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MC-16-1904 Inspection Worksheet Miami Shores Village L 10050 N.E.2nd Avenue Miami Shores, FL / Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-262801 Permit Number: MC-7-16-1904 Scheduled Inspection Date: October 31,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: PAGER, IRENE Work Classification: A/C Replacement Job Address:10070 N MIAMI Avenue Miami Shores, FL Phone Number (786)382-8091 Parcel Number 1131010210100 Project: <NONE> Contractor: ALL STAR HOME SERVICES Phone: (786)270-1860 Building Department Comments EXACT AC CHANGE OUT 2.5 TON Infractio Passed Comments INSPECTOR COMMENTS False TO CLOSE EXPIRED PERMIT MC 15-3108 1 1 - 0 L'D 3 l 1 1� Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. October 28,2016 For Inspections please call: (305)762-4949 Page 6 of 31 V 3 l * �9 o, Miami Shores Village "el 10050 N.E.2nd Avenue NWorkClarsst i �'I J OWC60*111 Miami Shores,FL 33138-0000 OoVE :: Phone: (305)795-2204 � ..: ie Ctatw 7181201 _� Expiration: 01/14/2017 Project Address Parcel Number Applicant 10070 N MIAMI Avenue 1131010210100 IRENE PAGER Miami Shores, FL Block: Lot: Owner Information Address Phone Cell IRENE PAGER 10070 N MIAMI Avenue (786)382-8091 MIAMI FL 33150-1216 Contractor(s) Phone Cell Phone Valuation: $ 5,414.00 ALL STAR HOME SERVICES (786)270-1860 _..... .......m .,.., ,_. _.,....,_., Total Sq Feet: 0 Tons:2.5 Available Inspections: Additional Info:EXACT AC CHANGE OUT 2.5 TON 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 $3.60 Invoice# MC-7-16-60526 DBPR Fee $2'84 07/08/2016 Check#:13463 $50.00 $163.77 DCA Fee $2.84 Education Surcharge $1.20 07/18/2016 Check*13483 $ 163.77 $0.00 Permit Fee $189.49 Scanning Fee $9.00 Technology Fee $4.80 Total: $213.77 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 AFFI AVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructionRao Futhermore,I authorize the above-named contractor to do the work stated. July 18, 2016 Anature:Owner / Applicant / Contractor / Agent Date Building Department Copy July 18,2016 1 ' 's Miami Miami Shores Village V n J it � Building Department JUL os 216 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 S.(M FBC/�2 i0k4 BUILDING Master Permit No. N G l�` q0 PERMIT APPLICATION Sub Permit No. BUILDING ❑ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ORENEWAL PLUMBING ® MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION F-1 SHOP ,�I / � CONTRACTOR DRAWINGS JOB ADDRESS: 10610 <�tS°I1� o"``4m "- City: City: Miami Shores County Miami Dade Zip: q3 i5o Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): J-an Q Paae!' Phone#: Address:_ /w U �-4' �^ A e Ll City: &�Oul 36A State: �1 Zip: 03/5-v- Tenant/Lessee Name: Phone#: Email: (� CONTRACTOR:Company Name: �l� / JIM(ps Phone#: Address X4'30 oy City rx1040jState: I 1 Zip: i Qualifier Name: bTyrWlY Phone#: State Certification or Registration#: 04C(8/63-3Z 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 ❑ Alteration ❑ New ["Repair/Replace ❑ Demolition Description of Work: o�" a1 'to 'V F Specify coor of'color thru tile: Po Submittal Feed Permit Fee$" C '(off "CO/CC$ t ; - �' I .$,' ..�' Notary$ JV Scanning Fee$ Radon Fee$ DBPR Technology Fee$ A • go Training/Education Fee$ Double Fee$ )01 Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ I ° (Revised02/24/2014) r 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. Signatu Signaturem OWNER or AGENT C CTOR The(foregoing instrumentwasacknowledged before me this The foregoing instru ent was acknowledged before me this day of -3 l�y 20�,by day of 20 I by e l`le- VCA C42T—who is personally known to 6 :TYW 1 who 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. NOTARY PUBLIC: NOTARY PUBLIC: (A�Sign Sign: Print: Print: l Seal: ";PFj-'. ERICA JOCELYN FELICIANO o � , ERICA JOCELYN FELICIANO Seal:Notary Public-State of FloridaNotary PUMIC-State Ot FloridaCommission d!FF 973738Commission#►FF 973736M�Comm.Expires Mar 25,2020 My Comm.Expires Mar 25,2020 * �t �x ** a* x� Pow APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r OR 93 Gr Miami Shores Village Building Department ■■■ 4■■■ 10050 N.E.2nd Avenue Miami Shores, Florida 33138 � Rrop 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 n'�o//]]t,,acceptable. Job Address(where the work is being done):_ zjo� N AXj6TA AI/Qfi a City: Miami Shores Village County: Miami Dade Zip Code: �-3/60- 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 2k ,Pc) 3Q 0&(6 AHU or PKG. UNIT MODEL# T36J 7 5TA&jr-A 5C 130 60/C COND.UNIT MODEL# ft KW HEAT �✓�� 01) IS NOM TONS off, !(o 'See r AHU 3b CU 14 PKG 1)M.C.A AHU CU PKG AHU 30 CU u PKG 2)M.O.P AHU 30 CU dS'PKG AHU L)CU Z'OPKG 3)VOLTS AHU ZYaCU eOKG PKG UNIT / / PKG UNIT ! EER/SEER Ap YES O REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES " NO YES O NEW 4"CONCRETE SLAB YES N0 YES N W NEW ROOF STAND YES NO YES • IVO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity(Wire Size): -k 00 2. Maximum Overcurrent Protection (Fuse/Breaker Size): / 7 3. Voltage of Circuit 008/240/480): dA0 - 4. Size Disconnecting Means: Contractor's Company Name: S' Phone: 3067 2 /560 State Certificate or Registration No. 0A?/8/b 33 Z Certificate of Competency No. Signature Date: 0 ) O e gnature) (Revised02/24/2014) DATE IMM/DD/YY" AC40R"® CERTIFICATE OF LIABILITY INSURANCE 6/21/2016 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 CONTACT NAME: Nancy Munoz Brown & Brown of Florida, Inc. PHONE (305)247-5121 FAC No:(305)248-8543 dba T.R. Jones & Co. E-MAIL .nmunoz@bbinsfl.com 1780 N KYome Ave INSURERS AFFORDING COVERAGE NAIC# Homestead FL 33030 INSURER A:As sociated Industries insurance Co 23140 INSURED INSURER B All Star Home Services, inc. INSURERC: 29790 Old Dixie Highway INSURER D: INSURER E: Homestead FL 33033 INSURERF: COVERAGES CERTIFICATE NUMBER:2016 WC 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1-1OCCURPRREEMA SES GETo Ea occu encs $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jECOT- F—] LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COEaMBINEaccidentD SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAR H OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION R STATUTE ER H AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E.L.EACH ACCIDENT $ 1,000,000 A (Mandatory in NH)EXCLUDED? AWC1056421 1/1/2016 1/1/2017 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) Nature of Buisness: A/C, Electrical, Plumbing maintenance and installation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE T Jones Jr./LOUMAR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) DATE @=D/YYYY)' ACoRV® CERTIFICATE OF LIABILITY INSURANCE 6/3/2016 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 POUCIES. 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(!Q. PRODUCER - 0 Ashley Stefanell _ Brown & Brown of Florida, Inc. PHONE (305)247-5121 FAX No):(305)248-8843 No.E4,dba T.R. Jones & Co. DR :astefanell@bbinsfl.com 1780 N Krome Ave INSURER AFFORDING COVERAGE NAICB Homestead FL 33030 INSURERA:Associated Industries Insurance Co 23140 INSURED INSURER B. _---_--.-- All Star Home Services, Inc. INSURERC• 29790 Old Dixie Highway INSURERO: INSURER E• Homestead FL 33033 1 INSURER F: COVERAGES CERTIFICATE NUMBER:2016 WC 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 ADDL SU R POLICY EFF POLICY EXP LIMfrS T TYPE OF INSURANCE POLICY NUMBER COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F—I OCCUR PREMISE Ee occunen $ MED EXP(Arty one rsgn) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECaf FLOC PRODUCTS-COMP/0P AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDAUTOSULED BODILY INJURY(Per acddent) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS t -- UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO I I RETENTION$ $ WORKERS COMPENSATION R SMATUTE I I ER AND EMPLOYERS'LIABILITY '-'—� Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N/A A (MendaMryInNH) AWC1056421 1/1/2016 1/1/2017 E,LDISEASE-EAEMPLOYE $ _ 1 000,000 If yes,desTIcribe under DESCRIPON OF OPERATIONS below F. DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remaft Schedule,may be attached d more space Is required) CAC1816332 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Building Department THE EXPIRATION DATE THEREOF, N0110E WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORRED REPRESENTATIVE T Jones Jr./LOUMAR ` ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD a INS025(2ouo1) This combination qualifies for a Federal Energy . Efficiency Tax Credit when placed in service between Feb 17, 2009 and Dec 31, 2014. Certificate of Product R14afttings AHRI Certified Reference Number: 7426795 Date: 12/15/2015 Product: Split System: Air-Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: 14AJM30 Indoor Unit Model Number: RH1T3617STAN Manufacturer: RHEEM SALES COMPANY, INC. Trade/Brand name: RHEEM; RUUD;WEATHERKING �S Region:All (AK,AL,AR,AZ, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, IA, IN, KS, KY, LA, MA, MD, ME, Ml, 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 name: x I1 Manufacturer responsible for the Mt of this system combination Is RHEEM SALES COMPANY,INC. Rated as follows in accordance`with`AiiRl Standard;:210/240.2008 for,Unitary Alr-Conditloning"and Air-Source Heat Pum Equipment and subject to verificetio of rating accuracy by AHRI-sponsored. Independent;,third party testing: 11' 3 7 Ct�OlitlgCrpaClty`{$ tit 2#$0E3* EER Rating(Cooiltl+c) 1 tat} SEED"Rating (Cooling): 16: * ..... :. 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.ahridirectory.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 make life 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. 130946723026545607 " ©2014 Air-Conditioning, Heating,and Refrigeration Institute COtTIFICATE NO.: N / s ,yhR, r Miami Shores Village Building Department n.. 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 1not acceptable. 1/ Job Address(where the work is being done): 10b-10 1�.1 uAb r(iw 1 �V t City: Miami Shores Village County: Miami Dade Zip Code: 3n 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 d Deo AHU or PKG. UNIT MODEL# COND.UNIT MODEL# 41,a5z97 3D o KW HEAT NOM TONS & 5 ee it AHU,z4,CU 17 PKG 1)M.C.A AHU,& CU O PKG AHU ) CU .V PKG 2)M.O.P AHU 0 CU KG AHU OCU PKG 3)VOLTS AH 0CURZ;PKG PKG UNIT / / PKG UNIT EER/SEER YES REPLACING DUCTS YES O NO REPLACING THERMOSTAT NO YES NEW 4"CONCRETE SLAB YES YES NEW ROOF STAND YES 99--) YES O NEW RETURN PLENUM BOX O 1. Minimum Circuit Ampacity(Wire Size): __Afi? 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3 Z) 1 3c) 3. Voltage of Circuit(208/240/480): .?Yy 4. Size Disconnecting Means: c I I , Contractor's Company Name: �, CI 0 I l[r�� /I'1 =Tf 1 V Phone: 16 LO c�-1 .1 8 State Certificate or Registration No. 35ZCertificate of Competency No. Signature �� s Date: J (Q is sig(ature) (Revised02/24/2014)