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG.UNIT MODEL# COND.UNIT MODEL# KW HEAT NOM TONS AHU CU PKG 1 M.C.A AHU CU PKG AHU CU PKG 2 M.O.P AHU CU PKG AHU CU PKG 3 VOLTS AHU CU PKG PKG UNIT I / PKG UNIT EER/SEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4"CONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity(Wire Size); 2. Maximum Overcurrent Protection(Fuse/Breaker Size): 3. Voltage of Circuit(208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: Phone: State Certificate or Registration N. Certificate of Competency N. Signature Date: tQualinees signature only) m -Aim--- SIM-WARD COUNTY LOCAL BUSINESS TAX. RECEIPT I °�8i tea' 's r`1t r 'i_ `cr v. i. i� �'a ' L 3-304 _ 95 �+_1at3 g ' VALID OC (3� 1,0,1 T� OUS SE"- �' 201 -Az CM ALLSTATE ATIR Of;py YsI6 a d. ING !NC I F1 BTLI •_��3Ik_} �y6 �,' Yom;_ alrttf; i$4m 1 j�tS n� ' 7 Hag "umber of"Offa`sw. 'eat ing T�r��. MK Itrs i?n? ( Tfersier Fag ` s ial+y NO(Vest- -Tate;PRid s T H RE-CEI ST B fOe ED CNSINCUOUSL= IN YOUR PLACE a U3SWESS THIS SEC M-ES A AX RECEIPT Thr,q*tax is levied for ft pcivilege o�doing Ob�*Ti55ss---i1thin B;-Oward-'-"Unty-,id i-e lis nabure, You!' u { ,meet a! County .€rfr Munici e Fa !, And zoning i'$[.u;re lents his SUsir$ss Tax "Receipt mwAf be iransfe"redd �y11$i ri-EN��'ALS_CIATE the busir ss is ar,,1111L bus na d r.3me has changed or -you have moved the L;usiness;$ctatlon.This re $.pL does:of indicate¢hat the business is f at or that it iz-,m compliance vwate?r tocai Wws ate;regulaf"'is- err i �J H.Ii _ '- Lily==�`vU, ?�i.e 33__-_-..v Wmf, 11-29-2011 JEFF ATVVATER STATE OF FLORIDA CHiEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES ' DIVISION OF WORKERS' COMPENSATION * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORK EW COMPENSATION LAW � CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 10/2512011 EXPIRATION DATE: 10/2.4/2013 PERSON: OYES RICARDO O FEIN: 043680910 BUSINESS NAME AND ADDRESS: ALLSTATE AIR CONDITIONING INC 5809 WEST HALLANDALE BLVD HOLLYWOOD FL 33023 SCOPES OF BUSINESS OR TRADE: 1- INSTALL & REPAIR A/C EQUIPMENT 2- A/C MAINTENANCE 3- CERTIFIED MECHANICAL CONTRACTO IMPORTANT: Pursuant to Chapter 440 . 0504), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover ban Its or compensation ender this chapter. Pursuant to Chapter 440.05(12), F.S., certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.0503►, F.S., Notices of election to be exempt sad certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate fie longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at my time tar failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW 9 D chapter. EFFECTIVE: 10/25/2011 EXPIRATION BATE: 10/24/2013 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be PERSON RICARDO 0 OWES H exempt.. apply only within the scope of the business or trade listed on FEIN: 043880910 E the notice of election to be exempt. BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt ALLSTATE AIR CONDITIONING INC and certificates of election to be exempt shall be subject to revocation 5809 WEST HALLANDALE BLVD if, at any time after the filing of the notice or the issuance of the HOLLYWOOD, FL 33023 certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this I- INSTALL & REPAIR A/C EQUIPMENT 2- AIC MAINTENANCE section. 3- CERTIFIED MECHANICAL CONTiRACTO QUESTIONS? (850) 413-1609 CUT HERE �► Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Ac 6-HU 32-3--- STATE OF.FLORIDA MrCTZON INDUSTRY SEQ#L120,8270230 aZ=LICENgE 1 �.ici :. Com, C054-4 t he MECH-A Tpuk T-o ;; _... Un dr tae p:rGvl -ors o Z E31 -loo date a AUG 31 2014", s E' ICARD Els'ff.CS.f V .- ALLSTATR AIR I�;yt 5 cU9 WEST HALLANDA.L.E BLVD (. WEST PMUKKEN LAWSON : SECRETARY ' ` 3 06/05/2013 09:25 9544759821 MOODY INSURANCE PAGE 01/01 Acc'R CERTIFICATE OF LIABILITY INSURANCE D06/03r2013Y) 06/03/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER;AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,corUin policies may require an endorsement- A statement on this certificate doaa not confer rights to the Certlflcate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME; KlmOerly L Knapp Moody Insurance Group PUUC N.HONE45a 286.7700 -�. FA� N 95d d7S982t 1939 Tyler Street E4kAILA ent6 MoodyingurepCe.CO Hollywood, FL 33020 _ INSURER(S)AFFORDING COVERAGE NAIC0 — - MBURER A: C rsss Pro o & INSURED Casmailly Insurance C9_ 111SU11ER B: ALLSTATE AIR CONDITION INC )NSURBRC; 5809 Hallandale Beach Blvd IN ug RCRb: West Park,FL 33023-5243 INSURER E; _ INSURER F COVERAGES CERTIFICATE NUMBER. 000073440 REVISION NUMBER: 7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE,TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, wTA! TYPE OF INSURANCE — -� 6t RUN -------"-- ---- POucr EFF POCK!?QUF; PO♦_IGY NUMBER MM DD Y) tmMmortyni, LIMITS q OCNCIt/�LuneluYY GFL1W354500 10510,6/2013 06/06/2014 EACH OCCURRENCE —L$� 300.05— A X COf�IERCWt GENERAL UABILTTY TO RENTED a c Is '100000 CLAIMS�1v1A0E ��OCCUR I NEDEXPEAnyone erewl) 3 5 000 -- I PERSONAL&ADV INJURY $ 300.000 GENERALACGREGATF. S_ 300,000 GENT AGGREGATE unnn APPLIES PER: I PRODUCTS-QOMP/OP A $ 3K000 I POLICY P;o- LOC AUTOMOBILE LIABILITY NED$INGLE LIMITS M. ALL OWNS I ! BODILY WJURY(Perpersdn) 5 AUTO ALL OWNED SCNEDULI:D AUTOS ALTOS ! BOD16Y INJURY(Per accident) L HIREDA)JTOS NON-0WNEO I PR PSRTYDAMAGE AUTOS FORY S VMORCLLA LIAREXCESS LIAB OCCURRENCECLAIM$Mr�DED RETENTION EWORKERS COMPENSATION ANO EMPLOYERS'LIABILITY U-ANY PROMETOWPARTNEWEXBCUTIVE YIN I a OFFICER/MEMBER EXCLUDED? N A I E.L.EACH ACCIDEhrr I$ (Mandatory in NN) If yea deaAN Under ; E.L.DISFASE-EA EMP40YE 5 DESCRIPTION OF OPERATIONS bebw El,DISEASE-POLICY LIMIT j$ .� DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Add(fteal Re~kt Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Mlartl i shores THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WTrH THE POLICY PROVISIONS. 10050 Northeast 2nd.Avenue Miami Shores,FL 3313$ AUTMOR)zeDREpRESENTATriItl G KLK ACORD 25 2010/05 (0 1980 ACORD C �ORATIO�NAIJights reserved, ( ) The ACDRD name and 1090 are registered marks of ACORD PTlnted by KLK on June 03,2013 at 10:28AM