Loading...
MC-15-2468 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-259090 Permit Number: MC-9-15-2468 Scheduled Inspection Date: May 25,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address: 1460 NE 101 Street Miami Shores, FL Phone Number (305)898-7882 Parcel Number 1132050240050 Project: <NONE> Contractor: ALISAEZ A/C INC Building Department Comments DUCTWORK A/C& EXHAUST FANS 5 TONS EXISTING Infractio Passed comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-258240. NEEDS REVISION AS BUILT Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid May 24,2016 For Inspections please call: (305)762-4949 Page 18 of 34 PC Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-258240 Permit Number: MC-9-15-2468 Scheduled Inspection Date: May 09,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address: 1460 NE 101 Street Miami Shores, FL Phone Number (305)898-7882 Project: <NONE> Parcel Number 1132050240050 Contractor: ALISAEZ A/C INC Building Department Comments DUCTWORK A/C& EXHAUST FANS 5 TONS EXISTING infractio Passed Comments INSPECTOR COMMENTS False v O Inspector Comments Psed Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. May 06,2016 For Inspections please call: (305)762-4949 Page 25 of 45 Miami Shores Village Building Department 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.4�r_ J�S'7- )z e PERMIT APPLICATION Sub Permit No. HC- IS- 2 68 ❑BUILDING ❑ ELECTRIC ❑ ROOFING F_� REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ` EECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: '�iCJL� j � ` ® ' City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO �I Occupancy Type: Load: Construction Type: 11 Flood Zone: BFE: FFE: l OWNER:Name(Fee Simple Titleholder): �° f.� N )�SU�#'g�g 5 -� 3y�p• Address: I4�; 5 S U6 e,, IE S - City: VO Ill( State: Zip ,3 Tenant/Lessee Name: Phone#: Email: '"' -�'U�©��� Q)_&01 A I L t4"'I CONTRACTOR:Company Name: &-A� z Phone#: jam_r Address: �`��� Z. \S 2 Q—0,0 L City: State: E=fc_ Zips: Qualifier Name: (ice— • ' . yam_. State Certification or Registration M Certificate of Competency#: DESIGNER:Architect/Engineer: �1 WZ. ,I - Phone#: ' Address: & `w� ity: 4J d)Z� Stated Zip: Value of Work for this Permit:$ � qu near Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace Demolition ___1i Description of Work: � P �• _ e I \. Specify color of color thru tile. Submittal Fee$ Permit Fee$ a CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ PP TOTAL FEE NOW DUE$ 9G7 (Revised02/24J2014) i • 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 citmmencement must be posted at the job site for the first inspection which occurs seven (7) days after the building per&rent ence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signatu O R or AGENT CTOR The for instrument was acknowledged before me this The forknowledged before me this ay of � 20 Is by day of a 20%� . ,by ,4,tfluL ,who is rsonally k wn to � -4;' ' �( personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sig - Sign: Print: �� rint: man NOWYPublic Slate of•` a Seal: Robert JaoSeal: EJ#f0"11,,:NcWry p�ic S�&�aw{yCeinmsEE 831y47 anna M Feliciano Com 082753a• res 01/1 018 * * *e**x**e�x�*x APPROVED BY " � tans Examiner Zoning Structural Review Clerk (Revised02/24/2014) car Arballo Fax:(306)677-2284 To: Fax:'.+1(306)756-8972 Page 3',ofs'.0912112015 9:24 PM .,...STATE OF-FLORIDA DEPARTMENT. F: u 1 ES : N0 PR4.FESISMNAL.'ZEGU " !ON a CONSTRUCTION INDUSTRY( LICENSING.BOARD `:'::'. :.' (85.0.} 487-1 �°,. ..: . 1940 NORTH MONR,QE STREET...,... TALLAI-U'#SSE:E F.02399 0783 . ARBALLO, HECTOR OSCAR ,ALISAEZAIR CONDITIONING. INC -..'f4516 SW 108TH STREET,....., ­­-. . , . . .. ... : .:Congratulationsi "With'this license'you bedbihs-one-of the-nearly - ..,_....r:,, one million Floridians licensed bythe Department of Business and :, ` :,;.,:..., ..................,.....:........ ,....,,...,.........,............,....,.:::: Professional Regulation. Our'professionals and businesses rangeSTATE -'m ;; ..:firom architects to yacht brokers,from boxers to.barbeque.restau[ants,':. ? :: anal they keep Florida's economy strong, : . MENi 4FBUSINESS.ANp Eve .... ,� ,.. �ULATIO.N::'. ry day we work to improve the way we do business in order to `' " " `' '" '"'` serve you better- For information about our services,please to onto, : y �Ar✓068020` T<'.... you can find 9 Q wWW.myfioridalicertse.com. "there y more Information es . ,.....GERT1FJvfl' Aabout our divisions and the regulations that impact you, subscribe department newsletters.and Learnr?ore AOH ou th4epartmenYsintiativISAEZ +R•::-M=,".? :. ur.misslon at the Department is: License Efficiently, Regulate Fairly. We constant) strive to serve you better so-that you cans ..... ... r . {:. customers. Y, erve your `:.,....., ,... - ,. Thank you for doing bustness..lp,Florld.;3, •.� .. ��� ''���^" :and congratulations.on ypur:new.1.100nse!. : . csiz z:.. : �P - itYda ,TIF1..1=A:u:rkde�^dhe prRvasiQP� of.Ch:4ee FS:.','=.�: .spare al�oaaas DE TACH:HERE RICK SCOTT; GpVERR0R. . .. K EN ... , , --STAT . , •E OF FLORIDA _ DEPARTMENT iV OF BUSINESS AND PROFESSIONAL REGUWIQN. ONSTRUCTIO.N.:INDUSTRY`!LICENSING BOARD' :'•'...:''.' ;.. .: .`' :; : " c�0,05.a.020' 77 77 7 ...:: ...... ... i....Th6-CJASS.BAIR-CONDITi(. I-NGCQNTRAOT?i '' s"'.>..;' ...`:; ,. '.' ,• Narnecl belorv':IS CERTIFIEQ.:.:- Under.the' rv' ' 4,. Q islons-- ,. p Qf,Cha , �. ..,. ter.489 1A ra 1 rt .. ...:.:x.... `. P..... t date>...AU.... . 1 .20.1.6......,, .... .. ., ,.,.. ... .,. . ...za>:: . :ate _. ^ : AFB .• a<, S' 1TIH I WAw, . ... ... .. .. .. , .. .:. ... .... .... .. ..... ...:....:.. '�,;: .:•,.'. .':?ter .N ... .1*wwroa>�.u.>,:w;�,,:...<*::::_...,, ,3 moi::.. '....:. ',. '.'..•e�,,c'x'•.. �':`:`hr;' e»�r; :.$`,::.:�'k';�,"^: r:�`p "l^ SEQ# L1409010000138 ,I.t"`)A(hl K �� df fa .,�''* �s �'Vir. � -YV� ,Zrr'e;s�>�r $¢�}-S✓� +'rY rrsf [[tk�+, r 1' F �7��. r���J,tS {�7r" r �.:,�).{ `_r�a�w"x`..�p F�r.�'� 9i{�,f:�.���Ss���JY�'�'sf p�kL �v✓S N��f�i�; �4$'S'i .,� /F3 r tu��t.<} '.,,y� �f fi���Nr J `t >w 'y4".,,s r"��4�i �,}� 1�I �, '+�5��,1f f f/ �� f f iS 4(�Y�y'�t'•nfa'� �•w��� l��jay��'t:�./� f y 7 '{{ S.. k�C%j�t1Fff 01. L ,t {lnfC l ,,r"3'i5 ,,� if j,�•��=C �..��5-G��S ��N��� �Fci 4n t� ][ --rfix s �'l� r'FCus,�v� ''���i F rfla i�. k� �r i �''at .�" j�� ;. u, 1 .E zr , � �',� s t s� '"�� r �< �tl to�n 1er" .�✓ � .r R t �} s^U .� 5 �w°{e`'E'1 KA. f s .sf ,� i fe�.r u LsFSG`,�" rpt o- y4s} r%• t ?t+... r 1 , ,� �''�1� ,• � { rw' rty ,h trw�Bd Iiw t�'�iruJ.4;t spti#+r d, n r .:K i l� •:F, 4.�r"i,'1 W.�}t'+} UieJr4 4 {,1a.�.:.�Y:.. .7 From:Oscar Arballo Fax:(305)677-2294 To: Fax: +1 (305)756-8972 Page 2 of 2 09!28!2015 12:55 PM CERTIFICATE OF LIABILITY INSURANCE °A'E"" "'�" 09/28/128/1 5 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 Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Hemisphere Insurance Group PHONE (305)501-2801 No): (305)553-9010 11401 SW 40 St Ste 340 L hemisphereinsgrpoaol.com Miami,FL 33165 INSURER(S)AFFORDING COVERAGE MAIC# Phone 305 501-2801 Fax 305 553-9010 INSIRERA: UNITED SPECIALTY INS COMPANY INSURED INSURER B: ALISAEZ AIR CONDITIONING INC INSURERC: 12973 SW 112 ST #131 INSURER D: MIAMI,FL 33186 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IRR TYPE OF INSURANCE POLICY NUMBERPOLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 Q COMMERCIAL GENERAL LIABILITY DAMAGE ES RENTED a occurrence) $ 100,000.00 A ❑ ❑ CLAIMS-MADE DCGO0847--00 01/11/2015 01/11/2016 MED EXP(Any one person S 5,000.00 PERSONAL&ADV INJURY $ 1,000,000.00 El GENERAL AGGREGATE S 2,000,000.00 GENL AGGREGATE UMITAPPUES PER: PRODUCTS-CCIVP OP AGG S 2,000,000.00 ❑ PCDJCY ❑ Ip ❑ LOC S AUTOMOBILE LIABILITYciIhED SINGLE LIMIT a erdent ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS BODILY INJURY(Per accident $ F-1PNON-O"REDAUTOS ❑ AUTOS D eracade $ F-1 RAMAGE F-1UMBRELLALIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIM ❑CLAMS-MADE AGGREGATE $ El DED ❑ RETENTION$ AND EERS COMPENSATION YIN ❑WC STA RYLITU• ❑ OIFL AND EMPLOYERS'LIABJLfrY ANY PROPRIETOR/PARTNEREXECUTNE OFRC EFWEMBER EXCLUDED? E-1MIA E.L.EACH ACCIDENT $ (Mandatoryin E.L.DISEASE-EA EIVPLOYE S Ifyyoes describe under DESO itPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCMP nON OF OPERATIONS/LOCATIONS/VEHICLES (Mach ACORD 101,Additional Remarks Schedtde,V more space is regmred) LICENSE NO.CA-0058020 CERTIFICATE HOLDER CANCELLATION MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE W LL BE DELIVERED IN BUILDING DEP ACCORDANCE WTH THE POLICY PROVISIONS. 10050 NE 2nd Ave. AUTHORIZED REPRESENrAT1VE Miami Shores,FL 33138 Fax 305-756-8972 , ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD scar Arballo Fax:(305)677-2294 To: Fax: +1(305)756-8972 Page 5 of 5 09121/2015 9:24 PM 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: 11/17/2014 EXPIRATION DATE: 11/16/2016 PERSON: ARBALLO HECTOR O FEIN: 591970684 BUSINESS NAME AND ADDRESS: ALISAEZ AIR CONDITIONING INC 12973 SW 112 ST 131 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 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 notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election lobe exempt shall be subject to revocation if,at anytime 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?(80413-1609 6. ■cc + lisaez HVAC design-build 12973 SW 112 ST. 131 Miami, FL 33186. Ph: 305-677-9556 Fax: 305-677-2294—alisaez@aol.com September 26, 2015 State of Florida County of Miami —Dade Before me this day appeared Hector Oscar Arballo who, being duly sworn deposes and says: That he will be the only person working on the project located at 1460 NE 101 St. Miami Shores FL 33138. Sworn to (or affirmed) and su n e fore me this day of r, 2015, r Personally know OR produce Identification Type of Identification produced ¢s«seMc o►i L&09'LO Ai"eq Sawwo, amp Name of Notary MM833#NOISSIYYYM AN ;,. :■: S3NVIN111 SOON" , Miami shores Village Building Department 10R1pA 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 AC OWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. s Signature: Owne State of Florida County of Miami-Dade The foregoing was acknowledge before me this_! day ofSWCXA�,201_� . By @i C A 6�tWk Ntcts . who ' personall known to me or has produced as identification. Notary: '•. SEAL: MY COMMISSION 0 EE87aW M, WEXPIRES Febrt ary 07,2017 No 39B Ot33 Horio.N�r�y9«Moa opn MIAMI-DADE COUNTY -STATE OF FLORIDA WA October 02,2015 MIAMFOA� LOCAL BUSINESS TAX RENEWAL 147330 2015 -2016 APPLICATION RECEIPT:147330 STATE#CAC058020 DBABUSINESS NAME: BUS.COMMENCEMENT DATE:08/24/1988 ALISAEZ AIR CONDITIONING INC SEC TYPE OF BUSINESS BUSINESS LOCATION: MECHS SPEC MECHANICAL CONTRACTOR 12973 SW 112 ST 131 10 MIAMI,FL 33186 OWNER/CORP. APPLICATION DETAILS ALISAEZ AIR CONDITIONING INC FEE AMOUNT PHONE# 305-677-9556 Receipt Fee 30.00 UMSA Fee 30.00 12973 SW 112 ST 131 Beacon Council Fee 15.00 MIAMI,FL 33186 Bingo Permit Fee 0.00 Nightclub Permit Fee 0.00 Multi-Municipal Contractor Fee 0.00 Restricted Contractor Fee 0.00 Library Fee 0.00 NAICS CODE: 238990 Transfer Fee 0.00 Doing Business without a License Penalty 0.00 Late Penalty 7.50 Collection Cost 0.00 NSF Fee 0.00 Prior Years Due 0.00 Amount Recently Paid - 82.50 TOTAL AMOUNT DUE: 0.00 ..........«.....».................................................................«.......................»........................................«......................«......................................................................................«.....................................». If no longer in business,please notify us In writing. To pay online go to wwwmiamidade.govttaxcollector Review and correct the information shown on this application. To pay by mail,make check payable to: Miami-Dade County Tax Collector A 25%penalty will be assessed to anyone found operating Business Tax without a paid local business tax,in addition to any other 200 NW 2nd Avenue penalty provided by law or ordinance(Sec 8A-176(2)). Miami FL 33128 To pay in person go to: A Certificate of Use and/or City Business Tax 200 NW 2nd Avenue Receipt may also be required. (305)270-4949,fax(305)372-6368 A service fee of not less than$25.00 up to a minimum of 5%D will be charged for all returned checks. t RETAIN FOR YOUR RECORDS t ...«..«..«........................«...««..«.... «......«.«.«.......«.....«». ...«.....«.«..«..«........«.«..«...«. «...»« ....... «.-......«................«......«.....«..«..«..........««......«..........«.«»...«..«...«....«..... MIAMI-DADE COUNTY- i DETACH HERE AND RETURN THIS PORTION WITH YOUR PAYMENT + WA Ocher 02,2015 STATE OF FLORIDA LOCAL BUSINESS TAX RENEWAL 2015 -2016 APPLICATION RECEIPT:147330 sraTE#caco56o20 147330 11111111131111111 BUSINESS LOCATION: 12973 SW 112 ST 131 MIAMI,FL 33186 BUS.COMMENCEMENT DATE:08/24/1988 SEC TYPE OF BUSINESS OWNERICORP. MECHS SPEC MECHANICAL CONTRACTOR ALISAEZ AIR CONDITIONING INC 10 APPLICATION IS HEREBY MADE FOR A LOCAL BUSINESS TAX RECEIPT OR PERMIT FOR THE BUSINESS PROFESSION OR OCCUPATION DESCRIBED HEREON.I HAVE BEEN INFORMED OF ALL ZONING RESTRICTIONS IMPOSED ON THIS RECEIPT. I SWEAR THAT THE INFORMATION IS TRUE AND CORRECT. ALISAEZ AIR CONDITIONING INC 12973 SW 112 ST 131 MIAMI,FL 33186 SIGNATURE REQUIRED SEE INSTRUCTIONS ABOVE Please pay only one amount The amounts due after Sept 30th Include penalties per FS 205.053. NPaid By Oct 31,2015 Nov 30,2015 Dec 31,2015 Jan 31,2016 Pieria Pay $0.00 $0.00 $0.00 $0.00 7000000000000000000000000147330201600000007500000000000006