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RC-14-2702 Miami Shores Village -FINx"'D Building Department ov 0i M5 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 20 )'-/ BUILDING Master Permit No._9C JQ — 2 20 2 PERMIT APPLICATION Sub Permit No.Po /j-- [:]BUILDING j--❑BUILDING ❑ ELECTRIC ❑ ROOFING % REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING 2 ECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: N E cf- 4 S City: Miami Shores County: Miami Dade Zip: 3313 Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): K '03 A-YO + A It 4 /yl 5% Phone#: 305 �3 7 / Address: /z, (o to A/ J�'Lf S.r City: yy(rt hb r-ff State:— r— / Zip: / 3 / Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: 4 101+ 5`/ �Lt Alm Phone#: 3 0-C-1- Z3e 6-5 62- Address: /3 !92,5- 114 2- u/ City: V111- . Ilk State: Zip: 3 3 1 0 k0 �(y Qualifier Name: � l/L AJ&SPhone#: State Certification or Registration#: C�"'C ® 5)1 24 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$_ /,�fl of Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New �Re air/Re lace p p ❑ Demolition a ,, Description of Work: 9 COIAC ie A�- OJ �/1//P� c� J- /� l A� ',2 l CJ,16"dt' bkt� Specify color of color thru tile: Submittal Fee$ Permit Fee$ C CCF$ I'j : n CO/CC$ Scanning Fee$ Radon Fee$ P DBPR$ Notary$ Technology Fee$ Training/Education Fee$ C) Double Fee$ Structural Reviews$ 2 Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Banding 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. G-` Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument as acknowledged before me this The foregoing instrument was acknowledged before me this � J; day of s„ .20 /6 by day of At 1rn ( 20 1!5 by M '9%p�nal y nown to �-i ,r /) — `J C1°il who is personally known me or who has produced T �- /a/1-i PeeW kC—t— as me or who has produced as identification and who did take an oath. identification and who d' ke an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign Sign: Print:trtey 2 1/ Print: Seal: R 99ft `iii Seal: " " Notary Public State of Florida MYCMUSSIONY FFOMIG Daniel Hemandez EXPIRES:Dwwber2,2Qt7 a My Commission EE 830923 11""Tlru kl"Pubrie Umlerm�ni o►q Expires 08/28/2018 **+*t***x*e* e***e***********e***e*****e*****+**+x*******+****+x**** APPROVED BY �V P15s Examiner Zoning Structural Review Clerk (Revised02/24/2014) r SgORE' .xG�93at Miami Shores Village �►� Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 �rORIDp' 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 sheetssiare not acceep-ttable. Job Address(where the work is being done): I Q / +�44 S/ City: Miami Shores Village County: Miami Dade Zip Code: 33i 3 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 1,N Pj 'tit' L MANUFACTURER AHU or PKG. UNIT MODEL# COND. UNIT MODEL# dl KW HEAT 'z�l 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 i 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): t !; '� 1" S 2. Maximum Overcurrent Protection (Fuse/Breaker Size): (�S 3. Voltage of Circuit(208/240/480): 4. Size Disconnecting Means: r� Contractor's Company Name: / S �� Phone: State Certificate or Registration No. C as G o 5-7 / 2-,4 Certificate of Competency No. Yc' 4 3 4- d Signature --- Date: q (Qualifier's signature) (Revised02/24/2014) 000190 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOTA BILL - DONOT PAY LBT 404434 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES FLORIDA STATE A C&REFRIG CO INC RENEWAL SEPTEMBER 30, 2016 13825 SW 142 AVE 4044U Must be displayed at place of business MIAMI FL 33186 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED FLORIDA STATE A C&REFRIG CO INC 196 SPEC MECHANICAL CONTRACTOR BY TAX COLLECTOR Worker(s) 10 CAC057124 $75.00 07/29/2015 FPPU02-15-017473 This Local Business Tax Receipt only confirms paymenI of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualifications,to do business. Holder most comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must he displayed on all commercial vehicles-Miami-Dade Code Sec Ba-276. For more information,visit mm miamidade gov/taxcollector 4 i 1 100% Ku"RY4s 4 t 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 fisted below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 8/19/2015 EXPIRATION DATE: 8/18/2017 PERSON: CHIRINOS ANDRES FEIN: 592153811 BUSINESS NAME AND ADDRESS: FLORIDA STATE AIR CONDITIONING&REFRIGERATION COMPANY 9125 SW 77TH AVE#A3O1 MIAMI FL 33196 SCOPES OF BUSINESS OR TRADE: HEATING,VENTILATION, AIR-COND Putsaram to Chapter 440.05(14),F.S.,an of&er of a earpora4on wtw eleriv ezrerrtp0nn from tlHa d�epter bq 66r�a cettifFmte of aeon under tlda seOion rr®y rmd remover herte6�or amrn under ltds Gmpter.Putst®td to C�440.05(12).F.S.. rates at elution to he eserryE..appAr Dory waldn the stype of the bsirress m trade Gated on the ttoitoe oteOacOmr to be� Putstrant to t 440.05(13).F.S..tQoOces otefmtion Eo be eYerrmi are1 oertifiotes of elriott to he®tenet sha0 t>B sum to revor�mt if,of arty time atter Ore Gang of th rrohce ar th iss�ese oiMa cetiifieale, th person named on Ste notice ar tartl8tata no Iwtger rnee@t the regtdtetnertts of fids section br ksuart�M e wrtikcate.The departttretd sha0 revoke a DFS-F2-DY1C-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(85OA13-1609 Ceftificate of Product Ratings AHRI Certified Reference Number: 6743257 Date: 10/1/2015 Product: Split System:Air-Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: 4TTV0060Al Indoor Unit Model Number: *AM8COC6OV51 Manufacturer:TRANE Trade/Brand name:TRANE 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, OH, OK, OR, PA, RI,SC, SD, TN, TX, UT,VA,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 region(s)for which they meet the regional efficiency requirement. Series name:'XV201. Manufacturer responsible for the rating of`this system combnation;i*TRANE Rated as follows in accordance with AHRI Standard 21012402008 for Unitary Air-Conditioning and Air-Source Heat Pump,Equipment and sub,)iW toverification of rating accuracy byAHRI-sponsored, Independent,third party testing: ,Cooling Capacity(Btuh): 54.000 EER Rating(Cooking): 12.75 SEER Rating (Cooling): 19.10 IEER Rating (Cooling): Ratings followed by an asterisk(*)indicate a voluntary rerate of previously published data,unless accompanied with a WAS,which indicates an involuntary rerate. DISCLAIMER AHRI does not endorse the product(s)listed on this Certificate and makes no representations,warranties or guarantees as to,and assumes no responsibility for, the product(s)listed on this Certificate.AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s),or the unauthorized alteration of data listed on this Certificate.Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS79 This Certificate and Its contents are proprietary products of AHRI.This Certificate 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;copied;disseminated; entered Into a computer database;or otherwise utilized,In any form or manner or by any means,except for the user's individual, personal and confidential reference. AIR-CONDITIONING,HEATING, CERTIFICATE VERIFICATION &REFRIGERATION INSTITUTE The Information for the model cited on this certificate can be verified at www.ahridirectory.org,click on`Verify Certificate*link we make lice better- and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which Is listed above,and the Certificate No.,which is listed at bottom right. ©2014 Air-Conditioning,Heating,and Refrigeration InstituteCERTIFICATE NO.: 130881966787800344 i Permit NO. M �s�!ORhs L, Miami Shores VillageRdkit ), .. is e tj 10050 N.E.2nd Avenue NE y {� CMISS�j 0h.ACWiltip fAltomflon Miami Shores,FL 33138-0000 'grfrtft�Ittrs;APPROVED Phone: (305)795-2204 'OGORIi1A � � s. qOW � Expiration: 12/09/2015 Project Address Parcel Number Applicant L1260 NE 94 Street 1132050100180 Miami Shores, FL 33138- Block: Lot: KRISTEN MUSTAD Owner Information Address Phone Cell KRISTEN MUSTAD 1260 NE 94 Street (305)661-6633 MIAMI SHORES FL 33138- 1260 NE 94 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 7,000.00 FLORIDA STATE A/C&REFRIGERATI (305)336-6894 (305)310-5030 Total Sci Feet: 200 Tons: Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Approved:In Review Rough Duct Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work:NEW DUCT WORK IN REMODEL ARE Underground Scanning:3 �JE Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $4.20 DBPR Fee Invoice# MC-6-15-55901 $3.68 DCA Fee $3.68 06/12/2015 Credit Card $222.56 $50.00 Education Surcharge $1.40 06/09/2015 Credit Card $50.00 $0.00 Permit Fee $245.00 Scanning Fee $9.00 Technology Fee $5.60 Total: $272.56 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 ify at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. F o thorizelhe above-named contractor to do the work stated. June 12, 2015 Authorized SigneZrtment :O er Applicant ntractor / Agent ate DepBuilding Copy June 12,2015 1 . Miami Shores Village C 'xilFID Building Department JUN 0-9 2095 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 13Y: a Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 d® BUILDING Master Permit No.LC IL1-2�0 2- PERMIT APPLICATION Sub Permit No.UL —1,-?96 ❑BUILDING ❑ EL CTRIC ❑ ROOFING ❑ REVISION [:] EXTENSION RENEWAL PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP P C CONTRACTOR DRAWINGS JOB ADDRESS: (�� 94 J7 • CiMiami Shores County: Miami Dade zip: Folio/Parcel#: I)• 32.05-• o IO - O)k® Is the Building Historically Designated:Yes NO Occupancy Type: R'2S Load: Construction Type: `-4S Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): /A.5v'i Phone#: 305-4-S9- 16 -5 Address: An = 0 City: State: �'� Zip: 5- 3,140 Tenant/Lessee Name: f Phone#: Email S Ld JAU� kA,sre 5. (fit CONTRACTOR:Company Name:s //I Phone#: 3057-33G -6�f X14 Address: 11125'- SW I N•Z AV e. City: MNCkvvA*�1 State: L- Zip: 331�f Qualifier Name: Ae Y)Lk dr �LA. C lir-; 16 Phone#: 0.Ke State Certification or Registration MA C ,,'� -+f 2 y Certificate of Competency#: DESIGNER:Architect/Engineer: VicA&r 6 r u-c-e— Phone#: 369 "310 S630 Address: 310 Aj I: 10 f St City: .i Sl.®ces State: FL-- Zip:3313 Value of Work for this Permit:$ ® 0® Square/Linear Fo tage of Work: Type of Work: F-1Addition ❑ Alteration F-1NewRepair/Replace n Demolition Description of Work: O°EW ®uj worx tti rGrna�-ewk agree& 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$ �• 500 (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 absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature klqv Signature OWNER or AGEN r CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 't _day of,I � 20 1. by A�day of %JUA--2 .20 15 by kasIMtri J . U4J4 41 who is personally known to MA / . j�f&ri•nQ S who is personally known to me or who has produced /flL#N2M 5/6 •22-AX-6s me or who has produced k1- CGS•?-0l 2?'X07 SOSar C� identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign:. t� /-t-4 Sign K-1.2 11� Print: u,c !t Print: WeAw GGA A /► ,e 4 Seal: Seal: INTI I, NIIIII, y1 11 r � R®ECA t.ARTIA4A TURNER rte R®ECA I.ARTIAGA TURNER b•• :►. +' MY COMMISSION#FF 130252 r; r MY COMMISSION FF 130252 a: SPIRES:August 24,2018 ' BonM Thre p bk24 Un&mitem hru Notary Public Underwftm A ***IkIIIklkslk* ****&d<�kt1* +elk***klklklYlk+k * *+kb*tllaeaelklk**IBIkIk+RIk1#tIP*Ik111***+kdlk APPROVED BY lans Examiner Zoning LV t Structural Review Clerk (Revised02/24/2014) F' STATE OF FLORIDA SSW7` DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC057124 ISSUED: 0910312014 CERTIFIED AIR COND CONTR CHIRINOS, ANU TERTTU FLORIDA STATE A/C & REFRIGERATION is CERTIFIED under the provisions Of Ch.4S9 FS L14Q9030001904 Expiration date . AUG 31, 2016 Local Business Tax Receipt Miami-Dade County,State of Florida -THIS IS NOTA SILL-DO NOT PAY �.LBT 404434 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES FLORIDA STATE A C&REFRIG RENELAAL SEPTEMBER 30,2015 CO INC 404434 Must he dispFayadat plots of LuNnass 13825 SW 142 AVE Punua itoCountyCode MIAMI.FL 33186 ChapereA—Arts&10 OWNER SEC.TYPEOPBUSINESS PAYMENT RECEIVED T"LOW DA STATE A C S REFRIG CO tog SPEC MECHANICAL BY TAX COLLICTOR INC CONTRACTOR 62.50 ?O108'2094 Worker.=:l 10 CAC057124 0229-15000154 This local Bveiaess Ta.Ruagt ealy ceefinn paywaat d Ue local BW...T...Th•Roe•ipl n a•t a lice•sa, perm it,sr a aediNcatieu of Ua Mlder s ynatihc Iliona,U to bo—W.holder wirer calsplp wIm any pentomeatol or xeapovann•oral regulanrp laws.nd NRuinnenn which apply le the husiae.. The RECEIPT NO ahoy now h•displayed en ap ummercial vehicle-Miasi-0a1a Cede Sec Ba-876. Aro Fornvry iaNra Im,vleit"w.wirgi4}{I }�Bu;fir TE Aco 06/04/2015 CERTIFICATE OF LIABILITY INSURANCE °6/04/2015 `...�� 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. 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). NT PRODUCER NAME: CT Pan Am Assurance Agency, Inc PHONEExtl, (305) 270-1424 FAX (305) 270-8997 9100 Sunset Drive EMAIL .carlos@panamassurance.com INSURER(S) AFFORDING COVERAGE MAIC 0 Miami FL 33173-3433 INSURERA:WesCO Insurance Company- 25011 INSURED Florida State Air Cond.6 Refrigerat INSURERS: 13825 SW 142nd Ave INSURERC: INSURER D: INSURER E: Miami FL 33186— INSURERF: 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. ILTRR TYPE OF INSURANCE POLICY NUMBER POLICY F POLICY EXP LIMITS A GENERAL LIABILITY WPP1249670 00 3/12/2015 3/12/2016 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / DAMAGE TO RENTED— PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE Fx_1 OCCUR / / / / MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 Fi EDX POLICY PR,FCO LOC / / / / $ A AUTOMOBILE LIABILITY NPP1252171 00 D3/12/2015 3/12/2016 (Ea acxIND SINGLE LIMIT $ 300,000 ANY AUTO / / / / BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED / / / / BODILY INJURY(Per accident) $ AUTOS AUTOS / / / / PROPERTY DAMAGE $ X HIRED AUTOS X AUT SWNEO Per accident) UMBRELLA LIAB OCCUR / / / / EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE / / / / AGGREGATE $ DED RETENTION$ / / / / $ WORKERS COMPENSATION / / / / WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N / / / / E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) / / / / E.L.DISEASE-EA EMPLOYE $ If yes,descnbe 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) A/C 6 Heating services Anu Terttu-AC057124 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Villages Building Department AUTHORIZED REPRESENTATIVE 10050 NE 2nd Avenue (' Miami Shores FL 33138- ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD .b W8 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: 8/19/2013 EXPIRATION DATE: 8/19/2015 PERSON: CHIRINOS ANDRES FEIN: 592153811 BUSINESS NAME AND ADDRESS: FLORIDA STATE AIR CONDITIr 13825 SW 142 AVE MIAMI FL 33186 SCOPES OF BUSINESS OR TRADE: HEATING,VENTILATION, AIR-COND Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by ifiing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,CertHioates of election to be exempL..apply only within the scope of the business or trade listed on the notice of election to be exempt Pursuant to Chapter 440.05(13),F.S.,Notice of election to be exempt and 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 no longer maets the requirements of this section for issuance of a certificate.The department shd revoke a ate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 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: 8!19/2013 EXPIRATION DATE: 8/19/2015 PERSON: CHIRINOS ANDRES FEiN: 592153811 BUSINESS NAME AND ADDRESS: FLORIDA STATE AIR CONDIT], 13825 SW 142 AVE MIAMI FL 33186 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 Bing a certificate of election under 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 election to be exempt Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shag be subject to revocation 9,at any time after the filing of the notice or the Issuance of the cerfMicats,the person named on the notice or cantticate no longer meets the requiramards of this section for issuance of a certificate.The department shag revoke a certificate at any time for failure of the person named on the cartificate to meet the requirements of this section. DF$-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 SgoREs D s,,, ,,,ll" Miami Shores Village a res WA � Building Department LpRipA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner one 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: r State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of �6-" ,20_j 5 . By Jo." /' 4t.,1. who is personally known to me or has produced A1.#Ma33 -510 - -70- 0.2D -d as identification. Notary: ( a &AAtiJ�L SEAL: // •"'r',,•,,, R®ECAI.ARTIACWTURNER �. W COh�AMION#FF 130252 : o;= EXPIRES:AUQUs124,2018 A FLORIDA STATE AIRCONDITIONING AND REFRIGERATION CO., INC 13825 SW 142 AVE. . MIAMI, FL 33186 Date: State of ��o r►�� County of /1%arn; n i Before me personally appeared I2�-f�LA, who, being duly sworn, deposes and says: That she/he will be the only person working on the project located at: 1260 NL C14 S1 . /`1NOm, Shores 3313k Sworn to (or affirme and subscribed before me this`� day of Junes .20 I�. by ruaZ REBECAI.ARTMA•TURNER YP Tqt� r= W COMMISSION,4 FF 130252 EXPIRES'august 24.?x)18 At; gonMThmtzc4aryL'u* .uvudiers Personally Known OR Produced Identification -0I Type of Identification Produced 0&ye 0 A �S-¢ ,�y.. _._._. .. :TURNER -F 1SW 2018 Print,type or Stamp name of the Notary