MC-15-2222 (2) Miami Shores Village ,3
10050 N.E.2nd Avenue NE
tt
Miami Shores,FL 33138-0000
Phone: (305)795-2204 �drit, f #� ( )
Expiration: 03101/2016
Project Address Parcel Number Applicant
10682 NE 11 Court 1122320280500
MARC ALBERT ILLOUZ
Miami Shores, FL 33138-2123 Block: Lot:
Owner information Address Phone Cell
MARC ALBERT ILLOUZ 1540 MERIDIAN Avenue
MIAMI BEACH FL 33139-
1540 MERIDIAN Avenue
MIAMI BEACH FL 33139-
Contractor(s) Phone Cell Phone Valuation: $ 5,000.00
FRIENDLY ROOFING INC
Total Sq Feet: 0
Tons: Available Inspections:
Additional Info:NEW A/C AND DUCT WORK Inspection Type:
Classification:Residential Final
Approved:In Review Rough Duct
Comments: Date Approved::In Review Review Mechanical
Date Denied: Type of Work: Underground
Scanning:3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $3.00 Invoice# MC-8-15-56910
DBPR Fee $2.63 08/31/2015 Cash $50.00 $147.26
DCA Fee $2.63
Education Surcharge $1.00 09/03/2015 Cash $ 147.26 $0.00
Permit Fee $175.00
Scanning Fee $9.00
Technology Fee $4.00
Total: $197.26
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 AFFIDAVIT, I cartfttDit all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction an Fut ore,I authorize the above- ed contractor to do the work stated.
September 03,2015
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
September 03,2015 1
Miami Shores Village _ ;
�-
Building Department 17A1012015
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 t�
BUILDING Master Permit No. MC I5~
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING aYM/ECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION SHOP
t 1 CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores Q County Miami Dade Zip• 3 e 3
Folio/Parcel#: 1 d 3� %Q �0 0 is the Building Historically Designated:Yes NO V
Occupancy Type: Load: Construction Type: { Flood Zone: BFE: [ FFE:
OWNER:Name(Fee Simple Titleholder): rll�C Phone#:
Address• -A .�
City: L Ot Ana c GState: LOQ zip: 3 1-3 2)
Tenant/Lessee Name: Phone#:
Email: VL .Xc)�-P Or !�h VV\,\ �. COIF
CONTRACTOR:Company Name: fi r C k as7t c a r Phone#:
Address:' �
S r o�e�A
City. Gro Col- ek o State:
Qualifier Name: syi7kd 6LO&C/ Phone#:
State Certification or Registration#: c4c f 11 S W Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address• City: State: Zip:
Value of Work for this Permit:$ Square/Unear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New i/ Repair/(place ❑ Demolition
Description of Work: dfl, ���/ A/C Z.Dre4 (, aK
Specify color of/co�olorr thhru tile:
Submittal Fee$ ��AL3
Permit Fee$ -7 CVCCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revi5ed02/24/2014) \��
•
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 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
12 day of 20 ,by r 3 day of ( 20 L .by
who is personally known to JY!` 6/A,4 who is personally known to
me or who has produced L as me or who has produced L as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign A4Sign•--/
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Print: ( Print: 4mi
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Seal: * * WC011MI10%l#FFWM Seal: -'*--.00mMWw#FF172359
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APPROVED BY V I s Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
■.■■ ou.�
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 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
AHRI DATA SHEET REQUIRED
Change disconnecting means:YES❑ NO❑ ARHI Sheet Attached:YES ❑ NO❑ Contract Attached:YES ❑
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 / / 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 No. Certificate of Competency No.
Signature Date:
(Qualifier's signature)
(Revised02/24/2014)
FRIENDLY A/C
lic#cac1815584
19515 Carolina cir,Boca Raton,FL 33434
PHONE:(561)674-1478
Fax:(561)826-7139
E-Mail:friendlyroofing@hotmall.com
Install a new air a/c and duct work previous company installed the air condition without a permitted.
Know friendly roofing and a.c.are now dealing with the permitted
GOODMEN DISTRIBUTOR
AIR HANDLER
MODEL#AWUF360816BB
SERIAL#1401181742
CONDENSOR
MODEL#130361EB
SERIAL#1401348998
VLTS 240Amps
FUSE#30AMPS
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14 DISPLAY AS REQUIRED BY LAW SM 04060400("501
RICK SCOTT,GOVERNOR IGEN LAWSON,SECRETARY
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20ISMS LOCAL BUSINESS TAX RECEIPT
61-234
DLY ROOFING AND AX;INC LM Number. 201108163
FRMWDLY ROOFING ANDAIC INC E"KPIRF.$. P'E'E 30s2016
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FRIENDLY ROOFING.AND AfC INC LM Number 2011001"
FRIEMt1LY ROOFING AND AfC INC E PI .SMERMIM 30,2016
11616 CAROLINA CR
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ACCOIII, DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 08/14/2015
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 certificate holder is an ADDITIONAL INSURED,the poiicypes)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns 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 CONTACT Noel Brown A032583
Brown Insurance Inc. PHONE941 493-1886 FAx 941-497-6325
1872 Tamiami Trail S. E-MAIL noel@brownins.net
Suite G INSURERS AFFORDING COVERAGE NAIC#
Venice FL 34293 INSURERA: ARCH SPECIALTY INSURANCE CO 21199
INSURED INSURER B
FRIENDLY ROOFING AND A/C,INC. INSURER C:
19515 CAROLINA CIRCLE INSURER D:
INSURER E
BOCA RATON FL 33434
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.
ILTR NSR SUOR TYPE OF INSURANCE POLICY NUMBER IMIDDINYM POLICY EFF POLICY EXP LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000
MISE
CLAIMS-MADE ❑X OCCUR DAMA E T RENTED $ 100,000
MED EXP oneperson) 10,000
A AGL0019779-00 12/06/2014 12/06/2015 PERSONAL&ADV INJURY 500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000
X POLICY JeRc°- �LOC PRODUCTS-COMP/OP AGG 500,00
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS
UMBRELLA LIAR OCCUR EACH OCCURRENCE
EXCESS LIAR CLAIMS-MADE AGGREGATE
DED I I RETENTION
WORKERS COMPENSATION PER OTH-
D EMPLOYERS'LIABILITY Y/N STA LITE I I
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE
If Yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB
DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES CORD 101 Additional Remarks schedule be attached N more Is required)
/ / (A ,may 1� req red)
ROOFING&AIR CONDITIONING CONTRACTOR STATE OF FLORIDA.SVIKLA ELMALAH LICENSE#CCC1327680 AND CAC1815584
ERTiFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Miami shores village Bid Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
10050 Ne 2Nd Ave
AUTHORIZED REPRESENTATIVE
Miami Shores FL 33138-2304 Noel 8r,,,/A032S83 epw
m 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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SWEMS DATE: ZWM14 EXPIRATION DATE: 7J2t}l2t316
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18515 Carolina Cir, Boca Raton, FL 33434
Phone: (561)674-1478
Fax: (561)826-7138
E-mail:ftiondlyroofing@hotmall.com
Date: 08/24/2015
Before me this day personally appeared SVIKA ELMALAH who , being duty sworn deposes and says:
That he will be the only person working on the project located at:
10682 NE 11th Ct, Miami shores FL.
Sworn to and subscribed before me this 24th day of Aug 2015 by
SVIKA ELMALAH
Produced identification DL
Notary Stamp
IIlk
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�Noun Miami shores V
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
W7
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 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 ,201
By A &L who is personally known to me or has produced
1 as identification.
Notary:
SEAL:
UJZP.ERLICH
e, EXPIRES;May 30,2018
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