MC-16-2336 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-265762 Permit Number: MC-8-16-2336
Scheduled Inspection Date: September 14,2016 Permit Type: Mechanical - Residential
Inspector: Perez,JanPierre Inspection Type: Final
Owner: SACCOMANI, ERIK( Work Classification: AIC Replacement
Job Address: 129 NW 96 Street
Miami Shores, FL 33138- Phone Number
Parcel Number 1131010250100
Project: <NONE>
Contractor: INFINITY CONSTRUCTION SERVICES, IN Phone: (786)443-9590
Building Department Comments
rEPLACEMENT OF A/C UNIT 4 TONS Infractio Passed Comments
INSPECTOR COMMENTS Fals
i 1 V
U2
i
Inspector Comments
Passed
Failed
Correction
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
September 13,2016 For Inspections please call: (305)762-4949 Page 21 of 44
Miami Shores Village >� 1 y{?B:Mechanicat-Res lderta
10050 N.E.2nd Avenue NW
.. A te+ M"it IC1fT Ci C8men
- ® Miami Shores,FL 33138-0000
er
Wits:
3138 0000Wits:APDI* ul:n
hfi R ` Phone: (305)795-2204
P.
Ex iration: 03/06/2017
Iss Date.X17120 6 ;;
Project Address Parcel Number Applicant
129 NW 96 Street 1131010250100
ERIK SACCOMANI
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
ERIK SACCOMANI 129 NW 96 Street
MIAMI SHORES FL 33150-
129 NW 96 Street
MIAMI SHORES FL 33150-
Contractor(s) Phone Cell Phone
Valuation: $ 3,000.00
INFINITY CONSTRUCTION SERVICES, (786)443-9590
._... v_. .._....,.. Total Sq Feet: 0
Tons:4 Available Inspections:
Additional Info:rEPLACEMENT OF A/C UNIT 4 TONS Inspection Type:
Classification:Residential Final
Approved:In Review Review Mechanical
Comments: Date Approved::In Review
Date Denied: Type of Work:
Scanning:3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.80
DBPR Fee InVOiCe# MC-8-16-61044
$2.00 08/18/2016 Check#: 100 $50.00 $72.80
DCA Fee $2.00
Education Surcharge $0.80 09/07/2016 Check#:5894 $72.80 $0.00
Permit Fee $105.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $122.80
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the oing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and z ing. Futhermore,I a ize the above-named contractor to do the work stated.
September 07, 2016
Authy rued Signature:Owner / Applicaril / Contractor / Agent Date
i
Building Department Copy
September 07,2016 1
c
nl
t 4 N°RESP Miami Shores Village
Building Department
AU X 161 �� .;; art;
... . . �� � 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
�woRmp Tel:(305)795.2204
r c$ r til Fax:(305)756.8972
AIR CONDITIONING R ► IllE1' T DATA
PERMIT NUMBER: MC_k(0_ 23`
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. 1
Job Address(where the work is being done): I �CA �k "I
City: Miami Shores Village County: Miami Dade Zip Code: I
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 spa
e, AHU or PKG. UNIT MODEL# i
G, , COND.UNIT MODEL#
k3 KW HEAT I�
4 CA 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 a
YES NO REPLACING DUCTS YES _N O
YES NO REPLACING THERMOSTAT YES O
YES NO NEW 4"CONCRETE SLAB YE Ui
YES NO NEW ROOF STAND Y S
YES NO NEW RETURN PLENUMBOXYES O
1. Minimum Circuit Ampacity(Wire Size): ° +
2. Maximum Overcurrent Protectio Fuse reaker Size):
3. Voltage of Circuit(208/4D480): vkqQ
4. Size Disconnecting, eans: 3 ( .fl AI h
Contractor's Company Nalme:
State Certificate ora istri tion No.C�c-1 t �'�rl`� Certificate of Competency No.
Signature Date:
�! Qualifiers signature)
(Revised02/24/2014)
ash This combination qualifies for a Federal Energy
Efficiency Tax Credit when placed in service
r a
between Feb 17, 2009 and Dec 31, 2016.
Certificate of Product Ratings
AHRI Certified Reference Number: 8242082 Date: 7/16/2016
Product: Split System: Air-Cooled Condensing Unit, Coil with Blower
Outdoor Unit Model Number: GSX160481F*
Indoor Unit Model Number:ASPT49D14A*
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, 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 Mame 16
Manufacturer responsible for the rating of this system combination ts.60.60MAN"MANUFACTURING CO., LP.
Rated.as follows"in accordance with AHRI Standard 210/240=2008 for Unitary Air-Conditioning and-Air-Source
Heat Pump Equipment and subject't"brification of rating accuracy by.,AHRI-sponsored, independent,third
party.
testing:-:
Goofiing CapaCitjr(Btuh}: 45000
EER Rating(Cooling): 13:00
SEER"Rating (Coofing): 16.00
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.ahridireetory.org.
TERMS AND CONDITIONS
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 snake hle 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. "--"
131131590861674217
02014 Air-Conditioning,heating,and Refrigeration Institute CERTIFICATE NO.:
• � �\° Miami Shores Village
�® g p
Building Department
� 2016
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 AUG 1
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
C 2011-4
BUILDING Master Permito.mc IG` 233ro
PERMIT APPLICATION Sub Permit o.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ® MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zi
Folio/Parcel#: 6 r -). 0 d 0'c� Is the Building HistoricallyDesi ated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):9 SHA M r Phone#:
Address: v,Q
City: Him ` C7 State: Zip:
Tenant/Lessee Name: • � � Phone#: •.� b
Email:
CONTRACTOR:Company Name: IA.n. AUJ �uC� °fir c ®e Phone#: � �
Address:
e ! L- &Lo ct kD A )_� -)�5(0
City: State: Zip:2rbi 6
Qualifier Name: A 1b k Du p 1 e»Got C11- Phone#:
State Certification or Registration#:CAL, I`& l 6') Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address City: State: Zip:
Value of Work for this Per4:$ o Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Rep it/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$ . O3 Permit Fee$ V f/ CCF$ �� CO/CC$
Scanning Fee$ !a Radon Fee$ Z DBPR$ ' Notary$
Technology Fee$ . �� Training/Education Fee$ ��� Double Fee$
Structural Reviews$ '0 Bond$
TOTAL FEE NOW DUE$ �2
(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 Signature
OWNE or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of TJ 20 I`� ,by day of 6 ,20 d by
who is,�perspnplly known to
'44&-k ,w aisoer mown to
p
me or who has produced Say's 'XQU I' G� as me or who has produced An J"� u u000(c _as
identification and who did take an oath. ide ification an o did tae oath.
NOTARY PUBLIC: OTARY PUB
y5V�1i6j BII/s,S
Sign: � ✓ Sign: --
Print:; Print: RAUI.NAVARR
0
6 � = =o= MY COMMI I
ffF)414% a ( 2020
Seal: Seal: EXPIRES:MAR 20.
�r va -,.. 2
'.`a .•:,,,>,.,, a s; ������ OF Bonded through ist State Insurance
ter,.�_ ;:.. • F �� � _
LIC.sT\X\®`\��w J�
APPROVED BY ° Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
INFINITY CONSTRUCTION SERVICES INC.
4156 SW 96 Avenue
Miami,Florida 33165
Telephone 786 424 0350
OWNER: SACCOMANI ERICK LICENSE#CAC 1816795
ADDRESS:129 NW 96t'Street DATE:
Miami Shores Fl.33150 2 CONTRACT#456
TELEPHONE:_► u v l
CONTRACT:
Between:Saccomani Erik,owner of the Property located at 129 NW 96''
Street, Miami Shores, FL.33150,and Antonio Luvara,qualifier of the Company
above mentioned
For the following job description: replacement A/C unit 4 Tons 10 KW.
Total Price: $3.000.00
(Three Thousand Dollars)
Accepted:
Sacc ni Erik(Owner)
Antdiio Luvara (Qualifer)
I
RICK SCOTT; GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
C4C1816795
The CLASS AAIR CONDITIONING CONTRACTt?fI � g
Named below IS CERTIFIED
Under ttte provisions of Chapter 489 FS.
Explfati6n-nate:-AUG 31,2916
LUVA-RA Aj* ONIO
Ii�IFIN#T C I BLit iIICES i vcsZ
41ft.5 96tH AVS ur�
f
I4�lAIktII:"': r 4 a
06
art. .�
ISSUED: =1712015 DISPLAY AS REQUIRED BY LAVA! StQ#, L1508170001294
e
N[rainr--Dade C0--,, ;r,eta, ..c F1'or rd
THISIS
NOTA-Bill—Do NOT`PAY
6987813"
BUSWF,SS:A[4MR0.oCA7i011[
1NFINKTY CONSTRUC-nON t;EC r luo.
SERVICES INC RENEWAL EX-P[AES
..
4156 SW 96 AVE' 7263363 SEPTEMBER 30-12016
MIAMI,FL 33165 Must be displayo-atpiamof business
Pursuant to CourWCode
. Chapter BA—Art9&TOk`
OWNER SEC.TYPE OF BUSWESS
INFINITY CONSTRUCTION
SERVICES INC 196 SPEC MECliANiCAL' PAYMENT RECEIVED
O`-/n'ANTONJO I I(VARA CONTRACTOR BY TAX COLLECTOR
Worker(s) 1 CAC1816795 _82.50 09/24/2015
This Local B 0235-15-006466
dsiaess Tax Receipt only con{inas Payment atthe Local Business Tax The Receipt is nota license,
permit or a oer6Ticatien of Me boldees quaf110tioes4p de business.Holder must
or noagovermaental regulatory laws and require vrhlc6 cmupiy uvith e�yOYernmentalaPPh to ffie business
The RId;E1pT N0.above most be displayed on all rcial vehicles-Miami-
Dade Code Sec 8a--276.
MIAMIpgpE
®
For mom irdomgtion,visitvrwwmiami �-----
DATE( 00D j
CERTIFICATE F LIABILITY INSURANCE
PRODUCER TFii CERTt IC_A tMUD ASA R I FTit?N
Florida Insurance Agency of Miami ONLY AND CONFERS NO RIGHTS UPON THE Ct R71FICATE
P.O.BOX 441340 HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Miami,FI;33144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P;306446-IMOO
INSURER AFFORDING COVFRAGE NAILS
INSURED INSURER A. Untied
I"flofty ConsInjolon Servieft Inc INSURER 8:
4156 sw 96 ave INSURER C:
Miami F) 33165 INSURER D:
INSURER E;
INSURER F:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T7-IE INSURED N AEO ALiO1fE AOR THE POLICY PERIOD INDICATED,NOT-
WITHSTANDING ANY REOUIREMENT,TERM,OR CONDITION OF ANY CONTRACT*OR CTI TER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL.TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL EFMTPIRATION
LTR INSR TYPE OF INSURANCE POLICY NUMBER (MMiD0,'YYj {F�IMmontYi LIMITS
GENERAL.LIABILITY � EACH OCCURRENCE I.W&000
x COMMERCIAL UEit RAL LIAL3w I PReM!SLS(ba 0%wencej 11101,100
I LAIMS MADE [.]UCGUK MEU Ex is Qn0 Pawn) 15,900
PERSONAL A AL IV INJURY OtlEl.Q00
411140 4I3L f tLLtl)1 d115 TOA 0710
GENERAL AIsGREOAiE 4000:9L
GEWL AGGREGA fE LIMIT*APPLIES PLRI PRZTL'UCTS-CC3Ps P1OP AGU 1000/000
F�,3UCY HitUJEZ: a r,1;;;
ALIABILITYOMB E I LIIRiI
ANY AU I O E0 eg ld n{} $
ALL OWNED AUTO$ -�
SCHEDULED AU"TOS (Per Parson) $
HIRtU Au I OS
NON-OWNED AUTOS (Per Awdenl) $
..(Per A=Ident)
ANY Au T G
ALL OWNED AUTO$ AUTO ONLY
CLAIMS PAALIE
EACH OC:CORRENCE
CIr:IdRt3 � -._--.
CiUREGATE
DEDUCTIBLE
#IE rENSION $
EMPLOYERS LIABILITY TOEIY LiMIY 3 AFL
ANY k'litX'Itik L4IIIdPAPtINEIdAtI CLII iVE - »�
OFFICEPtAMkMbIzR EXCLIJUL0 r
It yes desk(1ndrr
SPECIAL PROVISIONS beim
DESCRIPTION OF OPERATIONS,LOCAiiTIONStVEHICLES EXCLUSIONS ADDED By ENDOIRSC-PENT;SPECIAL PROVISIONS
Lic.#CAC1816795
x CERTIFICATE ttoLDER A %INSURED
SHouLD ANY of THE AeovF DESCRIBED POLICIES BE CANCELLED OFORE THE EXPIRA MN
Miami Shores Village DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR To MAIL V DAYS WRITTEN
Building Department NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT`FAILURE TO 00 SO SHALL
10050 N.E.2nd Avenue, IMPOSE NO OBLIGATION OR LIABrUTY OF ANY KIND UPON THE INSURED,ITS AGENT OR
Miami Shores,FI 33138 AUTHPORIVc R PRES-1A I E
Tony 7t3tJhla`}
4;/'C/11/
AaCORD 250001XIS) ACOS COORATION 1988
0—w .
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: 9/21/2015 EXPIRATION DATE: 9/20/2017
PERSON: LUVARA ANTONIO
FEIN: 364796470
BUSINESS NAME AND ADDRESS:
INFINITY CONSTRUCTION SERVICES INC
4156 SW 96TH AVE
MIAMI FL 33165
SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING SHEET METAL WORK- HEATING,VENTILATION,
CONTRACTOR INSTALLATIO AIR-COND
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing 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 r'latice of election to be exempt Pursuant to Chapter 440.05(13).F.S.,Notices of election to be
exempt and certifigtes 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 meets the requirements of this section for issuance of a certificate.The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609
INFINITY CONSTRUCTION SERVICES INC.
LICENSE#CAC 1816795
4156 SW 96 Ave.
Miami FL. 33165
Date: 08/16/2016
Miami Shores Village
10050 NE 2nd Ave.
Miami Shores Village, FI.33138
Miami
Before me this day personally appeared Antonio Luvara,who being dully swum,depose and say:
That he will be the only person working on the project located at 129 NW 96 St, Miami Shores, FL
33150.
Storm to or(affirmed)and subscribed before me this--- -C ----- day o.
Personally Know--- -------------------___w________
Or produce identification--�- -- - �--' -------------------Type of ID
RAUI NAVA X714
o�,r�......; MN COMMISS A 20 2020
:: pCP1RES'.
Bonded Ch�o��'1st State lasurance
Florida Insurance 3054451335 P.1
DATE(MM/DDlYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE lAuglS,2016
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Florida Insurance Agency of Miami ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 441340 HOLDER,THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Miami,F1.33'144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P;305.4454100
INSURER AFFORDING COVERAGE NAILS#
NSURED INSURER A: United Spec Co 12537
Infinity Construction Services Inc INSURER B:
4156 sw 96 ave INSURER C:
Miami F1 33165 INSURER D:
INSURER E:
INSURER F:
;overages
FHE POLICIES Of INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT-
MTHSTANDING ANY REQUIREMENT,TERM,OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
3ERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL EFFECTIVE EXPIRATION
LTR INSR TYPE OF INSURANCE POLICY NUMBER (MM/DD/YY) (MM/DD/YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE 1.000.8D0
x COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $100,000
CLAIMS MADE Fx OCCUR MED EXP(any one person) $5,000
A PERSONAL k ADV INJURY 1.000.000
S1110031319227 10/912D15 10/912016
GENERAL AGGREGATE 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 2000.000
x POLICY PROJ LOC
AUTOMOBILE LIABILITY COMBINED SINGLE UMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BOLXLY INJURY
SCHEDULED AUTOS (Per Person) $
HIRED AUTOS
NON-OWNED AUTOS (Per Accident) $
(Per Acxident) $
ANY AUTO
ALL OWNED AUTOS AUTO ONLY AGO
OCURR CLAIMS MADE EACH OCCURRENCE
AGGREGATE
DEDUCTIBLE $
RETENSION 3 $
EMPLOYERS LIABILITY TORY LIMITS1 ER
ANY PROPIERTOR/PARTNER/EXECUTIVE
OFFICERWEMBER EXCLUDED 7 A EMPLOYE
If yes describe under
SPECIAL PROVISIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL.PROVISIONS:
Mechanical Contractor CAC1816795
x CERTIFICATE HOLDER I JADD'L INSURED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BFORE THE EXPIRATION
Miami Shores Village DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL"DAYS WRITTEN
Building Dept NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
10050 HE 2 ave IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURED,ITS AGENT OR
Miami Shores FI 33138
AUTHORIZED REPRESENTATIVE
Tony Zoghbi
ACORD 25(2001/08) ACORD 7RPORATIN 1988
O
logo 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 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,ori 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:
wn
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of 20&.
B E�yl V\ J_
who is personally known to me or has produced
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S-A!�v- D.-GQ 0 "-'41s identification.
Notary: •
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SEAL.
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was Miami shores illage
In Building Department
R 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
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® ®er■aaeraoe���..........s.........e■.a......es■000v■■..................................
BUSINESS NAME:
BUSINESS ADDRESS: CITY STATE ZIP
BUSINESS PHONE: ( ) FAX NUMBER(_)
CELL PHONE L---j QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER: