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MC-13-1244Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: MECHANICAL JOB ADDRESS: ECt' JUN 0 5 2013 uL FBC 20 j Permit No. MC) 13— l09.q1- Master Permit No. %3 774, City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder): Address: City: Tenant/Lessee Name: Email: NO Flood Zone: Phone#: Zip: 33(3 Phone#: CONTRACTOR: Company Name: ca1KQ, b Phone#: , age, -au a(3 Address: City: Qualifier Name: State: LI Zip: 3_�ISri Phone#: 45(9.� . (9f) 4 State Certification or Registration #: CAC,) l y fl') Lp Certificate of Competency #: Contact Phone#: 5CU Lt.a15 Email Address: pet (VVIlJNc�Q�S,¢• OC,C� 'Q JT •'�T Y DESIGNER: Architect/Engineer: 60 Value of Work for this Permit: $ I ?ILinear Footage of Work: Type of Work: ❑Address ❑A1erasion w ❑Repair/Replace ODemolition Description of Work: 75/( /SIL—J Qp/T' S'i i $ /�t .�� �� !2 iggi/c ** ****** :* ***********************/*-***Fees******************************************** Submittal Fee $ Permit Fee $ (0 DO 4®b CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 3 6\ 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 coin encement must be posted at the job site for the first irztspe tion which_occurs_seven (7) days after the building permit is issued. n the absence of such posted notice, the inspection ill no ved a a reinspe ion fee will be charged. Owner or Agent The foregoing instrument was acknowledged before me this The fore•oing instrument was acknowledg I /s � day of , 20 /. , by 4- IT J& (�•-<( �� d[ , day of who is ersonally know o me or who has produced who is pe As identification and who did take an oath. Signature Contractor NOTARY PUBLIC: G '''.13( c 1(14 Q v t" LAURA BOURN BURS ER * MY COMMISSION # DD 859461 EXPIRES: 9, 1"00FFvos``° -Bonded TL Budge!June Notary Services My Commission Expires: , 20r by sonally know before me this to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Co on Expire ;;,Y :y •, JENNIFER GULLA ', ti. ;= MY COMMISSION # EE 873381 .d EXPIRES: March 24, 2017 �•: ,fir f1 SlpT Bonded Thai Notary Public Underwriters ************************************ II***g*******************************************.... * **x x* s *x**x*x APPROVED BY L U tans Examiner Zoning Structural Review (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Clerk Jul.12.2013 12:40 PAGE. 1/ 1 CERTIFICATE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. pdkses of Insurance ilsted below have been Issued to the insured named above end' are (n force at this time. Notwftttstending any requirement, term or condition of any contract or other document with respect to which this certlflcate may be issued or may perta'n, the insurance afforded by the policies described herein Is subject to all the terms, exclusions and condltions oI such poHdes, Ca LTR oilIarty of th COMPANIES AFFORDING COVERAGES: FLORIDA FARM BUREAU INSURANCE COMPANIES POLICY EFFECTIVE DATE (MM/DD/YY) P.O. BOX 147030 Company Letter A: GAINESVILLE, FLORIDA 32614-7030 CPP 9524064 02/26/13 Florida Farm Bureau General Ins. Co. NAME AND ADDRESS OF INSURED; Company CCotter PALMETTO BAY AIR CONDITIONING SERVICE INC ' B: 11271 SW 161ST TER MIAMI FL 033157 �tle Florida Farm Bureau Casualty Ins. Co. pdkses of Insurance ilsted below have been Issued to the insured named above end' are (n force at this time. Notwftttstending any requirement, term or condition of any contract or other document with respect to which this certlflcate may be issued or may perta'n, the insurance afforded by the policies described herein Is subject to all the terms, exclusions and condltions oI such poHdes, Ca LTR oilIarty of th TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/yy) ALL LIMITS IN THOUSANDS A General L1011149:General -'Commerdal General Liability (� Form) rrenceJ Owners a Contractor's Protective 7 Farmers Personal Liability CPP 9524064 02/26/13 02/26/14 Aggregate $ 2000 Productecompleted operations aggregate $ 2000 Personal aAdvertlsigInjury $ 1000 Each Occurrence $ 1000 Fire Damage (Any one fire) $ 5 0 Nadal Expense (Any ora parson) $ 5 • Automobile Liability: My auto : All owned autos ,:i Scheduled autos _ice autos =1 Non -owned autos Combined Single Limit $ Bodily Injury (Per Person) $ Bodily Injury (Per•Accident) $ Property Damage $ Excess Liability: 1 Umgrella Form .I otter tten Umbralia form Otx�rence $ Aggregate $ Employers Liability; Farm Employer's Uability l Farm Employee's Medical $ (Each ) Employes) t'ittier.`°'' s DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES: RE: WORK PERFORMED BY OUR INSURED CANCELLATION• Sh d e above described policies be cancelled before the expiration date thereof, the issuing 66mpany will endeavor to mail 10 days written notice to the below named certificate holder, but failure to mail such notice shall Impose no obligation or liability of any kind upon the oompany. NAME AND ADDRESS OF CERTIFICATE HOLDER: MIAMI SHORES VILLAGE BUIILDING DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COUNTY CODE' 13 DATE ISSUED 05/20/13 Serviced by DARE County Farm Bureau DAWN L BAIRD, CLU AUTHORIZED REPRESENTATIVE 93.7-692 (Rev. 5/93) Jul.09.2013 15:14 pry t, A k`UALA-- - '505 q5(0. 1Y1 0 PAGE. 1/ 3 AC"ORii®DAT! CERTIFICATE OF LIABILITY INSURANCE (tiIM/OD(YYYY) 5/20/2013 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 poilcy(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 Eastern Insurance Group, Ino. 9570 SW 107 Avenue _ tg CT David M. Lopez Peittemt (305) 595-3323( . No}. (9Ob)liyn-7130 :carQesaterninsuranoe.net Suite 104 Miami FL 33176 IN!luRER(8) AFFORDING COVeRAal, NAIL $ INSURER Associated Industries Ins. INSURED Palmetto Bay Air Conditioning Service, Inc. 11271 SW 181 Terrace Miami FL 33157 INeURER a : INSURER cI EACH OCCURRENCE INSURER 0: INSURER s : COMMERCIAL GENERAL LIAB(LITY INSURER P _ CERTIFICAT— • 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 lima wet) POLISrYNUMBER ,i •:1'.141 J. 1 .it: l LIMITS GENERAL UABIUTY EACH OCCURRENCE T COMMERCIAL GENERAL LIAB(LITY DAMAGE TO REN ftp PREMISES (Ee oagerenoe) CLAIM8-MADEri OCCUR MED EXP (Any one person) 5 i PERSONAL & ADV INJURY $ GEML AGOREGATE LIMIT APPUES PER: �. GENERAL AGGREGATE PRODUCTS - CCMP/OP AGO S � JECTPRG- n LOC AUTOMOBILE LIABILITY EOMBBINE0 DINGLE ['mi- aow s ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per persoq) $ AUTOS AUTOS BODILY INJURY (Per eoalden1) 5 HIRED AUTOS �TNON�VIR�ED PRbPERTY (SAMAdE (Per aaaklenll $ - $ "--- UMBRELLA Ilia EXCESS UAB OCCUR EACH OCCURRENCE 3 CLAIMS -MADE 1 AGGREGATE $ DED 1 RETENTIQN$ $ A WORKERS COFPENEATION AND E1. LOYER$ UABIUTY YIN WC eTATU- OiN. X I TORY LIMIT; I 1 ER ANY PROPRIETOR/PARTNERA_XE�CUTIVE OFFICER/MEMBER CXCLUDGD7 N / A El. EACH ACCIDENT ^9 C 01000 ((NMyasnedatoryRIM In NH) under OPERATIONS $ WC1016721 9/30/2012 9/30/2013 E.L. DISEASE -EA EMPLOYER '8 1,000,000 DESCRIPTIONIbelow E.L. D18L'ASQ - POLICY LIMIT f 1,000,000 DESCRIPTION OF OPERAYIoNs 1 LOCATIONS / VEHICLES (ABSch ACORD 101. AGOISanal Remarks Schedule, 0 mere sped* Of requlnd) Air Conditioning Contractor CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2 Avenue Miami Shored, FL 33138 ACORD 26 ((2010105) INR028/gymrim m SHOULD ANY OF THE ABovE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 80 DHUVERED IN ACCORDANCE Wr1-H THE POLICY PROVISIONS. AUTHORIZED REPRBSBNTATIVG David Lopez/AMANDA ®1968-2010 ACORD CORPORATION. AN rights reserved. TIB. Anostn name And Innn'rob ernitzyeaned marlre of Af:t7Rn Jul.09.2013 15:14 AC# 6199413 w.. . •.,....._ • ...... Y HtS DOCUMENT HAS A COLU1JED BACKGROUND • MIc )PRINTING • LINEFdARK {'AI. ENTED PAPEI41 PAGE. 2/ 3 STATE.OF FLORIDA' DISPARTMISNI or CQgNTNJ RLIC REGULATION RYENSING BOARD SE(,i# L12071200668 UANUPALH R LI NPR 07/1212012 � 12 12800765b CAC1$147T�.' The CLASS A AIR CONDITIONING CONTRUTGR' Named beiow :IS CERTIFIED Under the provisions of Chapter Expiration date: AUG. 31, .2014 $EERBOTT,EDWARD M ' PALMETTO BAY AIR CONDITIONING - VI: 10404 SW 187 STREET MIAMI FL 33157-491, RICK SCOTT' GOVERNOR .DISPLAY.AS..REAUIRF BY..LAW ........ REN LAWSON SECRETARY Jul.09.2013 15:14 ti 568667-1 THI81S NOTA BILL•.DO NOTPAY 14SFRV 8INC IWOVK CONDITIONING 1 44 00SW 187 ST 5 LININ DADE COUNTY °VOMETTO BAY AIR CONDITIONING mompiess rout wort rr woo rs war A LOCAL secarftrvilitCNANICAL CONTRACTOR DOEIF NOT Aran bfe zannfirgrig out iteauuOOLronv OH pcsuarr Monk ANY Prenrel Noy_ itED BY LAW 7 a At tarkiroor s 4uAugc,4 6 15000 12 000075.0051 SEE DTHEg BIDE RENEWAL STATErenr814776 583124-p PAGE. 3/ MR8T.CLASB 11.8. POSTAGE PAID PERMIT AMN' 281 WORKER/S 1 DO NO7 FORWARD P SERVICEOINC Y AIR CONDITIONING EDWARD MEERBOTT PRESIDENT 11271 SW 181 TERR MIAMI FL 33157 hJh limoliJ,Irl,,,1didl bul}nhhishnimfl 3 • r Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: (iiDING) JOB ADDRESS: 14/ -r4„slf.-62/A aZ 7✓�j City: Miami Shores II APR 1 6 2013 1,0 BY: FBC 20 Permit No. C C/ I -I-4 Master Permit No. ROOFING County: Miami Dade Zip: .d.Sr. Folio/Parcel#: Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder): — DV 5 LL,C Address:„,Q /Y` 9 Zip: .313 l � !'!"� ICLEphone#:& Flood Zone: Phone#:315 City: /7/14/1/ S[NOR-P.5 Tenant/Lessee Name: Email: State: CONTRACTOR: Company Name: MANZ”, C aa,/ &A/$r4'4t / t,A/ id'hone#: 9.47-9- 3/6- /2 54Z Address: /7 56 S'g/vSg /' iv (}c'-. City: /u©�' A4I (L!M I State: F �. F p: 5-3/g % J Qualifier Name: A VJ,P trt.N �,P rdt` Q 1J Phone#: l - 00 State Certification or Registration #: CSG '0..779 Certificate of Competency #: /�. V 3/ - / Z z y dilc 50 . . - , / Contact Phone#: �( y � Y Email Address. !T ONS /��% iC�• NYS DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ L'4-, a Vi Square/Linear Footage of Work: Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: _ w gig * , ak-- L _ _A. e., -- '. f 0 G il jJ �_: Color thru tile: ***************************************Fees********,*********************************** cx) Permit Fee $ 6‘260 CCF $ �' CO/CC $ WD10 Submittal Fee $ Scanning Fee $ 11" l/ Radon Fee $ Notary $ '' V Training/Education Fee $ Double Fee $ _ Structural Review $ DBPR $ S.Q J IV Bond $ echnology Fee $ 11 3' (gc, TOTAL FEE NOW DUE $ Jj 'C Bonding Company's Name (if applicable) a P 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 issuati nce of a building,permit with an estimated value exceeding $2500, the, applicant must promise in good faith that a copy of th no�tiice of�cominenc eme and construction lien law bro i . re will be delivered to the person whose property is subject to ' .4. -%e .ctertified.coW the recorded notice commencement ust be posted at the job site for the first inspe is occurs seven (7) da . after the building permit is '.sued. In the ab ce of such posted notice, the inspection nd a reinspection fee ill be charged. Sig The for day of who Signatur The fore ent was acknowledged befor 0 I , by to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: by e or who has produced As identification and who did take an oath. NOTARY ' UBLIC: Sign: Print: My Commi ion Expires: Sign: Print: My Co .min.'�at�•--•; •�01s�1! ..-- •moi if" •i• • xpifileiRES March 29. 2014 (407) 398.0153 Florldallolar 8erwoe,o®m e *************************************************************************.r1**** *********************** Plans Examiner Structural Review (Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009XRevised 3/15/09)(Revised 7/10/2007) y Zoning Clerk IVliami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: /-t/Critii,,c Coe s/ c , BUSINESS ADDRESS: /7 8'o $qiv .tet 1/uJ CITY AVo 44 jv1» t STATE FL ZIP CODE 3 3/ ?/' BUSINESS PHONE: ( g57') 3/G ,• /2 V FAX NUMBER (3e $) b g S7 7 -- CELL PHONE (qCV) 5/6 11 ©7i QUALIFIER'S NAME: 4/'4e/10 7e/c 1'/ jzj 14-1 QUALIFIER'S LIC NUMBER: C 66. 0 Ste/ QO `7 E-MAIL ADDRESS (IF APPLICABLE): 10G444144,‘@ yQ I c - Cb • Created on 3119109 BY MLDV 1 RV 3/26/09 MLDV / RV 6127111 AS STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET aw TALLAHASSEE FL 32599-0783 PERDIGON, ALBERTO ATLANTIC COAST CONSTRUCTION INC 1780 SANS SOUCI BLVD NORTH MIAMI FL 33181 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better.; For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that Impact you, subscribe to department newsletters and team more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! :1 L DETACH HERE :sTATR OF ,PLRIFli4:" ?;.. ACIP, 2Q 3; 6 9:-1 EPARTMENT• OF BUSINESS AND PRS}}ESSIQ1 L ;REGULATION CGC051904 �� f ,71.6 12 128009896 CERTIFIEI ATLANTIC r• r., *ACTOR RTJi .TION : INC .. IS CFRTIFiED nuder�the provieieee of Ch.489 Fe • ibgiirmUoo date AUG :31, •20:14 1,120]:600091 . THIS DOCUMENT HAS A'COLORED BACKGROUND •'MICROPRINTING •.LINEMARK":! PATENTED. PAPER :' ACft624.3 6' S.TATE:OF. FLORIDA DEPARTMENT O BUSINESS AND PROFESSIONAL REGULATION ::.CONsyTa TION; PopsTRY LICENSING, BOARD; SEQ#L12o7i600691 DATE 07%16/2'012,: 128009:8§76 :r CGCQS1904 " BATCH NUMBER LICENSE NBR.. The GENERAL CONTRACTOR Named,.below ::IS CERTIFIED Under the provisiohe of Chapt4„` Expiration date: AUG 31, 2014 PERDIGON, :ALBERTO •. ATLANmC COST CONSTRUCTION'I 1780 SANS SOUCI BLVD NORTH MIAMI - FL 33181 RICK :SCOTT 'GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY (1 NDRtH'MIAMI FLEIRIDA City of North Miami 776 N. E.125 Street • North Miami, FL 33161 • 305-893-6511 Business Tax Receipt/Certificate of Use Issued Date: 10/1/2012 Expiration Date: 9/30/2013 Business Tax Receipt #: BT -003924 ATLANTIC COAST CONSTRUCTION, INC. ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD NORTH MIAMI, FL 33181 OFFICE: GENERAL CONTRACTOR Business Name / Address: ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD NORTH MIAMI, FL 33181 Michael A. Etienne, Esquire, City Clerk NOTICE: BUSINESS TAX RECEIPT MUST BE TRANSFERED WHEN BUSINESS IS MOVED OR SOLD. NON -TRANSFERABLE • POST IN A CONSPICUOUS PLACE • NON -TRANSFERABLE Generated by CamScanner 07-24-2012 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: PERSON: FEIN: 07/24/2012 EXPIRATION DATE: 07/24/2014 SIERRA 650891825 BUSINESS NAME AND ADDRESS: ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD NORTH MIAMI FL 33181 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR ALBERT 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 sat recover benefits or compensation under this chapter. Pursuant to Chapter 440.051121, 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 al election to be exempt shall be subject to revocation if, et say time alter 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 al any time for failure of Ibe person aamed en 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 DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 07/24/2012 EXPIRATION DATE: 07/24/2014 PERSON: ALBERT SIERRA FEIN: 650891825 BUSINESS NAME AND ADDRESS: ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD NORTH MIAMI, FL 33181 SCOPE OF BUSINESS OR TRADE t- LICENSED GENERAL CONTRACTOR F IMPORTANT OPursuant to Chapter 440.05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(121, F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed an E the notice of election to be exempt. R 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 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 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 A D® CERTIFICATE OF LIABILITY INSURANCE DATE (MMI O//3 Y) 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 ROYALTY INSURANCE GROUP 8846 SW 129 TERR 2nd Floor MIAMI FL 33176 CONTACT TonyIglesias NAME: 9 PHONN . EM). 305-233-5333 (A/C No): 1 305-359-5117 E-MAIL a en ro Icom ADDRESS: 9 �� yal nsurance 9rou p• INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: GRANADA 0 INSURED ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD. NORTH MIAMI FL 33181 INSURER B : 1066-12 INSURERC: 09/11/2013 INSURER D: $ 1,000,000 INSURER E : $ 100,000 INSURERF: • • 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 VMTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE ADDL INSR SUER WVD POUCY NUMBER POUCY EFF (MM/DD/YYYY) POUCY EXP (MM/DDIYYYY) UMITS A GENERAL XDAMAGE UABIUTY COMMERCIAL GENERAL LIABILITY X 1066-12 09/11/2012 09/11/2013 EACH OCCURRENCE $ 1,000,000 TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE POLICY LIMIT APPLIES PER: PRO n LOC JECT PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURYPer accident) ( ) $ PROPERTY DAMAGE (Per acddent) $ $ UMBRELLA UAB_ EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) H yesdescribe under DESCRIPTION OF OPERATIONS below N / A WC STATU- TORY LIMITS OTH- ER EL. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule H more space Is required) CERTIFICATE HOLDER CANCELLATION MIAMI SHORES BUILDING & ZONING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FLORIDA 33138 (305) 795-2204 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. 07-24-2012 EFFECTIVE DATE: PERSON: FEIN: 07/24/2012 EXPIRATION DATE: 07/24/2014 PERDIGON 650891825 BUSINESS NAME AND ADDRESS: ATLANTIC COAST CONSTRUCTION INC 1780 SANS SOUCI BLVD NORTH MIAMI FL 33181 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR ALBERTO * IMPORTANT: 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 ander this chapter. Pursuant to Chapter 440.05(121, F.5., 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), 1.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocatloe 0, a1 any time after the tiling of the notice or the issuance of the certificate, the person earned on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shell revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 07/24/2012 EXPIRATION DATE: 07/24/2014 PERSON: ALBERTO PERDIGON FEIN 650891825 BUSINESS NAME AND ADDRESS: ATLANTIC COAST CONSTRUCTION INC 1780 SANS SOUCI BLVD NORTH MIAMI, FL 33181 SCOPE OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR IMPORTANT OPursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election I- under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt._ apply only within the scope of the business or trade listed on Rthe notice of election to be exempt. 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 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 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWG -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 ARI® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD"YYY) 04/09/2013 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 ROYALTY INSURANCE GROUP 8846 SW 129 TERR 2nd Floor MIAMI FL 33176 CONTACTTony Iglesias loco. N . Ext): 305-233-5333 ac, No): 1 305-359-5117 E-MAIL a ency@ ro a insurance rou 'comADDRESS: INSURER(S) AFFORDING COVERAGE NAIC N INSURER A : GRANADA 0 INSURED ATLANTIC COAST CONSTRUCTION 1780 SANS SOUCI BLVD. NORTH MIAMI FL 33181 INSURER B : 1066-12 INSURER C : 09/11/2013 INSURER D: $ 1,000,000 INSURER E : $ 100,000 INSURER F : $ 5,000 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POUCY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X 1066-12 09/11/2012 09/11/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES —I POLICY n PRO- JECT PER: LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL ONMED AUTOS HIRED AUTOS _AUTOS SCHEDULED NON-0VJNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS UAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes describe under DESCRIPTION OF OPERATIONS below y 1 N / A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space Is required) CERTIFICATE HOLDER CANCELLATION DVS LLC 9501 N.E. 2nd Ave Miami Shores, Florida 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD