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MC-15-3096 13 go (06 2g Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-249369 Permit Number: MC-12-15-3096 Scheduled Inspection Date: March 28,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPlerre Inspection Type: Final Owner: PERAGALLO, DINO$IRENE Work Classification: Kitchen Hood Job Address:55 NE 97 Street Miami Shores, FL 33138- Phone Number (305)995-5224 Parcel Number 1132060130990 Project: <NONE> Contractor. DELTA-TEMP AIR CONDITIONING LLC Phone: (305)506-5392 Building Department Comments HOOD FLU FOR KITCHEN Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid March 25,2016 For Inspections please call: (305)762-4949 Page 9 of 31 Y Wei Y il"`111 Miami Shores Village 10050 N.E.2nd Avenue NE •�• Miami Shores,FL 33138-0000 p y R Phone: (305)795-2204 € Expiration: 06/2612016 Project Address Parcel Number Applicant 55 NE 97 Street 1132060130990 DINO&IRENE PERAGALLO Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell DINO&IRENE PERAGALLO 55 NE 97 Street (305)995-5224 MIAMI SHORES FL 33138- 55 NE 97 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 500.00 DELTA-TEMP AIR CONDITIONING LL( (305)506-5392 (954)5440203 �..� .........� _........ �.. Total Sq Feet: 00 Tons: Available Inspections: Additional Info:HOOD FLU FOR KITCHEN Inspection Type: Classification:Residential Final Approved:In Review Rough Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work: Review Mechanical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.80 DBPR Fee $2 25 Invoice# MC-12-15-58049 DCA Fee $2.25 12/29/2015 Credit Card $115.10 $50.00 Education Surcharge $0.20 12/15/2015 Credit Card $50.00 $0.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $165.10 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 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. Futhermore,I authorize the above-named contractor to do the work stated. �--- December 29, 2015 Authorized Signature:Owner / Applicant Co ractor / Agent Date Building Department Copy December 29,2015 1 T Miami Shores Village CF'v�D Building Department DEC 15 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 FBC 20;1/- BUILDING Master Permit No. '_C'/1- ,S agBS PERMIT APPLICATION Sub Permit No. 9Ci�_&2a ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBINGMECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP rr CONTRACTOR DRAWINGS JOB ADDRESS: �J N IT-4 S`t City: Miami Shores County: Miami Dade Z10: 33159 Folio/Parc el#: 3 o�b w 3 �t�U Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): lytM '`/ r—Ph�� Address: City: lWINA1 AOM5 State: fG410 Zip: X13 g' Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: 0617A ZKY hone#: Address: 1/119 � 2 City: fttwk zip:-3311i Qualifier Name: r 1S CO I�I _ Phone#• State Certification or Registration#: r '/2<- Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 600 Square/Linear Footage of Work: Type of Work: ❑ Addition [S AlterationJ� ❑ New ❑ Repair/Replace ❑ Demolition ti Description of Work: r l � flu• ge &ii<_" _ Specify color of color thru tile: Submittal Fee$ Permit Fee$ t !0b CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (RWsedOZ/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage tender'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 low brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice o cement must be posted at the job site for the fast inspection which occurs seven (7) days after the building permit h i ued. in th absencesuch posted notice, the inspection will not be approved and a reinspection fee will be charged. /pf Signature JSignature �WNE'R or AGENT CONTRA OR The foregoing instrument was acknowledged before me this The for oing)nstr t was acknowledged beforer his 'S dao 20 .by b Zo Y ' da of Y ho is personally kno to ,,'day 5-v Q who is personally known to me or who has produced _ as me or who has produced ft p;tqu Z- ® 2,ZL-as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: �.�`� ��• NOTARY PUBLIC: S. S a ti0 �.�•:, .� : Sign: Print: 4>11 d Seal: 'e� C 4a*� _Z Seal: ,``:::"'. YENISSEY SANTOYO PINON �i� �t► ••+,,69Hn.' ♦♦♦ T*' * Commission#FF 213823 ♦ My Commission x nes s�i °� CommEP •••'• ��p `�♦♦ ' March 25, 2019 7APPROVED BY P ns Examiner Zoning Structural Review Clerk (Revised02/24/2014) T yt; s Miami Shores Village Building Department �m am 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 41NCH 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 Civercurrent Protection(Fuse/Breaker Size): 3. Voltage of Circuit(208/240/480): 4. Size Disconnecting Me Contractor's Company N +` A7l Gid / hone: State Certificate or Regi ration Certificate of tency No. ��L Signature Date: Z s (Revised02/24/2014) logo mm" Miami shores Village Building ®apartment 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tei: (305)795.2204 CONTRACTORS' REGISTRATION 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. 0000om000000000a ■■000eoo�000�00000000000a000w000000000000000a000a000000ao�000000aaa000 BUSINESS NAME: ✓ (e-nd BUSINESS ADDRESS:1 1119 Ij �f'✓ CITY ClLIvt ! STATE41 ZIP BUSINESS PHONE: } ` FAX NUMBER(w CELL PHONE(__j QUALIFIER'S NAME:,jj:(a''"NC1)GA > — QUALIFIER'S LIC NUMBER: Ld STATE CSF FLORIDA pRtFIAC�llLA"I`I�31d A 60345nn FAAN �T EMP iF / Y� t1=ttT�F1Ct uadr tha prtslssns at.Ch:49 1��3: .• two" it 40 STATE OF FLORIDA DEPAOT'Moo� S AND PROFESSIONAL IL REGULATION C"STRUCTIC INDUSTRY.LICENSING ABOARD ' rr a OM " .0it , L i A tf4 GQl i lTl 111 +G ITS, �A A C r°�...��" _,,."��.',A��k', ��`„�'��. :t''t""g S ,,.�. i.�...._ _.,,:-..amu..,. .�.,§.�,..�,. �_�h� _•� ��.�.�,_�S. fix...za .. . ., .��, ISSUED: USl2012014 DISPLAY AS REQUIRED BY LAW SEC!# L1408200001173 404YSS x � f a � s c, - � su�a�k z•�g �!, �y��n FY.,�,a�i a�y � �r�r.� s'L ` r a yy *W z y MCA wo F. Us Thi OP vpsms O�lfl AIR CONDM ;LLC 196 SPS MECH, ,, �nvM�at civ ` iACt350� Tn�c t .aeCT .: 0120/2{315. tEDiTC D-15-")729 3 , s $tx;iaasx� i ' Buslasts Tax.The ha ad a Wto,ine, catdiif � � Y a"gave �►�'o CERTIFICATE OF LIABILITY INSURANCE 12/8%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 policy(les)must be endorsed. N SUBROGATION IS WAIVED,subject to the teras 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 sndorsemengs). PRODUCER NAME Lissette Perez L P INSURANCE ASSOCIATION INC PH (305)888-5747 1 !uc No;(305)888-8926 801 W 48 Street Ste B ADDRESS:info@l insure.com Hialeah, FL 33012 uJatmtRIs)AFFORDING cCVEaaee waca INSURER A:Ascendant Commercial Insurance 13683 INSURED DELTA-TEMP AIR CONDITIONING LLC INSURER B: 11718 SW 113 TERR INSURER C: MIAMI, FL 33186 INSURER D: 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 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 CLAW. INSR AWL SUER LTRTYPE OF INSURANCE POLICY NUMBER LIMITS R COMMICIft GEMMA.WERM EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea copmertce $ 100,000 MED EXP(ft ons ) $ 5,000 A GL43278-2 11/01/1511/01/16 PERSONAL&ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER:- GENERAL AGGREGATE $ 2,000,000 B POLICY�J CST F LOC PRODUCTS-COMPIOP AGG S 1,000,000 OTHER: $ AUTOMOBILE LIABILITY Wza etxddent $ AWAUTO BODILY INJURY(Per person) $ ALL OS SCUTES LED BODILY INJURY(Per accident) $ NON-OWNED $ HIRED AUTOS AUTOS Per accident UMBRELLA LU16 OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION OTH- AND EMPLOYERS LIABILITY YIN SPTER ER ANY p MAA)90p ❑NIA E L EACH ACCIDENT $ OFFICEIWMEMBERm yyee y in NM E.L.DISEASE-EA EMPLOYE]':$ under DESGtRI VOWN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,AddUWW Remarks Schedule,maybe attached B more space is required) AIR CONDITIONING INSTALLATION, SERVICE OR REPAIR. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES, FL 33128 E'AX: 305-756--8972 Aur"° EPRESE TI ®1 88-2013 ACORD CORPORATION. All rights reserved. ACORD25(2013104) The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHW F AMIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SEAMES DIVISION OF WORKERS'CONWENSATION *CERTIFICATE Cid ELECTION TO 13E EXEMPT FROM.FLORIDA WORKERS'COMPENSATIONLAW*• CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed Wow has elected to be exempt from Flolids 1WWcxkerV Compensation law- EFFECTIVE DATE: 101112014 EXPIRATION DATE: W3012016 PERSON: i'IERNANDEZRIVERA YOHANCYS FEIN: 753212173 BUSINESS NAME AND ADDRESS: DELTA-TEMP AIR CONDITIONING LLC 2351 NW86TH AVE HOLLYWOOD FL 33024 SCOPES OF BUSINESS OR TRAM: HEATING,VENTILATION, AIR-COND Pursuant to Chapter44[.MM),F.S.,an of a *m elects exesnptin from this tester by INV a cwwcm of obefibit wuW#tt sec ton my nwrecover bamfda nr= pensedw mWoft rates.Pw nt to Chapter 44ti.Wj2),F.S..Celt cats ofoWJonto bo exempt,..any oMy vMM lite scope of the tam ortrade Items mt the nofteof ejwb"tat beams.PUMMM to Chapter 440OX131,F.S.,NottoesofetaftntDbe ez4 end 'xxttes�' �l�tsxtenpt stt�be �rev ;ff;at arty fvne. arttbr t ctittt�e ft#t�e arose �the cert4ica�, the peramnw ted On the:nOdw OrOWAOM fro tunpt3rrr OM the mWftm*of"*secOwtorftuarm of a wwome.The ftwwAfd Ad revoke a DFS>F2-W*r--252 CERTIFICATE-OF`ELECTlot4TO BE Ex PT REvIWC108-13 QUES17ON a(860)413-1609 Delta Temp Air Conditioning LLC License#CAC 050345 7302 SW 113 Circle Place, Miami, FL 33173 Date: M Iq d0137 State of: 014()A (-1\n County of: �—A—)�C Before me this day personally appeared YOH4 UG S HEP.000- who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: y5 Ne qq S� Sworn to (or affirmed) and subscribed before me this Iq day of C 20jS, by �IWArr-Ys H&t#8WW Personall ,,��{PP�COV k�AOR Produced Identification �� `�`�a►% Type of Identification Prod d p T,4 � 'v • �y z = 0 10 101 %,, Print,Type or Stamp name of Notary 1 R am AF fall SEES Miami shoresVillage 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 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 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 t6C, 20 By who or has produced as 0 % C-0,410% . ,�v No at lop SEAL: 4b 0. A