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MC-15-2643 (2) 2 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-253615 Permit Number: MC-10-15-2643 Scheduled Inspection Date: February 29,2016 Permit Type: Mechanical- Residential Inspector: Perez,JanPlerre Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address:9959 BISCAYNE Boulevard Miami Shores,FL 33138-2644 Phone Number (305)979-1781 Parcel Number 1132050190470 Project <NONE> Contractor. POLAR BEAR AIR CONDITIONING Phone: (954)895.4324 Building Department Comments REPLACED A SUPPLY GRILLES WITH ASSOCIATED Infractio Passed Comments FLEXES, COLLAR AND CANS. INSPECTOR COMMENTS False INSTALLATION OF 3 BATHROOM EXHAUST FAN, INSTALLATION OF 3 RETURN TRANSFER. REPLACEMENT OF A 5 TON SPLIT SYSTEM W/1 OKW HEATER Inspector Comments Passed Failed Correction a Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid February 26,2016 For Inspections please call:(305)762.4949 Page 45 of 60 CERTIFICATE OF LIABILITY INSURANCE °402(2"'°016 02/23/2016 THIS CERTIFICATE 13 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 policy(les)must be endorsed. If SUBROGATION 13 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 endorseme s. PRODUCER CMACT LEM DHANA Florida First Insurance of Broward - F - -- 9a4- 1880 854- 1831 N 66th Avenue tlgk_.:...._....__._ _._..__ ....... 881 .�.. 9106__....__.. aalesi&-inurarce.00171 Hollywood FL 33024 IMUMA: Federated National INSURED ".. ... _._......_. _".._ .._.. ....... i�iMBite: POLAR BEAR AIR CONDITIONING LLC _,..____......___...... ERE: .__ _._ ..,,_.....—..__, ._....._._. ,.. ._......_,_..,.... P.O.BOX 2022 HALLANDALEsi>ulRa et:E: FL 33008 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. AbMTYPE OF 11"RO ANCE Lam COMMERCIAL GENERAL LIABILITY ACW OCGURR E $ 1.6w,666— CLAIMS-MADE .6w 000CLAIMS-MADE DK OCCUR MED EX6 SAF!X arid. ;_ $N S^ ._...- A - mm Y GL-0000015578-03 02!22!2018 42122!2017 PERSONAL sAov INJURY $ 1.000,000 _ _.._.... _... _..._ ._...._... GEML AGGREGATE LIMIT APPLIES PER GEN!RAL AGGREGATE $ Z t0 P I_�l I-A LOC __ G ,PtrCrs..co►aaroP�G $ 2,t�000 OTHEM DEDUCTIBLES $ 260.00 AUTOMOBILE LIABILITY $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULEDINJ.._.._.. ._--. ) ...... ......_. AUTOS . BODILY URY Peracchfent $ NON-OWNED _•- ....., HiREDAUTOS AUTOS $ ..".. .............. $ U LA LM �CtIFt EAC�i OOGURRER $ EXCESS LIAe d AIMS MA1 __— .:,.. AGGREGATED WORKEIISCOMPENSAYM LIAR011Y ANYQFFJ,C SOPRIErOR MOLUDE EXECUTIVE E L:EACH ACCIDENT I MOLUDEN f A " .. F 4 IXSEASE-_EA EMPLOY rz L:MASE-powy LIMIT S - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sctredule,may be attached B more space Is required) AIR CONDITIONING SYSTEMS INSTALLATION SERVICE AND REPAIRS LICENSE NUMBER CAC 1817357 CERTIFICATE HOLDER IS ALSO ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE BUILDING&ZONING ACCORDANCE WITH THE POLICY PROVISIONS. DEPARTMENT 10050 NE 2ND AVENUE AUV40RM ReTATM MIAMI SHORES FL 33138 0" D/ k A♦'^' O 1888-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Miami Shores Village 10050 N.E.2nd Avenue awnj a Miami Shores,FL 33138-0000 ,SER x vt t f',rarf € * �c P • ,.,'i Phone: (305)795-2204 Expiration: 05130/ 01 Y j s �.f Project Address Parcel Number Applicant 9959 BISCAYNE Boulevard 1132050190470 GLOBAL REAL ESTATE ACQUIE Miami Shores, Fl- 33138-2644 Block: Lot: Owner Information Address Phone Cell GLOBAL REAL ESTATE ACQUISITIONS 9959 BISCAYNE Boulevard (305)979-1781 - ------ -- - MIAMI SHORES FL 33138- 995920817 SW 92 Court CUTLER BAY FL 33189- Contractor(s) Phone Cell Phone Valuation: $ 9,900.00 POLAR BEAR AIR CONDITIONING (954)895-4324 Total Sq Feet: 0 Tons:5 Available Inspections: Additional Info:REPLACED A SUPPLY GRILLES WITH ASSO Inspection Type: Classification:Residential Final Approved:In Review Rough Duct Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work: Underground Scanning:1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $6.00 Invoice# MC-10.15.57460 DBPR Fee $5.20 12/02/2015 Credit Card $375.90 $0.00 DCA Fee $5.20 Education Surcharge $2.00 Permit Fee $346.50 Scanning Fee $3.00 Technology Fee $8.00 Total: $375.90 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFI T: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructiod ;1;!T� I authorize the above-named contractor to do the work stated. December 02,2015 A orized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 02,2015 1 f l Miami Shores Village NOV 20 2015 Building Ing Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 _--- - Tel:(305)795-2204 Fax: 305} .756-8972 ( INSPECTION LINE PHONE NUMBER: M 762.4949 FBC 20 BUILDING Master Permit No��—\� PERMIT,APPLICATION, Sub Permit NO.M Us- 2683 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ® MECHANICAL ❑PUBLICWORKSCHANGE OF ❑CANCELLATION ❑ SHOP ),CONTRACTOR DRAWINGS JO8 ADDRESS: 9959 Biscayne Blvd City: Miami Shores County Miami Dade ZID Folio/Parcel#: 11-3205-019-0470 is the Building Historically Designated:Yes^ . NO Occupancy Type: Res Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titieholder)�--�� aw'� Phone Address:0 :51)t M Stater • ZIp: � Tenant/ Name• l� �.c�•s � �--, ,c�,�e Phonek2 ��—� \ Email: CONTRACTDt:Company Name: Polar Bear Air Conditioning, LLC Phone#: 954-895-4324 Address: 2225 Anchor Court City: Fort Lauderdale State: FL Zip. 33312 Qualifier Name: Matthew Rosen Phone#: 954895-4324 State Certification or Registration#: CAC1817367 Gertfficate of Competency* DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace ❑ Demolition Description of work: AIC Changeout -Split System Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$, CO/CC$ Scanning Fee$ Radon Fee$ _Q=t-) DBPR$ Notary$ Technology Fee$ x• Training/Education Fee$ `�c��� Double Fee$ Structural Review$ Bond$ TOTAL FEE NOW DUE$ e (Revised02/24J2014) 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. 1 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$2SW, 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 certifed 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 absence of such posted notice, the Inspection will not be approved and a reinspection fee will be charged �ad-9 S ature __C _ Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of_/I� ye 20 /3— .by _�j�day of� s� cc�c &= ,20 �'S"' ,by who is personally known to �C� Ig +o Is personally known to me or who has produced "'�- as me or who has produced aL as Identification and who did take an oath. identification and who did take an oath. NOTARY P ---, NOTARY PUBLIC: Sign: Print: Print: wry'Nblie Seal: Joanna M 1W Fe Sty�Florid Seal: My C raciano Flog °ja Sxpi 01/t 8082753 Mar 23..MY 0 EE IBM APPROVED BY v ns Examiner Zoning Structural Review Clerk (Revised02/24/2014) r "mew ®B)9�8fJ3P+Art4& Proposal From: To: Matt Rosen Samantha Gardner Polar Bear Air Conditioning, LLC CAC# 1817367 Property Address: 9959 Biscayne Blvd, Miami Shores, FL 33138 Scope of Work: 1. Install new 5.0 ton Goodman brand, bottom return air handler. 2. Install new 5.0 ton Goodman brand 14 SEER condensing unit. 3. Install new thermostat,tie downs,and float switch 4. Install new whips where needed S. Partial repair/rebuild condensation drain line 6. Install new stand for air handler. 7. Charge system with R-410A refrigerant. 8. Dispose of existing unit. 9. Unit comes with one year warranty on parts and labor and 10 year manufacturer's warranty. 10. Re-route copper refrigerant line set from master bedroom into attic through the roof overhang and down the exterior wall. 11. Install flex ductwork, box,and registers for two drops. 12. Install return balance vents for three bedrooms above bedrooms entrance doors. 13. Price includes all materials, labor,and taxes. Price: $5,300 Notes: 1. Contractor not responsible for any possible tears or leaks in existing ductwork. 2. Contractor will use existing copper line set. Contractor not responsible for any possible leaks in existing copper line set. 3. Contractor will use existing electrical lines and electrical components(disconnect box,whip,etc) 4. Owner to pay for building permit. S. Deposit of 50%required to start work,with the remaining 50%to be paid upon completion. Ir Owne esentative Date s Miami Shores Village Building Department .... 10050 N.E.2nd Avenue Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 AIR CONDITIONING REPLACEMENT DATA 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 tieing done): !2q-5.q 1 &6 3l Z D City. MIamI Shores Vlliage County: Miami Dade zip Code: 3 3 13 Tr ALL CONDENSING S G UNIT S 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 AHRI DATA SHEET REQUIRED Change disconnecting means:YES❑ NO� ARHI Sheet Attached:YESV NO❑ Contract Attached:YESV UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER aa&1>^1AA1 AHU or PKG.UNIT MODEL# COND.UNIT MODEL# KW HEAT NOM TONS AHU Cu PKG 1)M.C.A AHU pCU p PKG AHU CU PKG 2)M.O.P it AHUIC0 CU PKG AHU Cu PKG 3)VOLTS 'Z* Z 3 a AH4 CU PKG PKG UNIT / / PKG UNIT EER/SEER YES NO REPLACING DUCTS YES YES NO REPLACING THERMOSTAT 7M NO YES NO NEW 4"CONCRETE SLAB YES YES NO NEW ROOF STAND YES YES NO NEW RETURN PLENUM BOX YES O 1. Minimum Circuit Am aci Wire Size 2. Maximum Overcurrent Protection Fuse Breaker Size 3. Voltage of Circuit(208/240/480):� 23 D 4. Size Disconnecting Means: Contractor's Company Name:TGL�*4Ew Phone: GIS °IS' �32 State Certificate or Registration No._C A G,fSr 1'414? Certificate of Competency No. Signature Date; I`T�(S, .._..�_ (Qua woes ftnature) (Revised02/24/2014) uv'm rfifffi%cate of P1w0oftduct AHRI Certified Reference Number: 7984220 Date: 11/912015 Product:Split System:Air-Cooled Condensing Unit,Coil with Blower Outdoor Unit Model Number:GSX140601K* Indoor Unit Model Number.ASPT61014A* Manufacturer: GOODMAN MANUFACTURING CO.,LP. Trade/Brand name:GOODMAN;JANITROL;AMANA DISTINCTIONS; EVERREST;ONE HOUR AIR CONDITIONING AND HEATING;ENERGI AIR Region:All(AK,AL,AR,AZ,CA,CO,CT,DC,DE,FL,GA,HI,ID,IL,IA, IN, KS, KY, LA,MA,MD,ME, MI,MN, MO, MS, MT,NC,ND,NE,NH, NJ,NM,NV,NY,ON,OK,OR,PA,RI,SC,SD,TN,TX, UT,VA,VT,WA,WV,WI,WY,U.S.Territorles) Region Note: Central air conditioners manufactured prior to January 1,2015,are eligible to be Installed in all regions until June 30,2016. Beginning July 1,2016,central air conditioners can only be Installed in regions)for which they meet the regional efficiency requirement. Series name:GSX14 Manufacturer responsible for the rating of this system combine of t t1f QOODMAN MANUFACTURING CO.,LP. Rated as follows In accordance with AHRI Standard 2101240-200 for Unitary Air-Conditioning and Air-Source Heat Pump Equipment and submit to verification of rating accuracy byAAH nsored,Independent,third party testing: Cooling Capacity(Stuh): 57000 EER Rating(Cooling): 11.70 SEER Rating(Cooling): 14.00 IEER Rating (Cooling): Ratings followed by an asterisk r)indicate a voluntary ferate of previously published data,unless accompanied with a WAS,which indicates an involuntary rerate. a. DISCLAIMER AHRI does not endorse the product(s)listed on this Certificate and makes no representations,werrartttes or guarantees as to,and assumes no responsibility for, the product(,)listed on this Certificate.AHRI expressly disclaims all fiabli ty for damages of any kind arising out of the use of performance of the Product(sj or the unauthortzed aiterafton of date fisted on this Ce"Ificate,Cenined ratings are valid only for mo1eN and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS This Certificate and Its Contents are proprietary products of AHRI.This Certifi ante shall only be used for individual.personal and ; confidential reference purposes.The contents of this Certificate may not,in whole or In part,be reproduced;espied; ,. dissemithated entered Into a cornputer database;or otherwise utilized,In any form or manner or by any means.except for the user's Individual, Personal and Confidential reference. AIR-CONDITION 148,HEATING, CERTIFICATE VERIFICATION &RVIRWERATIoN INSMUTE The information for the model cited on this certificate Can be at www.ahridlreetary org,dict on"Verity Certificate"link we make file eller" and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which is Ilsted above,and the Certificate No„which is lsted at bottom tight. ©2014 Air-Conditioning,Heating,and Refrigeration Institute CERTIFICATE NO.: 130915818976MI'l Miami Shores Mage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 CONTRACTORS' REGIST TION Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ■s���sa•egst�saeraseseos■a��eoreoaea�����o��■■sass®a®a®asasse®.■■s■��a�o�s®orie�m®uvea®®o® BUSINESS NAME: fat A1C �� e t n r-r"!o�✓iw�; C C BUSINESS ADDRESS: 22 2 S' ANC{.far, Cr CITY STATE ZIP 3 3 31 Z BUSINESS PHONE: Cq o(( j ` ((3 2 q FAX NUMBER(_� CELL PHONE(15Y ,15; RS-tf32 Ll (�UALIFIEWS NAME: -r4ir oSG,N QUALIFIER'S LIC NUMBER: C Ac t a t -+36 � STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ROSEN, MATTHEW GEORGE POLAR BEAR AIR CONDITIONING, LLC 2225 ANCHOR COURT FORT LAUDERDALE FL 33312 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMF# T OF BUSINESS AND and they keep Florida's economy strong. PROFEJEA REGULATION Every day we work to improve the way we do business in order to CAC1817367 - SrUIt 07i0912014 serve you better. For information about our services,please log onto www.myfloridallowme.com. There you can find more information CERTIFIED A _r ONTJ about our divisions and the regulations that impact you,subscribe ROSEN,NIA to department newsletters and learn more about the Department's initiatives. - POLAR BEAR 0LC _ 3 0� . _- _ Our mission at the Department is:License Efficiently,Regulate Fairly. We constantly strive to serve you better so that you can serve your ` '~ customers. Thank you for doing business In Florida, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! a0stbn dets:Auo 31,2016 L1407MCCOM71 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CAC1817367 The CLASS B AIR CONDITIONING CONTRACTOR = i Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2616 ROSEN, MATTHEW GEORGE,---- POLAR BEAR AIR CONDI LL-c-, 2225 ANCHOR COURT FORT LAUDERDALE`- "PL 3 312 :mpk < ' �.�� " . '" , '',SfiA4�t'�85' �' +a�'is�'�,�2+,,: '' '.� •.; �^'' Sr"a ��»':•t'�",��s' r`",�.5?:��'35 �iw"C 'm �'; 5'a,�y BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#:183-2 6801 RTDTTION CONT R Business Name:POLAR BEAR AIR CONDITION LLC Business Type:HEATI(CLASS B ) Owner Name:MATTHEW G ROSEN Business Opened:07/24/2013 Business Location:2225 ANCHOR CT State/County/Cert/Reg:CAC 1817367 FT LAUDERDALE Exemption Code: Business Phone:954 895 4324 Rooms Seats Employees Machines Professionals 1 For VendhV Bushms Only Number of Machines: Venting Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 -0.00 0.00 _ 0.00 0.+00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory•in nature.You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: POLAR BEAR AIR CONDITION LLC Receipt #ICP-14-00011878 2225 ANCHOR CT Paid 07/09/2015 27.00 FT LAUDERADLE, FL 33312 07/08/2015 Effective Date F 2015 2016 A. ,eco CERTIFICATE OF LIABILITY INSURANCE 04120" " 11/08!2015 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 1arremm"holds►Is an ADDITIONAL INSURED,the pogcyr(ko must be endorsed,If SUBROGATION IS WANED,subject to the terms and c*r4 NmIIs of the Poficq,C&Mn Poklee MY relMM an e074110rsement.A statement on this certificate does not confer rights to she cergicate holder In lieu of such!m tonaemen ). j PRO LEtSA DHANA _ Florida First Inwrlenc a of Sroward 1831 N 66tt1Avenue — arrce com HolywoodFIERI@I AITORDOM CAYER"E L 3NAS E 3024 all A. Federated National - --- POURED INSUIRM POLAR BEAR AIR CONDITIONING LLC e' -- P.O.BOX 2022 PISURIM HALLANDALE FL 3;1008 E: mismARERF. 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 I _. . BFIBRt ____ TYPE OF INSURANCE POLICYNUNM EFF POKY EXP? -- I GBORAL UABLITY _ QTS EACH OCCURRENCE B 11.00b'000fC, NMMERpAI QENERALLIAfSUTY DAMAGETD_RENTED- CtAIMSaMADE MMISES(Ea oaurrma�al 5 100.000 OCCUR A Y GL-15678-02 8 MED exP(ArW ore ae*wu s 5.000 02/22/2015 02ra=161 PERsONAL a ADV INAw s 1.000.000 d AGGREGATE s_2.�.ODO GEML AGGREGATE LAW APPLIES PER ,GENERAL PRODUCTS•COMPfQP AGG b 2,000.000 -- f POLrcv - LOC DEDUCTIBLE $ 250.00 nurouo Lu�.lnr I tFa ) E ANY AUfO j BODILY INJURY(Par perm S ALLOV**D SCHEDULED AUTOS ALT ED SORRY INJURY(per til S - HiT;EDAUTOS ALTOS IPkOf�E ? S IJP LA UAB s OCCUR EXCESS LlAB EACH OCCURRENCECLAIMSAIADE !; __-_... AGGREGATE $ DED RETENTIONS i V901DONS CO ATI $ AND EN,PLOYEW UABAM YIN7 . SLIMlTS _EIL c - ANY PROPRIETORIPARTNEWEXECUTNE OFFX RiMppBER EXCUJOED? ❑N I A� E L EACH ACGDENT $ fy� inE L DISEASE-EA EMPLOYEE$ tZ3G�RIPTIOAI Of OPERATIONS beb� : E L DISEASE-POLICY UA1I T S DESCRIP7ION OFOPERATION$I LOCATIONS/voto=(A AC=101.A l PAMWb 8ai ,E rtgre a is AIR CONDITIONING SYSTEMS INSTALLATION SERVICE CERTIFICATE HOLDER IS ALSO ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRY POLICIES BE CANCELLED ED BEE THE EXPIRATION DATE THEREOF, NOTICE MIELL BE DELIVERED IN Miami S IWM Vitlap Building Deparim" ACCORDANCE tAfl7'H THE POLICY PROVISIONS. 10080 N.E.2nd Avenue MISrrd Shores,FL 33138 AU7KONM R1PRESIMATIVE ACORD 26 201OM5 ®1988.2010 ACORD CORPORATK)K All dgtds reserved. ( ) Tile ACORD nears and logo are regW Wred marks of ACORD JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW• CONSTRUCTION INDUSTRY EXEMPTION This certifies that the Individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 2/28/2015 EXPIRATION DATE: 2/27/2017 PERSON: ROSEN MATTHEW G FEIN: 461704488 BUSINESS NAME AND ADDRESS: POLAR BEAR AIR CONDITIONING LLC 2225 ANCHOR COURT FORT LAUDERDALE FL 33312 SCOPES OF BUSINESS OR TRADE: HEATING,VENTILATION, AIR-GOND Pursuarn to Chapter 440.05(14).F.S.,an~of a corporation who elects exemption from this chapter by ung a carmcate of election under this section may not recover benefits or compensation under this cimpter.Pursuant to Chapter 440.05(12).F.S..Cerittfcates of election to be exempt._appty only within the scope of the business or trade listed on the notice of sisation to be exempt.Pursuant to Chapter 440.05(13).FS..Notices of election to be exempt and certiricates of election to be exempt short be su*d to mvo=gon if,at any time atter the"of the notice or the Issuance of the certificate. the person named on the notice or certificate no longer meets the requirements of this section for Issuance of a car6lbcate.The department shatf revoke a DFS-F2-DWC-252 CERTIFICATE OF FLECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)4.13-1$08 Polar Bear Air Conditioning, LLC 2225 Anchor Court, Fort Lauderdale, FL 33312 CAC#1817367 November 10, 2015 State of -F1 o ri C(0 County of ?>Yuv-)Cir-c1 Before me this day, appeared Matthew Rosen,who is being duly sworn, deposed and says: That he or she will be the only one working on the project located at 9959 Biscayne Blvd., Miami Shores, FL 33138. Sworn to (or affirmed)and subscribed before me this 10"�" day of NuVemW2015 by: q c 4h e-W Q-u S-e r 1 Personally Known OR Produced Identification fZ25()-5Li--T --71-L4-LI e0_L Type of identification Produced l7riyef l i c E'ns JENMOR HERNANDU A Notary Public-State of Flo Wa MY Comm.Expires Jul 27.2018 '•o,o�� CommtsSion#FF 145407 - Print,Type, or Stamp Name of Notary Av Bonn Miami shores Village TINS Building Department R 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. f1. 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 and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami Dade The foregoing was acknowledge before me this, day of� who is personally known to me or has produced 1 "�;�^`' �^ �,' " as identification. .Hoof Notary.-., Te- n �v' 4c�c,�r-l-62— r.� r"L JENNIFER HERNMDEZ Notary Public-State of Florma SEAL: MY My Comm.Expires Jo127.201a '�•.�°,oi �r..• Commission*R 145407 RC c�5 -uq-3 yamMiami Shores Village OCT 19 2015 Building Department Even „�„M 10050 N.E.2nd Avenue 4 BY Miami Shores, Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 AIR CONDITIONING REPLACEMENT DATA 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): ?95c/ /J 1s C,4y,9Q &1✓d 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 AHRI DATA SHEET REQUIRED Change disconnecting means:YES❑ NO dARHI Sheet Attached:YES [!j"'NO❑ Contract Attached:YES Efl- UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER 2 A n!r 1= o(e o AHU or PKG.UNIT MODEL# raq CAI POGO L t i-t< ®Spa COND.UNIT MODEL# 13A 1 nr R V{ O KW HEAT 10 NOM TONS S AHU CU Lff PKG 1)M.C.A AHU 4a CU qV PKG AHU S4 CU qo PKG 2)M.O.P AHU sr CU ” PKG AHUXd*t CU14s21PKG 3)VOLTS AHU2 U! PKG PKG UNIT / / PKG UNIT EER/SEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES a✓' 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/Breal@er+Sieej: . . . .. •• • • . • 3. Voltage of Circuit(208/240/480): '. ': 0 41*see 0 : '. 00 0 4. Size Disconnecting Means: . ... .. ... . ... Contractor's Company Name: • Phone: .. . . . . . . State Certificate or Registration No. ..: :' '.'Ceifif)ca;%9f CbMpetency No. Signature Date: (Qualifier's signature) • • • • • • • • • • • • • • • • • ••• • • • ••• • • (Revised02/24/2014) yy ' �_.0 tail iN', % r OCT 1.9 2015 Certificate of Product Rat"jrKjS==-<W j, AHRI Certified Reference Number: 7648089 Date: 10/19/2015 Product: Split System:Air-Cooled Condensing Unit,Coil with Blower Outdoor Unit Model Number: BA14NA0601A Indoor Unit Model Number: FS4CNP060L Manufacturer: BRYANT HEATING AND COOLING SYSTEMS Trade/Brand name: BRYANT HEATING AND COOLING SYSTEMS Region:Southeast and North(AL,AR, DC,DE,FL, GA, HI, KY, LA,MD, MS,NC,OK,SC,TN,TY,VA AK, CO,CT,ID, IL, IA,IN, KS, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NY,OH,OR, PA, RI,SD, UT,VT,WA,WV,WI,WY, U.S.Territories) Region Note: Central air conditioners manufactured prior to January 1,2015,are eligible to be Installed In all regions until June 30,2016. Beginning July 1,2016, central air conditioners can only be Installed in regions)for which they meet the regional efficiency requirement. Series name: 14 SEER PURON AC Manufacturer responsible for the rating of this system combination Is BRYANT HEATING AND.COOLING SYSTEMS Rated as follows in accordance with AHRI Standard 210/240-2008 for Unitary Air-Conditioning.and Alt4otitce Heat Pump Equipment and subject''to Verification of rating accuracy by AHRI-sponsored, independent,third party testing: Cooling Capacity(Btuh): 0.00 EER Rating(Cooling): 11 ..... S1=ER-Rating.(Cooling).. 14.00 IEER Rating(Cooling): . >.. . •Radn9•followed by an asterisk(h indkate a voluntary reratts of previously published data,unless accompanied with a WAS,which indicates an involuntary rerate. DISCLAIMER •00 • • • • • + •• •++ AHRI does not endorse the product(s)listed on this Certificate and maAw no oWLsein4�tlo$s,1m es qr guarantees as to,and assumes no responsibility for, the product(s)listed on this Certificate.AHRI expressly disclaims all Ua Irl for damn as ofrarn kind aHsin out of the use or performance of the produtt(s),or the unauthorized afteration of data listed on this Certificate.Certified raft are U18 oni for mildels ans nations listed In the directory at www.ahridlrectoryorM TERMS AND CONDITIONS This Certificate and Its contents are proprietary products of AHRL 7#11 Per"tate sh%lfdhly Lsed fgflrglivRf�rA1,personal and confidential reference purposes The contents of this Certificate may not,inMrhote owls part,joe reproiu-oat;espied;disseminated; entered Into a computer database;or otherwise utilized,in any form SC,mef ftr&btar¢mef Qs, 1br titjtser's Individual, personal and confidential reference. ••• o • • • • AM4XNDiTNI NIN%HERTW% CERTIFICATE VERIFICATION &REFRIGMTION MS1111MM The information for the model cited on this certificate can be verified at www.ahridireetaryorg,click on`Verify Cerfl leste'link we make life bettwl and enter the AHRI Certified Reference Number and the date on whichwWoc ati icatra was iasu04• • • which is listed above,and the Certificate No.,which is luted at bottom right i � :•e : �308973M764163Q52 02014 Air-Conditioning,Heating,and Refrigeration Idstit .; ; ; ; IFICATE NC?-* Miami Shores Village Building Department OCT 10 z015 10050 N.E.2nd Avenue,Nliami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 LLq INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20K Master Permit No. e G 1s-- ;Z.3 BUILDING PERMIT APPLI TION Sub Permit NO.Ac-� 15- Z��J BUILDING MCECTRIC (l ROOFING REVISION [] EXTENSION []RENEWAL PLUMBING MECHANICAL ANICAL []PUBLIC WORnKS ❑ CHANGE OF CANCELLATION [:] O ❑ CONTRACTOR SHOP JOBADDRESS: n g�q 9j`sC&f City: iami Shores Con : Miami Dade Zi Folio/Parcel#: Is the Building Historically Designated:yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: ct ' OWNER:Name(Fee Simple Titleholder): Phone#: 7 O-" el 0 —1f 81�Ct+y'r m n-��iF @� n'@-% Address: ` It S 9 6 J S CA Q ✓ City: rI.QAA1 1 4;; C-,6'r e S State:- �- � Zip: �31 3� Phone#• Tenant/Lessee Name: Email: CONTRACTOR:Company Name: /'i7� c & C; ?4J Vccbd45 Z74a _Phone#: Address: 4 Z l Gt/ S'~ i2p�: City: �" 4•ft. Zip: 33043, �Se' 7" Phone#: Qualifier Name: / ` State Certification or Registration#: l� L Certificate of Competency#: Phone#: DESIGNER:Architect/Engin Address: City: State: Zip: Value of Work for this rmit$ Do square/Linear Footage of Work: Type of Work: 1-7] AdI El Alteration ❑ New E, Repair/Replace ❑ Demolition Description of work: Q CAcI�c �� ci AIs� �� Ate. ns �,4�0» o� 3 iiZ7lV�L"7' ��r�Yd Gl Iv Specify color of color thru tile: Submittal Fee$ .` 6 Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee Bond$ structural Reviews$ s , Bonding Company's Name(if applicable) Bonding Company's Address State Tip City 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 absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 4�IN day of 5E�M9ER .20 /S ,by day of SePkrn�6eX ,20 1,7S _,by S,®/I�oaj 1�tam (;A 40h) ho is personally known to � who is personally known to me or who has producedDL - 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: Sign:It X ll��1'Yt,�► rn ' v'"�,l(�,0-' Print: sPrint: M ME..lU1 Seal: I Seal: ��' �~ MY COMMISSION!!FF233158 tiliFF EXPIRES Mey 31.2019 MWY t401;A;C'bS PbhOWps • 5U cwe �ggg;g;i48ede;le$4k� il�& � 4 k8k&g$ki4biiiilklk44k$+i4i44Ybb4$+bABkYD�iAdB&$i3Ylnk+Mk1 APPROVED BY �a miner Zoning Structural Review Clerk I ...... BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA:AIR SYSTEMS INNOVATIONS INC Receipt#:183-1619 CONTRA(• R Business Name: Business Type:(CLASS A AIR CONDITIONING CONTR) Owner Name:JOSE A JR JIMENEZ Business Opened:09/12/2006 Business Location:631 NW 65 AVE StatetCounty/CerUReg:CAC1815166 MARGATE Exemption Code: Business Phone:954-793-6084 Rooms seats Employees Machines Professionals i 1 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 ! THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS' THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning i WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when i the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: JOSE A JR JIMENEZ Receipt #13B-14-00010406 P 0 BOX 938751 Paid 09/04/2015 27.00 j i MARGATE, FL 33093 i 2015 . 2016 RB JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 9/4/2015 EXPIRATION DATE: 9/3!2017 PERSON: JIMENEZ JOSE A JR FEIN: 205329943 BUSINESS NAME AND ADDRESS: AIR SYSTEMS INNOVATIONS INC 631 NW 65TH AVE MARGATE FL 33063 SCOPES OF BUSINESS OR TRADE: HEATING,VENTILATION, AIR-GOND Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by ging a cartitCets of emmorh unci this section may not recover benefits or compensation under 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 etac tIon to be exempt Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocaton If,at any time after the fig of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certifical s.The department shelf revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 ' • tom-�s Miami shores village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - workers' compensation Insurance Exem tion � Fla. Stat. 440.05 Statutes. § e Florida s under 440 0 f th e and cov C�� on insurance erg Compensation Lacer Workers mp 'on project prim to Florida constructs m flus �t for any PmJ themselves from require allows corporate officers m the construction industry to exempt the obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: -time or full-time � � construction industry who employs one or more pact em employees employerion coverage. Corporate officers employees,including the owe,must obtain workers'compensate elect to be or members of a limited liability company (LLC) in the construction industry may 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 Department of 3. The corporation is registered and listed as active with the Florida Dep 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 fled or the exemption Is revoked by the Division. You contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project In these circumstances,Miami Shores Village does not require verification of workers'compensation insurmce coverage from the contractor's company for day labor,part-tune employees or subcont metors- BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: ORner State of Florida County of Miami-Dale w1 of�� PM��� ,220J,5— The foregoing was acknowledge before me this �Y � ?" �ii MA)Fk who is personally known to me or has produced rt j ax ab DL as identification. ADRIWBI MU Nmotacy= Aja wA�. �tEs:A�21,019 • eoAedThm dOYPd sante AIR SYSTEMS INNOVATIONS, INC. P.O. BOX 938751 TEL: 954-793-6084 MARGATE FL 33093 FAX:954-970-1021 E-MAIL iiimenezasi@comcast.net CAC1815166 Date: 10-19-2015 State of 1::�49 -A County of Before me this day personally appeared v ds e�c�i 07P,!<'z- who,being duty sworn,deposes and Says That he or she will be only person working on the project located at clel-s-cl Sworn to(or affirmed)and subscribed before me this=�—day of 5tQ It rny> f .20)S- . By Personally know OR Produce Identification Type of Identification Produce ME!.-,,. My COMMISSION EXPIRES May 3 t, � � 'x► Plaf�iota 9orvka .. Print,Type or stamp Name of Notary