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MC-16-483Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. MC -2-16-483 Permit Type: Mechanical - Residential Work Classification: Addition1Aiteration Permit Status: APPROVED Issue Date: 3/11/2016 Expiration: 09/07/2016 Parcel Number Applicant 124 NE 96 Street Miami Shores, FL 33138- 1132060132690 Block: Lot: MICHAEL PUCHADES LOURDE; Owner Information Address Phone Cell MICHAEL PUCHADES LOURDES 124 NE 96 Street MIAMI SHORES FL 33138- 124 NE 96 Street MIAMI SHORES FL 33138- Contractor(s) DJ METZELAR A/C Phone (305)491-1995 Cell Phone Valuation: Total Sq Feet: $ 400.00 00 Tons: Additional Info: Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved: : In Review Type of Work: ONE NEW DUCT ONE NEW OUTLET Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.25 $2.25 $0.20 $150.00 $3.00 $0.80 $159.10 Pay Date Pay Type Invoice # MC -2-16-58770 02/22/2016 Check #: 4022 $ 50.00 $ 109.10 03/11/2016 Check #: 1231 $ 109.10 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Final Rough Duct Review Mechanical Underground 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 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. Futhermore, I authorize the above -nam -d contractor to do the work stated. March 11, 2016 Authorized Signature: Owner / Applicant / ♦. trac or Agent Building Department Copy Date March 11, 2016 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 C 1 6- 48 z Inspection Number: INSP-253393 Permit Number: MC -2-16-483 Scheduled Inspection Date: December 28, 2016 Permit Type: Mechanical - Residential Inspection Type: Final Owner: LOURDES STEPHEN, MICHAEL Work Classification: Addition/Alteration Inspector: Perez, JanPierre DI 1!`NAr1CC Job Address:124 NE 96 Street Miami Shores, FL 33138 - Project: <NONE> Contractor: DJ METZELAR A/C Phone Number Parcel Number 1132060132690 Phone: (305)491-1995 Building Department Comments ONE NEW DUCT ONE NEW OUTLET 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. December 27, 2016 For Inspections please call: (305)762-4949 Page 2 of 32 BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION 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 2 0/g �7 Master Permit No. % //5 Sub Permit No. MC/i5 94:173 ❑ EXTENSION ❑RENEWAL ❑ PLUMBING ECHANICAL ❑ PUBLIC WORKS CHANGE OF CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: 1 et 0: `i b�\ i �3 �7 City: Miami Shores County: Miami Dade Zip: 1 `meg Folio/Parcel#: Is the Building Historically Designated: Yes NO ._....--• Occupancy Type: Load: Construction Type: Flood Zone: �► e -Fo n-7 OWNER: Name (Fee Simple Titleholder): I.r?is�S �j rna i e, A.) Phone#:. — 33L �350� Address: 1741- N 9t��(L �^ City: rCytj .i.l �`(/�",,�i, State: Zip: (3 BFE: FFE: Tenant/Lessee Name: ky/4 Email: k1, L‘G(,t.a P� -'S' • ez Phone#: CONTRACTOR: Company Name: .sem \-1-6T LA -0 A -C Phone#: Address: 7--Z- c \J City: ket.Ak State: cA.. Zip: Q53 (F) Phone#: C•)4}S J 99 L I— 0 J Qualifier Name: -77 (C State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: tfP(...V, A --(A 0 t7CL Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 400 Square/Linear Footage of Work: J cZ cl Type of Work: ❑ Addition ❑ Alteration . New ❑ Repair/Replace ❑ Demolition Description of Work: 7IV G (X)119, a J(_ GJ / 0 N d /Vt-(n 1 (C) 0 ( ( Specify color of color thru tile: j� Submittal Fee $ ...9-0 -0(10 Permit Fee $ 15 0.9D CCF $ 0 ` Ga_ Scanning Fee $ 3' w Radon Fee $ . - --5—.DBPR $ - `)j Notary $ Technology Fee $ 0 ' 6CD Training/Education Fee $ O .- a0 Double Fee $ P 4 Structural Reviews $ Bond $ P TOTAL FEE NOW DUE $ 1 O T . 10 CO/CC $ 0 (Revised02/24/2014) 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. OWNER or AGENT The foregoing instrument was acknowledged before me this C\ day ofFC1--)rG , 20 (O , by t• -A �� ( kid/6(10A° is pgrsonaflly_known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: cute_ r\c0 1 GI 7F A -1,.14--1 CUES l7 -..E:. Jt,,. 21, 2017 E_ :c i . 1,1 Cf::3.nstr rco Signature ONTRACTQR _ 6_4 The foregoing instrument was acknowledged before me this 1� day of DifttAC-1 , 20 IU , by t / 1 i , Lie- .Q (CJc who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: -�f � / Print: r -rt € -C -.� i " /v ca,,Q Seal: i -- 41 MYC•C. ;',1OL8644 iiE.i- ,E'. J1A 21, 2017 L.-%- Bca.a,..,. tl 1_t£t,.e'n-_;-rc0 *********************************************************************************************************** APPROVED BY (Revised02/24/2014) Ilf�r(s Examiner Zoning Structural Review Clerk I 1, LICENSE NUMBER KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The CLASS A AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS .Expiration date. AU.G 31. 2016 METZELAR, DICK si DJ METZELAR AC LLC 225 NE 108TH ST MIAMI FL 33161 ISSUED C;7/29/2014 DISPLAY AS REOURED SY LAW SEQ # L1407290001232 AC'# 6201274 DATE 07 13 2012 ':,THIS DOCUMENT HAS A COLORED BACKGROUND-•„MICROPRINTINGLINEMARK?".PATENTED PAPER' STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NBR BATCH NUMBER 110415545 The CLASS A AIR Named below I -Under the pr. Expiration ate: 1 TIONING ERTIFIED isions of Chapter 48 •, AUG 31, 2014 1 • 0 METZE DJ MET 225 NE MIAMI DICK J ELAR AC LLC 108TH ST RICK SCOTT GOVERNOR FL 6 1 CTOR S. DISPLAY AS REQUIRED BY LAW SEQ# L].207130 KEN LAWSON SECRETARY 000272 Local Business Tax Receipt Miami -Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY 5754883 BUSINESS NAME/LOCATION D J METZELAR AC LLC 225 NE 108 ST MIAMI FL 33161 OWNER D J METZELAR AC LLC Worker(s) 1 RECEIPT NO. RENEWAL 2794148 LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SPEC MECHANICAL CONTRACTOR CAC054090 PAYMENT RECEIVED BY TAX COLLECTOR $82.50 10/05/2015 CREDITCARD-16-000895 This Local Business Tax Receipt only confines payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles — Miami—Dade Code Sec 8a-276. For more information, visit www.miamidade.aov/taxcollector ACRD �-- CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 3/7/2016 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 Ileu of such endorsement(s). PRODUCER Assure -lis 1880 NE 163rd St North Miami Beach FL 33162 CON fACf NAME: Kathryn Meriino PRONE FAx (ac, No, Ext): 335-956-7818 ' (Al, No): 305-956-5946 E4vuuL ADDRESS: katym@assureus.us INSURER(S) AFFORDING COVERAGE NAJC # INSURER A : Ascendant Commercial Insurance COMMERCIAL GENERAL LIABILITY INSURED D J Metzeler AJC LLC 225 NE 108th Street Miami FL 33161 INSURER B : GL -47665-0 INSURER C : 04/07/2016 INSUP.ER 0 : S 1,000,000.00 INSURER E : INSURER F : REVISION NUMBER • ' THIS IS TO CERTIFY THAT THE POLICES 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 NSURANCE 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 AUUL INSD UtsK WVD POLICY NUMBER POUCY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) UMrTS A J COMMERCIAL GENERAL LIABILITY GL -47665-0 04/07/2015 04/07/2016 EACH OCCURRENCE S 1,000,000.00 CLAIMS -MADE OCCUR DAMAtzt +u ttcN i to PREMISES S 100,000.00 J MED EXP (Any one person) S 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GEN% Ni AGGREGATE POLICY OTHER: LIMIT JECOT- APPLIES PER: LOC GENERAL AGGREGATE S 2,000,000.00 PRODUCTS - COMP/OP AGG $ 1,000,000.00 S AUTOMOBILE -- _ — _ LIABILITY ANY AUTO ALL AUTOS OW`IED HIRED AUTOS �_ _^AUTOS CHEDULED SAUTOS NON -OWNED COMBINED SINGLE LIMIT- (Ea accident) s BODILY IN.URY (Per person) S BODILY INJURY (Per accident) S t'FZOYEN 1 r UAMASct (Per accident) 5 S _ UMBRELLA LIAB_ EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ DED RETENTION S S WORKERS COMPENSATION AND EMPLOYERS' uABILtrY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) 11 yes, describe under DESCRIPTION OF OPERATIONS below N ! A eti{ STATUTE 01 H- ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CAC 054090 I - -- City of Miami Shores Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 V091.V•.S.V\, WV. SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kai-kryn Mtr(L..o ACORD 25 (2014/01) 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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: 3/20/2014 EXPIRATION DATE: 3/19/2016 PERSON: METZELAR DICK FEIN: 579747843 BUSINESS NAME AND ADDRESS: D J METZELAR NC LLC 225 NE 108 STREET MIAMI FL 33161 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR-COND 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 to be exempt shall be subject to revocation if, at any time after the riling 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 DJ METZELAR AIR CONDITIONING 225 NE 108TH STREET ML9MI, FL 33161 February 8, 2016 State of Florida County of Miami Dade Before me this day personally appeared Dick J Metzelar who, being duly sworn, deposes and says: All work to be performed by Dick J Metzelar or licensed and insured subcontractors. Sworn to (or affirmed) an • s ribed before me this V day of tb^ 0 KO by Personally know Or Produced Identification Type of Identification Produced Print, Type or Stamp Name of Notary , G� Cu1:1Rv3 S133:, t;X28344 ,.;j;; 21, 2317 iSt£' i31(!'Ur3T',Cu Notice to Owner — Workers' Com p IVliami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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. Signat Owner State of Florida County of Miami -Dade G -G The foregoing was acknowledge before me this -1 day of T eirk--Grli 20 ((9 . By LA (CDC FAL V c C'1/4A2 who is per all known to me or has produced as identification. Notary: SEAL: ""' "t1".7,1`:7 „ ii• • ^,I: . , �: 028344 •i . 21,1.017