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MC-16-735 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 �� ? Inspection Number: INSP-267020 Permit Number: MC-3-16-735 Scheduled Inspection Date: September 14,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: LAMB, PAUL Work Classification: New A/C System Job Address:161 NE 108 Street Miami Shores, FL 33161-7037 Phone Number (786)252-4455 Parcel Number 1121160090220 Project: <NONE> Contractor: TEST AND BALANCE AIR CONDITIONING CORP Phone: (305)218-1798 Building Department Comments INSTALL ONE(1)3.5 TON UNIT Infractio 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. September 13,2016 For Inspections please call: (305)762-4949 Page 27 of 44 Parry N� � Miami Shores Village BrIf Tie: G 10050 N.E.2nd Avenue NE � � Miami Shores,FL 33138-0000 --'alit StaAPPROVED Phone: (305)795-2204 ftnt �� �AW Xill' 4_28/ 0 Expiration: 10125/2016 Project Address Parcel Number Applicant 161 NE 108 Street 1121360090220 Miami Shores, FL 33161-7037 Block: Lot: PAUL LAMB Owner Information Address Phone Cell PAUL LAMB 374 NE 92 Street (786)252-4455 MIAMI SHORES FL 33138- 374 NE 92 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 6,000.00 TEST AND BALANCE AIR CONDITION (305)218-1798 Total Sq Feet: 0 Tons:3.5 Available Inspections: Additional Info:INSTALL ONE(1)3.5 TON UNIT Inspection Type: Classification:Residential Final Approved:In Review Rough Duct Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work: Underground Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.60 Invoice# MC-3-16-59088 DBPR Fee $3.15 03/21/2016 Credit Card $50.00 $178.90 DCA Fee $3.15 Education Surcharge $1.20 04/28/2016 Check#:1085 $ 178.90 $0.00 Permit Fee $210.00 Scanning Fee $3.00 Technology Fee $4.80 Total: $228.90 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,PL BING,MECHANIC L,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certi that all the forego' g information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futh ore,I authorize t above-named contract do the work stated. April 28,2016 Authorized Signatu . Ap nt ontractor / Agent Date Building Department Copy April 28,2016 1 .. . Miami Shores Village - - --- Building Department MAR 10, 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 20A BUILDING Master Permit No. e 6 - T3 q- PERMIT APPLICATION Sub Permit No. �_ � ® 73,'5— BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL ❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS ( JOB ADDRESS: l 0 a c , C City: Miami Shores County: Miami Dade Zip: is Folio/Parcel#: ~2-13 (D --®®� 2� Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: '' FF�E/: ay OWNER:Name(Fee Simple Titleholder Phone#: �_1 `` — 6 1C Address: 2 1 1 0 & 9 City: akfs, o � Ct -eS State: \12-11" Zip: .3 3 3'c5 Tenant ssee N Phone#: CONTRACTOR:Company f lame7r- 1 + 2)P",0'JC-e_ R-k Phone#: Address: �-� 0 0 \ S City: ' 1 State: Zip: Qualifier Name: W, 0��`_-z— Phone#: State Certification or Registration#: t►�1 1 ,ty Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: k // City: State: Zip: Value of Work for this Permit:$ to Square/Linear Footage of Work: Type of Work: ❑ Addition Alteration ❑ New ❑ Repair Replace ❑ Demolition Description of Work: -�- ���'� \ 1 o A-p \� Specify color-0 rotor thru"tile~ Submittal Fee$ �� Permit Fee$ �` d `' CCF$ _ . „ ;..CO/CC$= -v• Scanning Fee$ Radon Fee$ > • S DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ 10 Bond$ TOTAL FEE NOW DUE$ (RevisedO2/24/2014) r 1 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 �l.(�P� Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was 4acrowledged before me this day of NA G--r-Gk 20 1 , by ay of 2d4 , by P who is personally known to o is 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. A NOTARY PUBLIC. NOTARY PUBLIC: Sign: Sign: Print: T . G Print: r EXPIRES:FeMttvtp 27,2018 Seal: =QViEXPIRES.: Seal: ,f, ,N�,•• i edThNtoryPu�alh e J.DVZ�I860 B9 FF 16 o oWY Fu 1eurB APPROVED BY Plans Examiner Zoning i Structural Review Clerk (Revised02/24/2014) l . ya�os Miami Shores Village Building Department .... .a.M 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 arenotacceptable. Job Address(where the work is being done): / / SVG / C S• I{A44f1, City: Miami Shores Village County: Miami Dade zip Code: 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 A NEW UNIT MANUFACTURER AHU or PKG.UNIT MODEL# COND.UNIT MODEL# Z 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 / J EER/SEER YES NO REPLACING DUCTS NO YES NO REPLACING THERMOSTAT NO YES NO NEW 4"CONCRETE SLAB S NO YES NO NEW ROOF STAND NO YES NO NEW RETURN PLENUM BOX NO 1. Minimum Circuit Ampacity(Wire Size): 2. Maximum Overcurrent Protection(Fuse/Breaker Size): 3. Voltage of Circuit(206240/480): 4. Size Disconnecting Means: Contractor's Company Name: Phone: •r State Certificate or Registration No Certificate of Competency No. Signature Date: /� (Quaff is signature} (Revised02/24/2014) 1111111i RICK i •GOIVEFOM 'V I.,��\ z � S'ECRE f/�2Y f NNW ggUEMr �a DISPLAY AS REQUIRED BY LAW L1 I i i . 1t _ 1 • i Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 6172266 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES TEST 8 BALANCE AIR RENEWAL SEPTEMBER 30, 20'f 6 CONDITIONING CORP 6436638 Must be displayed at 8355 W FLAGLER ST#164piece of business MIAMI,FL 33144 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED TEST&BALANCE AIR 196 SPEC MECHANICAL BY TAX COLLECTOR CONDITIONING CORP CONTRACTOR 90.00 09/30/2015 Worker(s) 1 CAC1815710 FPPU10-15-008444 This Local Business Tax Receipt only conli als paymeatof the local Business Tax.The Receipt is nota license, permit,are cerh7cation of the holder's quaifficatioas,to do business.Holder must comply with any governmental Of nongovernmental regulatory laws and regakenrerts which apply to the business. MJAM�a The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 8e-276. For more Information,visit wwwmjamidgdgMy&=Iiector s, !�"� � y� °%� D � ��,�, �� > To: 3057568972 From: Pinnacle Insurance 3-14-16 11:39am p, 2 of 2 CERTIFICATE OF LIABILITY INSURANCE031(MM/ D/YYYY) 4/16 THIS CERTIFICATE IS ISSUED ASA 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: Ifthe certificate holder Is an ADDITIONAL INSURED,the policypes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the pollcy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: Marcia C Alvarez Pinnacle Insurance Group In C. PHONE (305)854-9898- (305)854-9899 29 Ponce De Leon Blvd -M ILAppinnacleins comcaSt.net Coral Gables,FL 33135 PRODUCER Phone (305)854-9898 Fax (305)854-9899 CUSTOMER III*' INSURER(S)AFFORDING COVERAGE NAIC s INSURED INSURERA: Granada Insurance Company Test and Balance Air Conditioning,Corp. INSURER B: 8355 West Flagler Street#164 INSURER C: Miami,FL 33144 INSURER D: INSURER FNSURER E: I 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, �gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C��L��AIMS..pp LTRR ADDL SUB TYPE OF INSURANCE POLICY NUMBER MMMDD/YYYY MOMfDDnwy LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 0 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEIT-- PREMISES Es occurren e $ 100,000 ❑ ❑ CLAIMS-MADE Q Y N OCCUR 0185FL00073109 MED EXP(Any one person) $ 5,000 '4 0 $500 deductible 07292015 07/29/2016 PERSONAL&ADV INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER ; PRODUCTS-COMP/OP AGG $ 1,000,000 ❑ POLICY ® PRO- ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident $ HIRED AUTOS PROPERTY DAMAGE $ (Per accident) ElNON-OWNEDAUTOS $ El $ ❑ UMBRELLA UAB ❑ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ❑ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN IA ITS ER OFFICER/MEMBE EXXCLUDED? CUTIVE N/A E.L.EACH ACCIDENT $ Ifyes,d sodbeIn runder E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I I I -T DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Air Conditioning Contractor- Paul Lamb 161 NE 108 Street Miami Shores,FL 33138 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE FAX 305-756-8972 u,r 7 ACORD 25(2009/09)QF ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TESTS<-1 OP ID:MDH AC'CJRL7` 70:41/28/2016 (MM/DD/YYYY) �,.,. CERTIFICATE OF LIABILITY INSURANCE (MMID 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). PRODUCER NAME: Philip Zelman NCF Insurance Associates PHONE 305-446-5474 FAX No: 305-444-8796 8700 West Flagler Street#320 Arc No Ext Miami,FL 33174 nI oRLEss: zelman@ncfins.com Philip E.Zelman INSURERS AFFORDING COVERAGE NAIC# INSURER A:Associated Industries 23140 INSURED Test&Balance INSURER B: Air Conditioning Corp. Attn:Augustin Alvarez INSURER C: 10309 NW 9 St Circle#202 INSURER D: Miami,FL 33172 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. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMBS LTR i POLICY NUMBER MM/DD MWDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO ENTE CLAIMS-MADE FIOCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY a JECOT- E LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER _ A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N AWC10445U 04/01/2016 04/01/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A —-- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) A/C Contractor License No.CAC 1815710 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2n Ave Miami,FL 33138 AUTHORIZED REPRESENTATIVE 1? e 94 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ♦5�izc.ES iK Miami s Village Building Department u1R1DA 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 ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of �`�� ,20 1 to . By who is personally known to me or has produced as identification. J.DUIZ Notary: A = W CMMON#FF 161380 EXPIRES:Anmy 16,2D19 SEAL: ft1dW ft NPu*W*mftm