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MC-14-1749 2C Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-217668 Permit Number: MC-8-14-1749 Scheduled Inspection Date: October 14,2015 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: MARTINEZ, RAFAEL Work Classification: Addition/Alteration Job Address:511 NE 101 Street Miami Shores, FL 33138- Phone Number (305)458-2502 Parcel Number 1132060171090 Project: <NONE> Contractor: BLAZER CORP. Building Department Comments AS PER PLAN NEW UNIT DUCT BATHROOM FAN NEW Infractio Passed Comments COPPER LINE. INSPECTOR COMMENTS False �I I f Inspector Comments Passed IF Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. October 13,2016 For Inspections please call: (305)7624949 Page 2 of 69 Miami Shores Village ����ED Building Department Au 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 B Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201 BUILDING Master Permit No. 1Z )q �- PERMIT APPLICATION Sub Permit No. M0__ N— d ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING LKMECHANICAL ❑PUBLICWORKS ❑ CHANGE ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: cJ V A0 City: Miami Shores County: Miami Dade Zip: / Folio/Parcel#: 0 7 37-6/® 'CA )l- IMI Q Is the Building Historically Designated:Yes NO t� Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): XLF,�,eJ log-4;n cx Phone#: Address: D y �i,s,ca✓ _ � 41f- //3 City: State: Zip: 3313 Tenant/Lessee Name: Phone#: Email: V'4F'0►@.1 M - er)0-v C'-,?- AP R �hGl+ GDvy, CONTRACTOR:Company Name: Z J='jeoy Phone#:3d-A�_-,XaP- ®`-6 Address: City:. �I���.F ` r State: Zip: Qualifier Name: / i \AAn Q__, 1 U-,— Phone#:-.4 Qom`a.4 q-, o ,6/ja State Certification or,Registration#: �'`��� Certificate 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 E92AIteration ❑New ❑ Repair/Replace ❑Demolition Description of Work: V'119� k&C 'P�-'A---- �_k "-t );- Specify ;-S eci color of color thru tile: roVU Submittal Fee$ Z71�j - Permit Fee$ CCF$ CO/CC$ Scanning Fee$ ((� Radon Fee$ DBPR$ Bond$ Notary$ � Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ T✓�+ TOTAL FEE NOW DUE$ 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 ELECTRICAL WORK,PLUMBING,SIGNS,WELLS,POOLS, FURNACES,BOILERS, HEATERS,TANKS and 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven(7)days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. SignatureSignatur - Owner or Agent Contractor The foregoing instrument was acknowledged before me this 7 The foregoing instrument was acknowledged before me this, day of , �2014 by �"i�- L'7' day of �' 20 L by ee/'® ///i� -01 ' ced who is personally known to me or who has produced who is n' #{ � ndmimmi� -If@lh llll� _ As identification and who did take an oath. }'... .:;a=as i FIRPOW18i I take an oath. k IR ••..�,o►*.,,,:,'`— June 20,2017 NOTARY PUBLIC: NOTA d.roota seNi�a.� Sign: Print: ^\� ::o ®° �Fy">rn Print:�All�\A iN— S My Commission Expires: ;N v j = My Commission Expires: nuinu� APPROVED BY ,1 1 Plans Examiner Zoning - ` Structural Review Clerk Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012))(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC058456 ISSUED: 07/01/2014 CERTIFIED AIR POND CONTR MALCOLM, LEROY MICHAEL BLAZER CORPORATION IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31,2016 L1407010000914 001922 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY N.. LBT/ 4461349 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES BLAZER CORPORATION RENEWAL SEPTEMBER 30, 2014 15492$W 102 AVE**** 4657616 Must be displayed at place of business MIAMI FL 33157 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED BLAZER CORPORATION 196 SPEC MECHANICAL CONTRACTOR BY TAX COLLECTOR Workers) 1 CAC058456 $75.00 08/01/2013 FPPU05-13-002437 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8o-276. For more information,visitwww.miamidade,govAncollector 01-15-2013 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 01/15/2013 EXPIRATION DATE: 01/15/2015 PERSON: MALCOLM LEROY M FEIN: 650408667 BUSINESS NAME AND ADDRESS: BLAZER CORPORATION 15492 SW 102 AVENUE MIAMI FL 33157 SCOPES OF BUSINESS OR TRADE: 1- HEATING, VENTILATION, AIR-COND IMPORTANT: Pursuant to Chapter 440 . 05114), 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 440.05112), 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 440.05113), F.S., Notices 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 meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW & D chapter. EFFECTIVE: 01/15/2013 EXPIRATION DATE: 01/15/2015 Pursuant to Chapter 440.05112►, F.S., Certificates of election to be PERSON: LEROY M MALCOLM H exempt... apply only within the scope of the business or trade listed on FEIN: 650408667 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: BLAZER CORPORATION E 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 revocation 15492 SW 102 AVENUE if, at any time after the filing of the notice or the issuance of the MIAMI, FL 33157 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 certificate'8t any time for failure of the SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this 1- HEATING, VENTILATION, AIR-COND section. QUESTIONS? (850) 413-1609 CUT HERE Carry bottom portion on the job, keep, upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 1 r�B_R S n .... a�.� Miami Shores Village Building Department AOR 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: I. 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.In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,you may be personally liable for the worker compensation iniuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Contractor Print Name: e� Print Name: �� �- Signa — Signature: State of Florida) State of Florida) County of Miami-Dade) l County of Miami-Dade) Sworn to and su ed before me this Sworn to and subscribed before me this day of ,20 k i \\"7u''ida of ver y 20 � ' N By •.,,pyres• '% _ ...� By 19 � (SEAL) = 3 ����°��' (SEAL) Type of Identification produced o n = Type of Identification produced NOTM %, �F113 ..��G` = Commission �';:�,�'�'?�• OF �;v�;� ��'•.EE173059.��Q-�� F �N OF CERTIFICATE OF LIABILITY INSURANCE DATE 08/11/114 YY) 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(ies)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). PRODUCER CONTACT VERBERT ANDERSON NAME: J.V. Insurance Agency P ANN : (305)253-7555 AI�No• (305)2541461 17690 S.Dixie Hwy.Suite A E'M RE : ivantvrun@beilsouth.net Miami,FL 33157 INSURERS AFFORDING COVERAGE NAIC# Phone (305)253-7555 Fax (305)254-1461 INSURER A: TAPCO UNDERWRITERSILLOYDS OF LONDON INSURED INSURER B: PROGRESSIVE INSURANCE Blazer Corp Mechanical INSURER C: 15492 SW 102 Ave INSURER D: Miami,FL 33175 (305)338-0066 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 CLAIMS. ILTR TYPE OF INSURANCE INSR WVD BR POLICY NUMBER MPMIIDICY EFF MMMILDICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 O PREMISESS COMMERCIAL GENERAL LIABILITY DAMAGE (Ra occurreENTED nee) $ 500,000.00 ❑ ❑ A CLAIMS-MADE ❑ Y 04/14/2014 04/14/2015 OCCUR JGKGZ MED EXP(Any one person $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN.L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00 ❑ POLICY [3JECT PRO- ❑ LOC $ AUTOMOBILE LIABILITY COM13IINdED SINGLE LIMIT $ ❑ ANY AUTO BODILY INJURY(Per person) $ 10,000.00 ALL OWNED SCHEDULED 01968118-1 BODILY INJURY(Per accident) $ 20 000.00 B ❑ AUTOS ❑ AUTOS 12/0612013 12/0612014 Q HIRED AUTO Q AUT OS PROr accidentPERTY AMAGE $ 10,000.00 Pe ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION 1:1TORYTAI ❑ETM AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) El E.L.DISEASE-EA EMPLOYE $ If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER IS ALSO ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT 10050 N.E.2 AVE AUTHORIZED REPRESENTATIVE MIAMI FL 33138 ��d aal-', I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105)OF The ACORD name and logo are registered marks of ACORD