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MC-14-2802 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-225763 Permit Number: MC-12-14-2802 Scheduled Inspection Date: June 01, 2015 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: DAIDONE, GLENN Work Classification: Addition/Alteration Job Address:54 NE 97 Street Miami Shores, FL Phone Number (305)788-2711 Parcel Number 1132060130770 Project: <NONE> Contractor: NEW SERVICE COMPANY Phone: (305)324-754_ Building Department Comments INSTALLATION OF NEW 12000BTU MINI SPLIT SINGLE Infractio Passed Comments AIR HANDLER INSPECTOR COMMENTS False i Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. May 29,2015 For Inspections please call: (305)762-4949 Page 4 of 27 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-225763 Permit Number: MC-12-14-2802 Scheduled Inspection Date: June 01,2015 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: DAIDONE,GLENN Work Classification: Addition/Alteration Job Address:54 NE 97 Street Miami Shores, FL Phone Number (305)788-2711 Project: <NONE> Parcel Number 1132060130770 Contractor: NEW SERVICE COMPANY Phone: (305)324-754_ Building Department Comments INSTALLATION OF NEW 12000BTU MINI SPLIT SINGLE Infractio Passed comments AIR HANDLER INSPECTOR COMMENTS False I r Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. May 29,2016 For Inspections please call: (305)762-4949 Page 4 of 27 ' Miami Shores Village - - Building Department M4 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 _ Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20PO BUILDING Master Permit No. tC—�j(4- 3 PERMIT APPLICATION Sub Permit No. f o ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING MECHANICAL [:]PUBLICWORKS [:] CHANGE OF ❑CANCELLATION ❑ SHOP qCONTRAC`TOO�R DRAWINGS JOB ADDRESS: �_ 1«q`�`e City: Miami Shores County: Miami Dade Zin• / Folio/Parcel#:_ 11 og&z> e 7—/19 Is the Building Historically Designated:Yes NO Iv' Occupancy Type: Load: Construction Type: Flood Zone: BFE: p�FFE: I / OWNER:Name(Fee Simple Titleholder): PJV i Phone#: —.300 �� ` r Address: 2 City: �� State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Phone#: Address: V1 'I —= City: Stat Zip: Qualifier Name: f Phone#: State Certification or Registration#: ificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$__ �® � Square/Linear Footage of Work: Type of Work: ❑ Addit�n ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition �bescription of Work: ic $2 P I f j 120 /a a LAt Ajt 'C&BA w� [� Ile- A,+,� f ems. Specify color of color thru tile: _ Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,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 which occurs seven (7) days after the building permit is issued. In the sence of such posted notice, the inspection will not be approved and a reinspection ee will be charged. Sig Signature nature OWNER rAGENT ONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this _day ofL ,20 t by day of bTr 0.20 by who i �ers.nmlyknown who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign• ee a Sign: 1) Print: 2- Print: of , . MABI:LlS E FERNANDEZ Elizabeth Rome Seal: _:: �t is Seal: QCUMISSIONiPEE073677 o, MY COMMISSION#FF 127992F�tPIRESoMAR.14,2013 EXPIRES June 1,2018 AOA° ;a0°o4, AARONNOTARY mm (407)396-0153 Florldallota,y8 ,vice.com ######### ################################################################ APPROVED BY A✓ t6 lans Examiner Zoning 1 Structural Review Clerk (RevisedO2/24/2014) 010248 Local Bd i' r fi Miamii,bads C©U . r>ty Stake flora a TMS 1115 NOTA BILL —DO N07`PAY 551x9$1 Btu�u►M ttEc iPr NO. WIRES NwaEco�ulPAir . IRfIa1kINAL. SEP'FIW� 3Q, 2Q'15 501 l 5302 = l6�7:i943b" tit,e oQspiaYed aR place of twsiness' MIARAI fL 33130 - Phlrsuantto:emn*rb" " -OWNER. SEC.TYPE OF Bug"F4110 NEIN SLICE comPANY 196 GENAL MECHANICAL�N ERACTOf����T Workers) 2 CAC1814442 TAX COLLECTOR . $45.00 07/17/2014 EPPU12-14-006219 ihietaselBv� sortiirpapa�eataF tcal&istaeasTaa 71m8eisMg" {i , p Loreoer�foa800�tla� Ide a, to do bushum NNdera taepaply imw raB�itory�ws •�raja9nRwit�6apidyto� :.-. _. 7hsRECMqtMi&=mjmth8 0284 P0000101 ve�iolerl lrltemi=e�da!' a S�ea-Z1B FormarePufotao�oa, - RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTIQI INDUSTRY LICENSING BOARD CAC1814442 *_ The CLASS B AIR CONDITIONING CONTRAC � #� Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration ate: AUG 31,2016 - PEREZ,.PEDR0J. '� •� s f NEW-bI=RUICE COM P � 501 S.W. 1ST SUIT 'M 1•; FL 33 .� ■ ISSUED: OSIM zo14 DISPLAY AS REQUIRED BY LAW SEQ# L140803DD0 M JEFF AMNATER C nEP FWANt2AL OFFICER STATE OF FLORIDA DEPARTEIENT OF FINANCIAL.SERVICES DIVISION OF WORKERS'COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORA WORKERS'CONATION LAW CONSTRUCnON INDUSTRY E EMFnON Tris and w that the individual fided bd=has dected to be wmmpt from FWdda VftiwW Compmebw law EFFECTIVE DATE: 101812(M4 EXPIRATION DATE: 10/7/2018 PERSON: PEREZ PEDRO J FEIN: 43198M BUSINESS NAIL AND ADDRESS: NEW SERVICE COMPANY 501 SW 1 ST STREET MIAMI FL 33130 SCOPES OF BUSINESS OR TRADE: HEATING.VENTILATION, AIR-COND Pursuart to Chspter4ftGR14).F.M.an aMm of a ampaatlmi who eleea exmupfms them fde dreptm by ftM a of eledms undardds sedsls may notmecolaw, fil or underfds dtapber.Pw sudto C.hopW44CARI ).F.S.,Cmf fates of elecon to be ems.-a"a*wMb fro scope offthwimessortaftbWonew al-Wil, to be exmrspt Pwmudto Cheptarm gln 0A,Na6oes of colon to be exempt am! an h of etedon to be exanspi sh fi be subjeet to kf st my tbn dtmtha c?ft a orfre lswroe.offro tffl ' ,ftpersmnwmwonftnoUceor IM I no tmsgarrsysele fro mpftemmft of fds eea§mfar hamotee of a cmtlW&The depaeWM dW mvake a amtEcete sd sny tone forfaum of ft proems don fro os IM, l a to tnel fro impdsm affde sectte. DFS-F2-OWC-=CERTIFICATE OF ELECTION TO BE EXIT REVISED 0742 QUESTIONS?( O)413.1809 • i. SBORES ♦�c.>9sa Miami shores Village Building Department �IORi� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers'compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company. Therefore,you may be Personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner antra Print Name: )► 1 o,- Print Name: — cu S Signature: Signature: 1 State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) (Cl Sworn t d subscribed before me this f� Sworn to ands cribed before me s I day of ,20 4 4 day of 120 By .aMA IS By '• s'I MY COMMISSION av,•- 27992 (SEAL) ' .�.... EXPIRES (SEAL) °"`�a�e0s�oe Elizabeth 190MO T e of Id rodam T of Identification � ° 1K,f, PaeO°`QwwwAwNmorAw=P A' ° CERTIFICATE OF LIABILITY INSURANCE DATE D/YYY1� �hrrear'"'- 122/23/23!14 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policyges)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO ERCT Maria Mendez Mendez M Insurance Agency Inc. PHOWC,NEFM: (305)278-2886 ac No): (305)278-2261 11655 South Dixie Highway ADDRESSO Maria@mendezminsurance.com Pinecrest,FL 33156 INSURERS AFFORDING COVERAGE NAIC# Phone (305)278-2886 Fax (305)278-2261 INSURERA: Canopius US Insurance INSURED INSURER B: New Service Company CAC1814442 INSURER C: 501 SW 1 Street,suite 302 INSURER D: MIAMI, FL 33130 (305)324-7504 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY 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. INSR TYPE OF INSURANCE ADD UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM D M D GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED 100,000.00 © COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ ❑ ❑ CLAIMS-MADE Q OCCUR OUS018014321 MED EXP(Any one person $ 5,000.00 A ❑ N N 08(04/2014 08/04/2015 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,DO0.00 ❑ POLICY ❑ JECT PRO ❑ LOC $ AUTOMOBILE LU\BILrIY OMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ❑ AUTOS ❑ AUTOS ❑ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ ❑ AUTOS Per accident ❑ ❑ 1 $ ❑ UMBRELLA UAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑WC STATU- ❑OTH- AND EMPLOYERS'LIABILITY Y/N TORY ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) ❑ E.L.DISEASE-EA EMPLOYE $ If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Mechanical Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Dept THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Miami Shores,Florida 33138 Maria Mendez(electronic signature) @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD