MC-17-270 (4)LE 10 83J
Miami Shares Village 03AI3338
Building Department U-11
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949 s4�X
FBC 201`t
BUILDING Master Permit No. T2C( (o— 2.14'1 ,
PERMIT APPLICATION Sub Permit No. --Mc
G n -Zlpo
(BUILDING ❑ ELECTRIC ROOFING REVISION EXTENSION r7RENEWAL
PLUMBING M MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: 515 Grand Concourse
DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-3206-017-1340 Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Gregory Palmer Phone#: 954.410A695
Address:515 Grand Concourse
city. Miami Shores State: FL Z;p: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Sansone AC
Address: 590 GOOLSBY BLVD
Phone#: 954-428-8919
city: DEERFIELD BEACH State: FLORIDA Zip; 33442
Qualifier Name: SCOTT SANSONE Phone#: 954-428-8919
State Certification or Registration M CIVIC 1249260 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address City: State: Zip:
Value of Work for this Permit: $ �,+ f� Gi 0 Square/Linear Footage of Work: & G 0 )4i
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: HVAC PER PLAN L t a-t ta. S -TbK-s
Specify color of color thru tile:
OD
Submittal Fee $ S,0 •00 Permit Fee $ QUCF $ /! r• $ ( LCO/CC $
Scanning Fee $ Radon Fee $ Z DBPR $ �-t • Z� Notary $
Technology Fee $ •� Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
iRevisedo2/24/20141
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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
promise In good faith that a copy of the notice of commencement and construction lien low b
whose property is subject to attachment. Also, a certified copy of the recorded notice of comme
for the first inspection which occurs seven (7) days after the building permit is issued. In t
inspection will not Pe approved and a reinspection flee will be charged.
Signature Ci�. t,Signature
Ing $2500, the applicant must
vill be delivered to the person
must be posted at the job site
ce of such posted notice, the
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of t— -e 20 t-7 . by
`eC cwho is personally known to
me or who has produced • as
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before me this
1 day of FEBRUARY 2017 by
SCOTT SANSONE who isperson � ally known to
me or who has produced as
identification and who did take an oath. ii
NOTARY PUBnn& i 1
Print:
Seal: +° r.••.� * MY 640SION t FF ISM27 Seal:
* EXPIRES: M81ch16.2019 ASHUYDZIEWIT
or oesor4wTta 84d Notary $►"*e% Vy CX)MM1SSION k "9 "39
+4,ap EXPIR 'Nebnay07.2=
APPROVED BY . Y Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
,iCORblt CERTIFICATE OF LIABILITY INSURANCE
%.,-'
DATE(MMIDDNYYY)
1 12/1/2016
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 coMftcats does not confer rights to the
certificate holder in lieu of such endarseme a).
PRODUCER
Randi Arnold
Frank H. Furman, Inc.
PHONE (954) 943-5050 FAX (954)942-6310
1314 Bast Atlantic Blvd.
E10 randiBfurmanineurance.com
P . O. BOX 1927
1 AFFORDING COVERAGE
NAIL /
s+SURERAITational Trust Ina Co
120141
Pompano Beach FL 33061
INSURED
_IMSMR S FCCI Insurance Co
10178
iNsuRERCFrid efield Employers Ins Co
10701
Sansone LLC dba: Sansone Air Conditioning
590 Goolsby Blvd.
INSURERD:
INSURER E
Deerfield Beach FL 33442
INSURER F:
""VY wmt.CM w1^ A ^"ff mmnw It• wliaz ==.
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
POLL EFF
EXP
LIMITS
A
X
COMMERCIAL GENERALLU15JUTY
CLAIMS -MADE ❑Y OCCUR
GLOO161624
12/l/2016
12/1/2017
EACHOCCURRENCE
S 2,000,000
DAMAGE TO RENTEDencal
$ 100,000
MEDEXp one )
$ 51000
PERSONAL BADVINJURY
$ 11000,000
GENI. AGGREGATE
ppLIMIT APPLIES PER
POUCYTJECT ELOC
OTHER:
GENERAL AGGREGATE
$ 21000,000
PRODUCTS -COMPIOPAGG
$ 2,000,000
$
A
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALLOWNEDODUlEO
AUTOS AUTOS
HIRED AUTOS N AUTOSPROPERTY
CLOO2740207
12/1/2016
12/1/2017
COMBINED
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
DAMAGE
$
B
X
UMBREWILIAB
EXCESSL.IAB
OCCUR
CLAIMS -MADE
UMOOZ17257
12/1/2016
12/1/2017
EACH OCCURRENCE
$_ 5,000,000
_
AGGREGATE
$ 5,000 000
DED I X I ReTewioiis 30 000
S
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/O(ECUrIVE
OFFICER�A�EMBEREXCLUDED7
(MandgmInNN)
R yyeess,� describe under
DEBCRIPrONOFOPERATIONS behw
NIA
003054159
1/1/2017
1/1/2018
X CT"_
STATUTE 1 1 ER
E.LEACH ACCIDENT
S 2,000 000
E.L. DISEASE - EA EMPLOYEE
S 1,000 000
E.LDISEASE- POLICY LIMIT
S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more qmc* is rsqulred)
RE: XECRANICAL CONTRACTOR LICENSE # CMC1249260
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
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
DeJong / RA
01989-2014 ACORD CORPORATION_ All rinhtc rAaA,-ArP_
ACORD 25 (2014MI) The ACORD name and logo are registered marks of ACORD
INS025f2mA H)
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2016 THROUGH SEPTEMBER 30, 2017
DBA: Receipt#:�TING%AIRCONDITION CC Name' SANSONE AIR CONDITIONING Business Type: (MECHANICAL CONTRACTOR)
Owner Name: SCOTT J NSONE/QUAL Business Opened:l2/11/2003
Business Location: 590 GOOLSBY BLVD State/County/Cert/Reg:CMC1249260
DEERFIELD BEACH Exemption Code:
Business Phone:954-428-8919
Rooms Seats Employees Machines Professionals
75
For Vending Business Only
Number of liNachines: Vendinn Tvnw_
Tax Amount
Transfer Fee
I NSF Fee I
Penalty
I Prior Years
Collection Cost
I Total Paid
150.00 1
0.00
0.00
1 0.00
1 0.00
1 0.00
150.00
•
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non -regulatory In nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location. This receipt does not indicate that the business Is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
SCOTT J SANSONE/OUAL
590 GOOLSBY BLVD
DEERFIELD BEACH, FL
33442
2016 - 2017
Receipt #04B-15-00007802
Paid 09/01/2016 150.00
STATE OF FLORIDA
a, DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
;. CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
SANSONE,SCOTTJOHN
SANSONE AIR CONDITIONING
590 GOOLSBY BLVD.
DEERFIELD BEACH FL 33442
Congratulationsl 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
I og onto www.myfloridalicense.com. There you can find more
information about our divisions and the regulations that impact
you, subscribe to department newsletters and learn 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!
RICK SCOTT, GOVERNOR
STATE OF FLORIDA
DEPARTMEN,LOF BUSINESS AND
PRO
CMC1249260
CERTIFIED
SANSONE,
SANSONEi
14' a.
I5 CERTIFIED under th
EzptrG doh AUG 31, 2018
DETACH HERE
e
R;r'Mslons of Ch.488 FS.
0605WOW1379
KEN LAWSON, SECRETARY
STATE OF FLORIDA
i DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
CMC1248260 - —_--
The MECHANICAL CONTRACTOR
Named below IS CERTIFIED -
Underahe -provisions of Chapter 489 FS.
I Expiration date: AUG 31, 2018 -
SANSONE, SCOTT J-OHN _... ,
I , ,.SA �NE.AIR CC NAI
-5t� OCJ SBV
".QI=ERNELIJ.
r r-,•' �„r'F% Wit,• ..-_ `. � = "- .r "^'^•-�,"i"
ISSUED: 06/0212016
Tr'✓ -.a:
�t'LA AS 1711
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Ely SEQ # 0606020001379