MC-15-3176 (2) Inspection Worksheet
Miami Shores Village
10050 N.E.2nd Avenue Miami Shores,FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-249970 Permit Number: MC-12-15-3176
Scheduled Inspection Date: May 23,2016 Permit Type: Mechanical - Residential
Inspector. Perez,JanPlerre
Inspection Type: Final
Owner. KING,ROGER&JUDITH Work Classification: A/C Replacement
Job Address:137 NE 105 Street
Miami Shores,FL 33138- Phone Number (305)_-
Parcel Number 1121360050120
Project: <NONE>
Contractor: JOSE C YANE AIR CONDITIONING&APPLIANCES SERV IN,
Building Department Comments
INSTALL MINI SPLIT A.0+ Duplex PER PLANS. Infractlo 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.
May 20,2016 For Inspections please call: (305)762-4949 Page 6 of 36
s=
f y
Miami Shores Village
10050 N.E.2nd Avenue NE
u•
Miami Shores,FL 33138-0000
Phone: (305)795-2204
Y
'' r Expiration: 07/0 2016
Project Address Parcel Number Applicant
137 NE 105 Street 1121360050120 ROGER&JUDITH KING
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
ROGER&JUDITH KING 137 NE 105 Street
MIAMI SHORES SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,850.00
JOSE C YANE AIR CONDITIONING S I
. _....,.,.,. w.. Total Sq Feet: 0
Tons: ' Available Inspections:
Additional Info:INSTALL MINI SPLIT A.0+DO DUPLETS Inspection Type:
Classification:Residential Final
Approved:In Review Review Mechanical
Comments: Date Approved::In Review
Date Denied: Type of Work:
Scanning:1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20 Invoice# MC-12-15-58153
DBPR Fee $2.25 01/07/2016 Credit Card $110.70 $50.00
DCA Fee $2,25
Education Surcharge $0.40 12/23/2015 Credit Card $50.00 $0.00
Permit Fee $150.00
Scanning Fee $3.00
Technology Fee $1.60
Total: $160.70
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.
OWNSWAFF I certify that all the foregoing information is accurate and that all work will be done in compliance with ail applicable laws regulating
constrrmore,I authorize the above-named contractor to do the work stated.
January 07,2016
re:Owner / Applicant / Contractor / Agent Date
Buildingrtment Copy
January 07,2016 1
Miami Shores Village
Building Department 3 015
10050 N.E.2nd Avenue,Miami Shores,Florida 33338 C 2
Tei:(305)795-2204 Fax:(305)756-8972
INSPECTION UNE PHONE NUMBER:(305)7524949
FB C 20 I q
BUILDING MasterPe nit No q-q -/, .;v
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ELECTRIC ❑ ROOFING REVISION ❑EXTENSION ❑RENEWAL
❑PLUMBING 5PECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: L S
Miami ShoresCounty: Miami Dade Z :
FopoJP : Ls
the Building Htstoriglly Desigru te&.Yes NO
Occupancy Type: Load: Construction Type: //,,�►► Flood Zone: BFE: FFE.
OWNER:Name(Fee Simple Titleholder): .�V b,r'T)! �,A-17 IV Phone#:
Address: 0 '7 AZ e. /b J•' � ��
State:_ 'L Zip: 3e
Tenant/Lessee Name: Phone#-
Email: �1
CONTRACTOR:Company Nam 8 `e J*f
Address: ZV'xl_ AA A9
city: - State Zip:
Qualifier Name: f C !l. S Phone#•
State Certification or Registration#: r 7 fe Certificate of Competency#:
DESIGNER:Architect/Engineer: ": J
Phone#: CJ-- 36�
Address $ 464 Gty: LGrf W Stat=L• Zip: J Sw s y
Value of Work for this Peffi t:$ Square/Linear Footage of work:
Type of Worla ❑ Addition (rK Alteration F] New ❑ Repair/Replace ❑ Demolition
Din of Work:/Ar XZ4Ws.�., "1 1A-T "
00
Specify color of collorrtthru tile.
Submittal Fee$� `'� Perri*Fee$ �_ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
t
9' Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$
Bond$
TOTAL FEE NOW DUE$ I ®
# wLted 24/2014)
Bonding Company's Name(if applicable) A
Bonding Company's Address
C'i'ZY State zip
Mortgage lender's Name(if applicable)
Mortgage Lender's Address 24
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 taws 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."
Motke to Applicant. As a condition to the issuance of a bum permit with an estimated vakre eneedhV$2500, the appttcant must
promise in good faith that a ropy of the notice of commencement and construction rwn tow brochure wilt be dethrered to the person
whose property is subject to attachment Also,a certified copy of the recorded notice ofcommencement must be posted at the job site
for the first inspection which occurs seven (7)days after the btuldM permit is mued in the absence of such posted notice, the
inspection MY notbe a a reinspection fee wilt be charged.
Signature ignatu
NERAGE C M'rRACT R
The foregoing instrument was a owledged before me this The foregoing instrument was acknowledged before me this
r
day of .20 day of If _ by
J
l- ,�..
�"ar" A wh
. o' p�rsona-lly known-t6' Jc-re, �� _,who ersonally know to
me or who has produced as me or who has produced as
Identification and who did to oath. identification and who di to an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: C Y-• Sign:
Print: Print• cru
F
0
Seal: Ho�yi2�� Seal: te �
2016
APPROVED BY PIExaminer Zoning
Structural Review Clerk
i
(RevisedOZ124/2014)
T
To:
Miami Shores Building Department
10050 NE 2"d Avenue
Miami shores FL 33138
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that Roger King and Judith King,
jointly and severally (hereinafter referred to as "Principal") has made, constituted and
appointed, and by these presents does make, constitute and appoint Leonard Feldman
of Star Construction Company, Inc. (hereinafter referred to as "Agent"), true and lawful
attorney for Principal and in the name, place and stead of Principal.
This Power is given to enable the Agent to legally represent the Principals and to
take all actions necessary and to execute any and all documents, applications and
permits in connection with the issuance of Electrical, Mechanical and Plumbing Permits
under Master Permit No. RC-9-15-2395 regarding the property at 137 NE 105 ' Street,
Miami Shores FL 33138
The Principal exonerates the Agent from liability for all non-negligent acts of the
Agent. All acts done by Agent pursuant to the powers conferred herein, shall have the
same effect and inure to the benefit of and bind the Principal.
GIVING AND GRANTING unto said Agent full power and authority to do and
perform all and every act whatsoever requisite and necessary to be done, as fully to all
intents and purposes as the Principal might do, hereby ratifying and confirming all that
said Agent shall lawfully do or cause to be done by virtue of these presents until this
power is revoked or terminated by the Principal.
IN WITNESS WHEREOF, the hand and seal of the legal representative of the Principal
has hereunto been affixed this day of December 2015.
*RE G
STATE OF FLORIDA
COUNTY OF MIAMI DADE 7�
The forgoing Power or Attorney s swo to and su before me this
day of December bypo ✓ h di did not n oath.
Notary Pub c
STATE OF LORIDAyF ,yq
My Comm' ion Expires:
yts Miami Shores Village
Building Department
.n, ctrl 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): 137 V 5 t N_-!l S7�
City: Miami Shores Village County: Miami Dade Zip Code: ?313
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
AHU or PKG.UNIT MODEL# JloL(J 6rivi r,
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 Overcurrent Protection(Fuse/Breaker Size):
3. Voltage of Circuit(208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name: Phone:
State Certificate or Registration No. Certificate of Competency No.
Signature Date:
(Qualifier's signature)
(Revised02/24/2014)
STATE SSS FLORIDA
DEPARTAWNT OF 6U M&ROFINWHAL Tom
CONSTRIIINQIJSYR1t i.R; 90m
�181�74
The CLASS 8 AIR CONDITIONING CONTRACTOR
Ned tit IS CERTII<RED
U r the.pvAelom of Chapter 48 488 F'S.
Expiration+tete: AUG 31,
2016
JOSE CLEMENTE
JOSE C YAW AIR C4NDTn NTNG&APPLIANCES SERVICES INC
1021 NE 13214D ST �
NORTH AAI FL 33161
ME0. 08M412014 DISPLAY AS REQUIRES BY LAW SEQ tt L1408140WIM
003521
,a s
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+ff A/C&APDL 5W&UC -�1.96• $$ �flE PpYM .
1.ri�i181 74 r W TAX
X45 00 0/21/2M'
CtfDffc4 D--15-m74w
1 F a A Ta TGe is rm a .
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CERTIFICATE OF LIABILITY INSURANCE 11i30
/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS No RX3HTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEM EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONST RITE A CONTRACT BETWEEN THE ISSUM INSURER(S�AUTNOROW
RgSENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
1111PORTANT: 9 the cord icate holder b an ADDITIONAL INSURED,the poky(m)must be endorsed. H SUBROGATION 1S WANED,subpot to
the terns and COndidons of the Poj►,certain policies may re*e as sukwaemant. A atatonent on this o0r6110 does not coffer d&b to the
oe"Poste holder In Isr of such e s
111WIRIM W Towels iasuraaae Agency
Torres Insuz=06 Agency Inc. (305)512-5880
61.35 NW 167 STREET # E25 taosts:a-sees
Miami Lakes FL 33015FO.M�A.IftPfre =n om Qnsyminy
two re
Jove C Vanes Air Conditioning 6 Appliamcoa
.
Services, Inc. o
1021 NE 132 Street
North Miami FL 33161
COVERAGES CERTIFICATE NUMBF.R:CL15111827216 REVISION NLS•
THIS M TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE DOMED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUF"ENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUIAENT WITH RESPECT TO VMCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES L MiTB SHOWN MAY HAVE BEEN REDUCED BY PAID CLAII S
TMOPINSURANCE ADM SIM ufAfTB
afflum LLlAMMY
EAf,11 C 'Al 1,000,0001
7C o C M ISI NERy�AL LMOU Y 10
_
A OCWR 323760 1/13/2015 /13/2016 NW EXP ane $ 5,
C1 1ADE 1 000
NALAxw[NJURY $ 11000,000
GENMALAt UMM-TE $ 2,000,0001
t,TMA GREGATELa11rAPPLESPER PRODUCTS-CONElOPAM s 1,000,000
x LOC $
AUTONOMM IJAINI Y Gr
B ANYAUTO OWLYRaw(per P—) $
ALLOVAMAUTOS AUTOS
XSCHMNAM 613012000f443- _ _ /17/2015 /17/2014; soAlEv eLR1Rlf{Pa►a�adenq $
HUED AUTOS AUTOS DA $
PE43AWC $ 10,000
ur LtA LIAR O EACH OCCUMMICE $
>IN LM C , AGGIMMM $
111(OMMSCOMPENSAT1010anrU.
NoYIN -�
ANY i.�l EL FAC.11ACfAaEWT $
in NK) i.-J NIA E DEEASE-I:AEAAPI 9
*' EL DMEASE-POLICYLUT
OFOPERATE!LOCATIONSIVWGMJ[s~ACMM,AdMMMRW=ftswmmqwnkmqukem
Air Conditioaiag Xnstallatum
Blanket Additional Insured apply to Gon*=1. Liability policy # C8-000323760-5 as
2033. • xn1 and mrine: small Tools $5 x 000! $500 Dad � by cx►ntr>Psst' ('X;
per Item/$3,000 per oacns�ca. 100$ Coins.
s)Ccaroial Auto: Veh 1: 2002 Mord/ Ecnols,ne 3250 Van$ 1198, Veh 2: 2005 Chevrolet Silverado Via#6819,
Veli 3: 2006 Clwvrolut 8apraas Via$ 22433
$500 CallIzeum and Comprehensive Dad applscable only on 2005 Ctwm=let Silverado Vin # 6519
CERTIFICATE HOLDER CANCELLATM
(30S)756-0972 SHOULD ANY OF THE ABS DESCRMED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Miami. Shozvo Village Bldg Dept ACCORDANCE VMW THE POLICY PROVISIONS,
10050 NF 2nd Ave AurxoRfzao�R NrAt
Miami Shores, FL 33138
ACORD 25(2011MIM 01IM2010 ACORD CORPORATION. A8 rights reserved.
INS026 PMOM)m The ACORD name and logo are registered mamas of ACORD
JEFF ATMIM sTaT�
CHIEF FIMaaMI. DEPARTUMM OF FINIMICIAL SERVICES
WMMOFWIONCBW OWDODAIM
••COMMA-M OF>1ACMU TO BE EMAFr FRM FUWM WOMOM COWWWTM LAW••
TRY
Tills QeMm so Ila d beer has elected 10 be SOMP ftM F bdde WbrMW COMMafitan 18W.
EFFECTIVEDATE: IOAMrA14 01PHtA7ION DATE lorM ms
PERSON: YANES JOSE C
FEIN: 205350894
BUSSIMM NAME AND AVIVIRFAM
JURE C YANES ASR CONDI I UNING&APPLIANCES SERVICES INC
1021 NE 132ND ST
NORTH ML40 R. 33161
SCOPES OR BUONO=OR TWOM
HEMING.VENTILATION.
Ap 4XWD
Pncaampsf4j:F.s.aadbmrasaonehaetaeBmeaawbisd�apmrOr�g a absddeetlan uraedOrt
msrnaRaamrsrbdr I manddsa6wplar_Fisa�tbOb4F.�.tia�ae�del�monbbsmaroaly'
vAmftsmpv*fvmbmdussiarftftWWcn*vnaiBeatgiii®oabba61E0mpf PaaBaBtQlD t (73),E.S..Npgbedeb +bbs
ale�aa�aplasdTonbbsafaa�ot alaSleaotiJaaltntla��da�+b�eSbydbsnaSoeor2lebbed4re
Sepnammmeremmear an 1mmbnWWmftGW twhommaects, 01 Tfad8pWhaabda8mWdWa
CERTWATE tF ELEcnm TO BE E7EWT WASM OF 12 QUESTMS9(MD)4'13-
T�
JOSE C. YANES AIR CONDITIONING&APPLIANCES
1021 N.E. 132D. STREET
NORTH MIAMI, FL. 33161
TEL: 786-683-9345
12/15/2015
State of Florida
Dade County,Florida
Before me this day personally appeared: Jose C. Yanes,who being sworn,deposes and
says:
That he will be the only person working on the project located at:
137 N. E. 105TH. ST.
Miami Shores,F1.33138
Sworn to(or affirmed)and subscribed before me this l Vh Day of December,2015 by:
Personally kno
OR Produced Identification
Tvae of Identifi tion Produced
i of Notary
s 'VY4
�M X04 ��
rsear ut1
■n� nm
Miami shores Village
z2 �a Building Department
fi R 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305)756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
A
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: Z1712�
Ow e
State of Florida
County of Miami-Dade ,/
The going was acknowledge before me this day of ,20�.
--�
By 0 s personally known to a or has produced
as identification.
Notary:
.-
SEAL: ' ;' G
U