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MC-11-870Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Ci/ Inspection Number: INSP - 160405 Permit Number: MC -5 -11 -870 Scheduled Inspection Date: June 01, 2011 Inspector: Perez, JanPierre Owner: MANZO, LAEL Job Address: 9720 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: BLUE BREEZE AIR CONDITIONING Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1132060143260 Phone: 305 - 865 -1220 Building Department Comments REPLACE EXISTING A/C UNIT 3 TONS -T---60 41/4) Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments G1- May 31, 2011 For Inspections please call: (305)762 -4949 Page 24 of 25 5[(4" '/u14vfiami 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 �`�` Permit Nol' '��' I 1---7 77 T7 MAY 1 fl 2011 ij BUILDING PERMIT APPLICATION FBC 20 Master Permit No. Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): Z '4 &L rn4900 Phone #: Address: 9 .700 3I6C•y/4 vb City: OVA Al 1 ,S1/0 41)i, State: FL- Zip: 3313 8 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: City: -6L6c4-11,)L Miami Shores Folio/Parcel #: County: aZ 03 Miami Dade Zip: Is the Building Historically Designated: Yes (N Flood Zone: CONTRACTOR: Company Name: L. c? Our_ Phone #: 505- 5 - t2.ZO Address: Cp 5 ki A.. LS City: R R. A .f #t4 State: L Zip: '�- Qualifier Name: RATA /a- .s 'To-zit-7_011_4 Phone #: '106- 2 c /5C State Certification or Registration #: C A.-e j' 1:3 Q q. ;%, Certificate of Competency #: Contact Phone #: '2)05- lie 5 O Email Address: at .LA e . tS . ovc_az,LAL 1114 (ir tom_ DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: Type of Work: ❑Address Description of Work: $ ❑Alteration L/a Square/Linear Footage of Work: UNew R -r1 tv ORepair/Replace ❑Demolition u n.f 1 d 3 -'c . s * * * ** * * ** ***************************Fee i ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ ¶J'hi " Permit Fee $ ")....10 L/ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $1 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 commencement must be posted at the job site for the first inspection which occurs seve (7) days after the building permit is issued. In the absencof such posted notice, the inspection will . t be approved and a reinsp- .tion fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged'.efore me this tz The foregoing instrument was acknowledged before me this day of m ¢ , 20 k , by day of , 20 �, by 1'lflA3 1Sst who is personally known to me or who has produced L, as identification and who did take an oath. Signature Con who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Co Tie to .fi o, . Commission DD778217 pires 04/13/2012 NOTARY PUB C: Sign: Print: My Commi 4441410.1444,er e •y Commission DD778217 xpires 04 /13/2012 dede**** *: F9: :F4evk3c9e:F:F*4:deaY4::0d:*: *** *** ** 4rR*** -* * *kbY: *******:F:F**** ** * **** *** **** ***** ***Y***** **k**.+e *** ** 1� 1 APPROVED BY (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) lans Examiner Zoning Structural Review Clerk a. Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (05) 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): 9 Zo a 1 Y-441A)€.. 3Li 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 ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO i' ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT 'MU/ MANUFACTURER IF/D14e Lp / J 0 AHU or PKG. UNIT MODEL # NI b ;46 0 34-Z. COND. UNIT MODEL # 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 YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4 "CONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES 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: OIV1 T Phone: State Certificate or Registration N. Signature .305- t7e5 - oi2 •_• e Certificate of Competency N. Qualifl�g s si nature only) Date: Q5/ iZ /2'. 'i AU-`��' CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 05/20/11 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 Family Insurance Services Inc. 6750 Stirling Rd. Hollywood, FL 33024 Phone (954) 966 -2224 Fax (954) 966 -2216 CONTACT NAME: PHONE Fax (A/C. No. ExU: ( 954 ) 966 -2224 (A/C, No): (954) 966 -2216 E-MAIL ADDRESS: tamm famil insuranceservices.com y� y INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Bankers Insurance Company GENERAL LIABILITY V COMMERCIAL GENERAL LIABILITY INSURED E C A Air Conditioning DBA Blue Breeze One Hour Air ID 617667 655 NW 118 St Miami, FL 331682520 (305) 865 -1220 INSURER B : 090005347943100 INSURER C : $ 50 000.00 INSURER D : MED EXP (Any one person INSURER E : INSURER F : $ 1,000,000.00 MBER: 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. INjR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) 03125(2011 POUCY EXP (MM /DDIYYYY) 03/25/2012 UMITS EACH OCCURRENCE $ 1,000,000.00 A GENERAL LIABILITY V COMMERCIAL GENERAL LIABILITY 090005347943100 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50 000.00 ❑❑ n CLAIMS -MADE L) OCCUR MED EXP (Any one person $ 5,000.00 PERSONAL &ADVNJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PEOCT- ❑ LOC PRODUCTS - COMP /OP AGG $ 1,000,000.00 $ AUTOMOBILE UABIUTY ❑ ANY AUTO ❑ALL OWNED r- SCHEDULED AUTOS .. AUTOS ❑HIRED AUTOS ' NON -OWNED Li AUTOS ❑ ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA UAB 'J OCCUR ❑ EXCESS UAB Li CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- = TORY LIMITS ❑ ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CANCELLATION CITY OF MIAMI SHORES VILLAGE 10050 N.E SECOND 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 POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 05/18/2011 12:17 FAX CERTIFICATE OF LIABILITY INSURANCE a 0001 /0001 DATE (MM/DD/YYYY) 05/18/11 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 Ilan of such endorsement(s). PRODUCER Family Insurance Services Inc. 6750 Stirling Rd. Hollywood, FL 33024 Phone (954) 966 -2224 Fax (954) 966 -2216 INSURED E C A Air Conditioning DBA Blue Breeze One Hour Air ID 617667 655 NW 118 St Miami, FL 331682520 (305) 865 -1220 COVERAGES CERTIFICATE NUMBER: CONTACT NAME: (P�HyONE Extr (954) 966 -2224 ADDRESS tanmy @familyinsuranceservices.com FAX NA): (954) 968 -2216 INSURER(S) AFFORDING COVERAGE INSURER A: Bankers Insurance Company NAIC # INSURER B : INSURER C: INSURER D : INSURER E : INSURER F : REVISION NUMBER: INDICATED CERTIFICATE EXCLUSIONS ILTR g� NOTWITHSTANDING ANYGREQUIREM NT, TE�RMIOR CONDITION OF ANY CONTRACT MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED OR OTHER DOCUMENT WITH RESPECT TOUWHICH PERIOD THIS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, BY PAID CLAIMS. TYPE OF INSURANCE ADDLSUBR tNSR MD POLICY NUMBER ( POLIO 03/25/2011 (MUD EXP D/pYyY� 03/25/2012 LIMITS A GENERAL LIABILITY 090005347943100 EACH OCCURRENCE $ 1,000,000.00 M COMMERCIAL GENERAL LIABILITY PREMISES 60,000.00 ■ M CLAIMS -MADE ■ OCCUR (EaENTED nD ce) MED EX jAny one person) $ $ 5,000.00 ■ PERSONAL & ADV INJURY $ 1,000,000.00 ■ GENERAL AGGREGATE $ 2,000,000.00 GEM. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO $ 1,000,000.00 • POLICY 0 R8i ❑ LOC $ AUTOMOBILE LIABILITY [ COMBINED D SINGLE LIM (Ea acci $ • ANY AUTO BODILY INJURY (Per person) $ ALL NED ❑ • ACHEDULEO BODILY INJURY (Per accident $ HIRED AUTOS : A� g� PROPE , AMAGE (Per accr $ 11.] UMBRELLAIJAB • OCCUR EACH OCCURRENCE $ ^0 0 EXCESS LIAB • CLAIMS -MADE AGGREGATE $ • DED • RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY CUTNE / N �ICR IET R N /A WC STATU- OTH ❑ TORY LIMITS ■ ER EL EACH ACCIDENT $ EXCLUDED? (Mandatory EL DISEASE - EA EMPLOYEE $ �In If yyeese DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 151, Additional Remarks Schedule, fr more space le required) CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES VILLAGE 10050 N.E SECOND 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) QF 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD