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MC-16-229Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-268070 Permit Number: MC -1-16-229 Scheduled Inspection Date: September 28, 2016 Inspector: Perez, JanPierre Owner: Job Address: 175 NW 109 Street Miami Shores, FL 33168-4316 Project: <NONE> Contractor: ATLANTIC AIR CONDITIONING Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number (786)444-2945 Parcel Number 1121360030170 Phone: (305)885-9523 Building Department Comments REPLACE 4 TON UNIT Infractio Passed Comments INSPECTOR COMMENTS g_Q False Passed INAA- Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP-251737. frank cancelled 9/26/16 September 27, 2016 For Inspections please call: (305)762-4949 Page 38 of 39 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit No. MC -1-16-229 Permit Type: Mechanical - Residential Work Classification: A/C Replacement Permit Status: APPROVED Issue Date: 6/14/2016 Expiration: 12/11/2016 Parcel Number Applicant 175 NW 109 Street Miami Shores, FL 33168-4316 1121360030170 Block: Lot: JCAS FUND CORP Owner Information Address Phone Cell Contractor(s) ATLANTIC AIR CONDITIONING Phone Cell Phone (305)885-9523 (305)216-2675 Valuation: Total Sq Feet: $ 5,000.00 1400 Tons: 4 Additional Info: Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved:: In Review Type of Work: REPLACE 4 TON UNIT Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $3.00 $2.63 $2.63 $1.00 $175.00 $3.00 $4.00 $191.26 Pay Date Pay Type Amt Paid Amt Due Invoice # MC -1-16-58474 06/14/2016 Cash $ 191.26 $ 0.00 Available Inspections: Inspection Type: Final Review Mechanical 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 respons'•' ity for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMB! 1ECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVI construction an Bu Aut cell' al the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating ping.. % • -, authorize the above-named contractor to do the work stated. - - .. � • n� ature: Owner / Applicant / Contractor / Agent ing Department Copy June 14, 2016 • Date June 14, 2016 1 � Miami Shores Village 191 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 20 BUILDING Master Permit Not 2q9/ PERMIT APPLICATION Sub Permit No./-/Cli— 7Z7 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ,MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titlehollder): � . �� I " �notW D Phone#: D `( �("i Z�� - Address: 5 606 W1I 3. CAW , I (96 )1 City: 1'\ r G v" 1 State: 1,, Tenan /Lessjjse/e Name: \ , Phone#: l� Email: `O (/� ,(�1 rVw �1/l�il(l l . c__ ^ CONTRACTOR: Company Name: /1�/viii/ / C /1/, Address: A2.470 • U/ /1,-3 fl/e City: /71-,.--4:?'"/^ Qualifier Name:C- ........- 07 iv State Certification or Registration #: CA 0 5770 State: Zip: /1 7 01Y, Phone#: / zip:33/78 z Phone#: 3o81$3 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: OD e,o : State: Zip: Square/Linear_Footage,of,Work: oV wr"F1s.dCr.,3 Address: a: Value of Work`forthisPe m : $ Type of Work: " ❑ Addition De' c iption of Work: "WIN - ___• Alteration ❑ New [Repair/Replace n Demolition a 1-0 epap Specify color of color thru tile: Submittal Fee $ CI)Permit Fee $ Scanning Fee $ 3 ' CO Radon Fee $ 'G3 DBPR $ " 6 2 Technology Fee $ - Cok. Training/Education Fee $ [ . 115(,07) CCF $"�•G1 co/as Q� Notary $ Double Fee $ Structural Reviews $ 2 Bond $ TOTAL FEE NOW DUE $ " 1 . 2C:" (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 inspect ion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not •e approve' •nd a reinspection fee will be charged. Signature OWNER or AGENT The �or foregoing instrument was acknowledged before me this f t o day‘of 3.90 , 20 � by NibC'` C • Qtnn•c ew-f-'t-',Who is personally known to me or who has produced as identification and who did take an oath. NOTARY ' 1 BLIC Sign: Print: l 1 Seal: HEIDY CERTAIN blic - State of Florida . Expires G.1 3, it bion # EE 840251 • ,w ,r ArNr"Ormilii Signature CONTRACTOR The foregoing instrunrS was acknowledged before me this c?-5day of�,Jt J 4 ', , 20 /6 , by / '1/who is pe sonally known to me or n.hio.a rurturod �h�.V 4- as identific NOTAR NIBYA MODRONO .4 �`y otOti 1r�n 9rithot Florida � ' * �w� • c My Comm: Expires Sep 24, 2017 � �� "` Commission # FF 024124 0` 9lE-O''• : F F��F•`• 1 , ,,,Bonded Through National Notary A n.' Sign: Print: /C//' 4' _,•'1--1.....^-,;92 Seal: ******************************ass*************s************************************************************ (6, APPROVED BY (Revised02/24/2014) Plans Examiner Structural Review Zoning Clerk t Miami Shores Village Building Department 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): / i ' Al (A) /o 9? � 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 NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL # ( OOC �/�n COND. UNIT MODEL# (171 ' 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 NO YES NO REPLACING THERMOSTAT NO AYVE YES NO NEW 4"CONCRETE SLAB NO YES NO NEW ROOF STAND YE CN -6___) YES NO NEW RETURN PLENUM BOX YES j 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 Registr tion No. C)€ -c_ � 5 0 L Certificate of Competency No. Signature(7 CI (Revised02/24/2014) ualifier's signature) 2c1c0‘r0 c©I'1L-9) Date: RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The CLASSAAIR CONDITIONING CONTRACTOR''.-. Named below IS CERTIFIED „ ».�, Under the provisions of Chapter 489 FS. �--,—;"--- '~, Expiration date: AUG 31, 2016 .,'-. " '' ; _.,-'. GONZALEZ, GREGORIO :., ATLANTIC AIR- CON D,& ='REFRIGERATION -10670 NW 123•STREET-ROAD.- �'--. -` BAY 101- 1 -.-.--'".------ MEDLEY FL 33.78- = •'`tet '44',----Z4'. •'''�., ISSUED: 07/03/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1407030000724 000488 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 1476704 BUSINESS NAME/LOCATION RECEIPT NO. • ; ATLANTIC AIR CONDITIONING & REFRIGERATION RENEWAL 10670 NW 123 ST RD 101 1476704 MEDLEY FL 33178 OWNER FLA AIR'COND & REFRIGERATION INC Worker(s) 10 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 CAC057704 PAYMENT RECEIVED BY TAX COLLECTOR $45.00 07/20/2015 CHECK21-15-099372 This Local Business Tax Receipt only confirms 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.gov/taxcollector FLORAIR-02 ONAPOLES ACpCERTIFICATE OF LIABILITY INSURANCE �-�' DATE (MM/DD/YYYY) 1/6/2016 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(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 Collinsworth, Alter, Fowler & French, LLC 8000 Governors Square Blvd Suite 301 Miami Lakes, FL 33016 CONTACT NAME: PHONE 305 822-7800 FAX 305 362-2443 (A/c, No. Ext): ( ) (A/C, No): (305) E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Scottsdale Insurance Company 41297 INSURED Florida Air Conditioning & Refrigeration, Inc. DBA: Atlantic A/C & Refrigeration 10670 NW 123 St Rd Bay 101 & 102 Medley, FL 33178 INSURER 8 : Business First Ins Co 11697 INSURER C : 01/04/2017 INSURER D : $ 1,000,000 INSURER E : INSURER F : X 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. NOTWTHSTANDING 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRINSD TYPE OF INSURANCE ADDL SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CPS2134955 01/04/2016 01/04/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A 52112267 12/29/2015 12/29/2016 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Gregorlo Gonzalez CAC057704 CERTIFICATE HOLDER 1 Miami Shores Village Building Department 10050 N.E. 2 Avenue Miami Shores, FL 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 4Pc....?... ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD