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RF-15-1348Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 5 NE 105 Street Miami Shores, FL 33138-2030 Owner Information Perms Issue Date: 6124/2015 Permit NO. RF -6-15-1348 Permit Type: Roof Work Classification: Tile Permit Status: APPROVED Expiration: 12/2112015 Address Parcel Number 1121360060090 Block: Lot: Applicant RED RIVER USA LP Phone Cell " RED RIVER USA LP 3250 NE 1 Avenue MIAMI FL 33137- 3250 NE 1 Avenue MIAMI FL 33137- Contractor(s) UNIVERSAL GROUP INC Phone (305)796-9556 CeII Phone Valuation: $ 15,000.00 Total Sq Feet: 2100 Type of Work: Re Roof Additional Info: NEW ROOF TILE MALIBU RED Classification: Residential Scanning: 3 Fees Due Bond Type - Owners Bond CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - New Roof Scanning Fee Technology Fee Amount $500.00 $9.00 $4.50 $4.50 $3.00 $300.00 $9.00 $12.00 Total: $842.00 Pay Date Invoice # 06/24/2015 06/24/2015 06/04/2015 Bond #: 2761 Pay Type RF -6-15-55824 Credit Card Credit Card Credit Card Amt Paid Amt Due $ 500.00 $ 342.00 $ 292.00 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Up Lift Report Tin Cap Final Roof Tile In Progress Renailing Affidavit Review Roof Cap Sheet 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 ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRIC LUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT construction and zoning. fy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating rmore, I authorize the above-named contractor to do the work stated. Authorized Signat :Owner / Applicant / Contractor / Agent Building Department Copy June 24, 2015 Date June 24, 2015 Oct. 08 / RV 8/31/09 &Or, BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC. 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 f,i,-7.6-1, CEIVED1 JUN o0�32015 IB'Y: FBC 20 l o Master Permit No. 4) 5 - 13 9 l� Sub Permit No. PC -6 -SLI ROOFING ❑ REVISION ❑ EXTENSION Ei RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRE S J P�� /p S ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS M.%.4- 4; 33/'SC 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 Titleholder): Pei h; ua 0A� Address: pp3ox 3a(36c. f-1 ?3(3” City: State: Zip: Phone#: $Co 5'6 6 15 // Tenant/Lessee Name: Phone#: Email: CONTRACTOR: �� Company N, alme: Address: 7 vU '1J ) City: DSI (CM( I Qualifier Name: C� A/r,'� a,1 axaito g State Certification or Registration #: tee. .i 3 a X12 9g Phone#: � 79(/r%�>+o State:( DESIGNER: Architect/Engineer: t u Address: Zip: 7/6%U Phone#: 3c.7c a96 q5 S6 Certificate of Competency #: £ Se 1 1 CI'V' Phone#: City: State: Zip: Value of Work for this Permit: 1 6-.000 ' y —^f $ r_ Square/Linear Footage ofWork d t00 ® New G ❑ tRepair/Replacep�pi"ti Description of Work: it mole CA) ,rl e w__ 2Q 4ls)mac- 13. 2)-73 Type of Work ❑ 'J Addition', 1•* ❑ Alteration ❑ Demolition Specify color of color thru tile: Submittal Fee $ S0.OQ� 1 Scanning Fee $ Radon Fee $ Permit Fee $ • W CCF $ CO/CC $ Technology Fee $ Structural Reviews $ DBPR'$ Notary $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 12' VV Bonding Company's Name (if applicable) Bonding Company's Address . City it 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 isued . In e absence of such posted notice, the inspection will not be approverand a reinspection fee will be charged. Signature ER or AGENT Signat 1.1 IlI,11 ,w 1T• 'rte• TRACT.' The fo egoing instrument was acknowledged before me this The foregoing' 2, day of VV� , 20 , , by kl �J/ ` '''wh me or who has producee5t.c identification and who did take an oath. NOTARY PUBLIC:' ?O.''' ���0 ELLIOT SOTO *MY COMMISSION # E1: 107020 EXPIRES: August 5, 2015 Bonded Thni Budget Notary Services '40F FO Seal: as strument was acknowledged before me this day of AA , 20 iy , by erdfri , who is personally known to me or who lias produced /1-'Sku'e' as identification and who did take an oath. NOTARY PUBLIC: Si t4 - Print: Seal: f s �.143 Pt„,,,- EWOTSOTO * MY COMMISSION # EE 107020 EXPIRES: August 5, 2015 Bonded Thru Budget Notary Services ****************************_ ************************* ***********************:?*** *****iii************** APPROVED BY Plans Examiner Zoning Structural Review Clerk Detail by Entity Name 1 •iI �'�tl �iA i! � S� A iliT��i �' N r).�d-�"e� �.�1.° rt' £ F tkora ; F .^ ,F •�A, w M }. ,�s�o of oRpoRAsr=�QNs .:,;(111b1 t Page 1 of 2 Re. 3-• ! - r LI r Detail by Entity Name Foreign Limited Partnership RED RIVER USA LP Filing information °ocument Number B12000000280 FEI/EIN Number 80-0868059 Date Filed 11/30/2012 State DE Status ACTIVE Principal Address . % CI PROPERTY SERVICES LTD 250 NE 1 i" Vl- - UNIT 316 MIAMI, FL 33137 Mailing Address RED RIVER USA LP 124 SLOANE ST LONDON, UK, SWIX 9BW XX Registered went Name & Address CORPORATION SERVICE COMPANY 1201 HAYS STREET TALLAHASSEE, FL 32301-2525 ! General Partner Detail Nagle & Address Document Number F12000004750 •OBD"SSEY VENTURE PARTNERS LIMITED CORP. 124 SLOANE ST LONDON, UK, SWIX 9BW XX Annual Reports Report Year .Filed Date 2013 04/09/2013 2014 01/20/2014 2015 01/14/2015 1 /T /fl C1 1 Ir, 1 Tl 1nnPIA 1c { 1. 111111111111111111111111111111111111111111111 CFN 2015R0162592 OR Bk 29534 Pss 4165 - 4169; (sass) RECORDED 03/12/2015 12:02:36 HARVEY RUVIN, CLERK OF COURT MIAMI-DADE COUNTYr FLORIDA Dated January015 POWER OF ATTORNEY By RED RIVER USA LP TO TIMOTHY JAMES MARSH AND JAMES THOMAS BLACK Gibbons P.C. One Gateway Center Newark, New Jersey 07102-5310 INDEX Clause Heading 1 Appointment and Powers 2 Duration 3 Validity 4 Governing Law and Jurisdiction 2 Page No. 3 3 4 #18( //N.", jOF+5.i Uhi rr�nrordi�t. iLi.deto�irt ,v� This POWER OF ATTORNEY is granted on January t 2015 BY: (1) RED RIVER USA, LP, a Delaware limited partnership, with a registered office at c/o Corporation Service Company, 2711 Centerville Road, Suite 400, City of Wilmington, 'County of New Castle, State of Delaware, 19808 (herein, "Principal") TO (2) TIMOTHY JAMES MARSH, of 300 S Pointe Drive, Miami Beach, Florida 33139, and JAMES THOMAS BLACK, of 100 Jefferson Avenue, Miami Beach, Florida 33139 (collectively, "Attorney"). BACKGROUND: A. The Principal is a Delaware limited partnership (the "LP"). The general partner of the LP is Odyssey Venture Partners Limited Corp. B. The Principal has agreed to appoint the Attorney as its attorney-in-fact to do and execute certain documents and deeds on behalf of the Principal on the terms and conditions set out below. 1. Appointment and Powers 1.1 The Principal appoints the Attorney as its attorney with full power to sign, seal, execute and deliver any deed or document necessary or desirable for the Principal to execute. 1.2 Each Attorney may act severally and individually in any matter. 2. Duration 2.1 This Power of Attorney shall continue until it is expressly revoked. The Principal may revoke this Power of Attorney by a writing delivered to the Attorneys in person, by registered mail or overnight mail service addressed to the Attorney at Cogent Investments, 3250 NE PI Avenue, Suite 316, Miami, FL 33137 (or such other address to which Cogent Investments may relocate) or by electronic mail addressed to jb@cogentinvestments. Com and tm@cogentinvestments.com. 2.2 If not previously revoked, this Power of Attorney shall cease to be effective on the dissolution of the LP. 3 9 3. Validity The Principal declares that a person who deals with the Attorney in good faith may accept a written statement signed by the Attorney to the effect that this Power of Attorney has not been revoked as conclusive evidence of that fact. 4. Governing Law and Jurisdiction This Power of Attorney (and any dispute, controversy or proceedings or claim of 'whatever nature arising out of or in any way relating to this Power of Attorney or its formation or anyact performed or claimed to be performed under it) shall be governed by and construed in accordance with the laws of the State of Florida, and the Principal submits by executing this Power of Attorney, and the Attorney submits by purporting to act under the terms of this Power of Attorney, to the exclusive jurisdiction of the courts in the State of Florida. This instrument may not be changed orally. INWTNESS WHEREOF, on behalf of the Principal, I have hereunto set my hand and seal this w ay of January, 2015. Signed, Sealed and Delivered ci S a "Deed Principal: Red River USA LP Witness IZAMTe L t D€& VorrNAddress By Odyssey Venture Partners Limit Its General Partner BY: 3 (� Name: Title: E4 - PEMBERTON GREENISH LLP SOLICITORS Witness o/! % ?9ivnrA kiA , 4 45 UAL XIAN tiAHL3tNS LONDON SW3 2AQ DX: 35113 CHELSEA T: 020 7591 3333 F: 020 7591 3300 E: taw@pglaw.co.uk Address • [.Asi TO ALL TO WHOM THESE PRESENTS MAY COME: On 6th January 2015 in the Royal London Borough of Kensington & Chelsea England BEFORE ME Nicola Jane Plant Notary Public by Royal Authority duly admitted authorised and sworn and practicing at 45 Cadogan Gardens London SW3 2AQ England APPEARS SIMON PIERS BECKWITH of 401 Fulham, Road London SW10 9TU .identified by his United Kingdom driving licence number BECKW710308SP9WV and such other relevant documentation and who produces to me the annexed Power of Attorney for use in the United States of America which he has prepared and signed in his capacity as a Director of Odyssey Venture Partners Limited in my presence and of his own free will AND I THE NOTARY CERTIFY: 1. I have caused an inspection to be made at Companies House in the City of London; and 2. That ODYSSEY VENTURE PARTNERS LIMITED (Registered Company No. 03913139) is a private limited company duly incorporated and registered at 124 Sloane Street London SW1X 9BW and existing in accordance with English Law; and 3. That SIMON PIERS BECKWITH is listed as a director of that company. IN FAITH AND TESTIMONY whereof I the said notary have hereunto set my hand and affixed my seal of office in the Royal London Borough of Kensington & Chelsea England aforesaid this Sixth day of January Two Thousand and fifteen Quod Veritat attestor 5' Art OF FLORID COUNTY OF DAD'E I HEREBY CERTIFY this is a true co, y of the day of A 2 NITNESS my ha flick)! Seot. r !PRVEY RUVI' A„ �i o Circuit and County Courts nr. NICOLA JANE PLANT Notary Public 45 Cadogan Gardens London SW3 2AQ EVE ` R CASTILLO #197509 OU3211$ Local Business Tax Receipt -. Miami—Dade County, State of Florida' -THIS IS ;NOTA BILL.- DO NOT PAY 6526199 BUSINESS NAME/LOCATION UNIVERSAL CONSTRUCTION 7228 NW 56 ST MIAMI FI: 33166 OWNER UNIVERSAL GROUP INC Worker(s) 1 • EXPIRES RENEWAL 'SEPTEMBER 30, 2015 6796578 . . Must be displayed ai place of businei:s Pursuant to County Code Ch4lter 8A - A. 9 & 10 SEC. TYPE OF BUSINESS 196 SPECIALTY BUILDINGPAYMENT RECEIVED CONTRACTOR CCC1329249 BY TAX COLLECTOR • $75.00 09/30/2014 CREDITCARD-14-042697 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, visitwww.miamidade.govItaxcollector STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERSCOMPENSATION CONSTRUCTION INDUSTRY EXEMPTION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW EFFECTIVE DATE:9/19/2014 PERSON: MATOS GABRIEL FEIN: 300511129 BUSINESS NAME AND ADDRESS: UNIVERSAL GROUP INC UNIVERSAL CONSTRUCTION INC 7228 NW 56 ST MIAMI FL 33166 EXPIRATION DATE: 9118/2016 P SCOPES OF BUSINESS OR TRA 0 L D H E R E IMPORTANT Pursuant to Chapter 440.M(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 chap(er. Pursuers to Chapter 44110502), 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 Chapter440.05(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 alter the Ming 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. LICENSED GENERAL HEATING, VENTILATION, ;CONTRACTOR AIR-COND ROOFING - ALL KINDS AND DRIVER STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CCC1329249 The ROOFING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 MATOS, GABRIEL PIERRE. - UNIVERSAL GROUP INC - • 7228 NW 56TH STREET MIAMI FL 33166=4247 ISSUED: 08/31/2014 • DISPLAY AS REQUIRED BY LAW SEQ # L1408310003702 ACGRDY CERTIFICATE OF LIABILITY INSURANCE k.../- DATE(MM/DD/YYYY) 01/27/2014 , PRODUCER Westward Insurance Services (305) 418-8411 2500 NW 79th Avenue Suite 283 Doral FL 33122 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 BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Universal Group, Inc. 7228 NW 56 ST. Miami FL 33166 INSURER A: Republic Vanguard Insurance Company A INSURER B GENERAL LIABILITY �o COMMERICAL GENERAL LIABILITY' INSURER C: t INSURER D: ' INSURER E: " 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADM_ INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY �o COMMERICAL GENERAL LIABILITY' 1556605 01/27/2014 01/27/2015 EACHOCCURENCE $1,000,000 " DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 II. IIII CLAIMS MADE CI OCCUR MED EXP (Any one person) $5,000 & ADV INJURY $1,000,000 IIIPERSONAL GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 0 POLICY II PROJECT I. LOC $ • AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Each Occurrence) $ . • ANY AUTO • ALL OWNED AUTOS BODILY INJURY (Per person) $ • SCHEDULED AUTOS • HIRED AUTOS BODILY INJURY (Per accident) $ • NON -OWNED AUTOS • PROPERTY DAMAGE (Per accident) $ I—I GARAGE LIABILITY NO ANY AUTO AUTO ONLY - EA ACCIDENT $ . OTHER THAN EA ACC $ • AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY • OCCUR I. CLAIMS MADE - - EACH OCCURRENCE $ . AGGREGATE $ $ 1. DEDUCTIBLE $ • RETENTION $ $ WORKERS COMPENSATION ANDWC EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECU- TIVE OFFICER/MEMBER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below - • STATU- OTH- - TORY LIMITS woo ER E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ EL DISEASE - POLICY LIMIT $ OTHER . DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CCC 1329249 ERTIFICATE HOLDER CANCELLATION Miami Shores Village Building 10050 NE 2"d Avenue Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. I AUTHORIZED REPRESENTATIVE © ACORD CORPORATION 1988 We Construct the Best Remodel the Rest! DATE: April 29, 2015 STATE OF FLORIDA MIAMI DADE COUNTY BEFORE ME THIS DAY PERSONALLY APPEARED GABRIEL M4TOS WHO, BEING DULYSWORN, DEPOSES AND SAYS" THAT HE OR SHE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED AT.• 5 NE 105 ST MIAMI GARDENS FL 33056 SWORN TO AND SUBSCRIBED BEFORE ME THIS 2 DAY OF JUNE 2015 PRODUCED ID TYPE OF ID PRODUCED ELUOT SOTO * *, , * MY COMMISSION # E`e 107020 q ° EXPIRES: August 5, 2015 +reoF �e Bonded Ttu'v Budget Notary S PRINT, TYPE OR STAMP NAME OF NOTARY 7228 NW 56 ST. MIAMI FL 33166. T: 305.796.9556 —F 305.887-5519 - Visit us: unigrp.com GENERAL CONTRACTOR CGC 1517453 + ROOFING CONTRACTORS CCC 1329249 Notice to Owner — Workers' Com p Miami 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' compensate insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of orida er County of Miami -Dade The foregoing was acknowledge before me this 2(0 day ofA/M , 20 By J rr 9 W (S /��itt/i4 "(-7QC1G who is personally known to me or has produced tLX,)r (JL /L %��✓c2 Notary: SEAL: as identification. `,•* ELLIOT SOTO MY COMMISSION; EE 10702 EXPIRES: August 5, 2015 mrireoFtt esO! Balled Thu Budget Notary Senices JUN 032015 P_ Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNERS'S AFFIDAVIT OF EXEMPTION ROOF TO WALL CONNECTION HURRICANE MITIGATION RETROFIT FOR EXISTING SITE - BUILT SINGLE FAMILY RESIDENTIAL STRUCTURES PERSUANT TO SECTION 553.844 F.S. To: Miami Shores Village Building Department 10050 NE 2nd Ave Miami Shores, FI 33138 Re: Owner's Name: 2 ' —� LP Date: Property Address: es ('e- (t)$tt 51-/ Roofing Permit Number: Dear Building Official: / I James b/ad certify that I am not required to retrofit the roof to wall connections of my building because: AteThe just valuation for the structure for purpose of ad valorem taxation is less than $300,000.00. Please attach proof of ad valorem taxation. o The building was constructed in compliance with the provisions of the Florida Building Code (FBC) or with the provisions of 1994 e•in of thl.outh Florida Building Code (1994 SFBC) • 411 ature Print Name State of Florida County of Dade The undersigned, being the first duly sworn, deposes and says that he/she is the owner for the a ove property mentioned. Sworn to and subscribed before me this 441? --day of 47(--1)\�PEu IOTSOTo * MY COMMISSION # a 107020 Notary Public, Sate of Florida at Large EXPIRES: August 5, 2015 d>4p,.F F`,oe Bonded Thu Budget Notary Services • When the Just valuation of the structure for purpose of ad alorem taxation is equal to or mon; than $300,000.00, and the building was not constructed with FBC nor a 1994 SFBC. Then you must provide a building application from a General Contractor for the Roof to Wall connection Hurricane Mitigation. Revised on 5/21/2009 BY: C ET .7 D JUN 032015 Florida Building Code Edition 2010 High Velocity Hurricane Zone Uniform Permit Application Form Section A (General Information) Master Permit No. Process No. Contractor's Name to l u f Gip Job Address ❑ Low Slope • Asphaltic Shingles ROOF CATEGORY Mechanically Fastened Tile 0 Metal Panel/Shingles ❑ Mortar ❑ Wood S ❑ Prescriptive BUR -RAS 150 ROOF TYPE O New Roof 0 Reroofing 0 Recovering 0 Repair ❑ Mainte ROOF SYSTEM INFORMATION Low Slope Roof Area (SF) Steep Sloped Roof Area (SF) 2[oO Total (SF) . . .. • . 2-'- ) --• • • . . . SECTION B (Roof Plan)•••• •••• • • •Sketch Roof Plan: Illustrate all levels and sections, roof drains, scypjig;s, ov• er low • • scuppers and overflow drains. Include dimensions of sections and 1evbIs, clearly identify dimensions of elevated pressure zones and location of pararets. 5 it 0 . . • . . . • .. E { I 0 tn- . . Florida Building Code Edition 2010 High Velocity Hurricane Zone Uniform Permit Application Form Section C (Low Sloped Roof System) Fill in Specific Roof Assembly Components and Identify Manufacturer (If a component is not used, identify as "NA") System Manufacturer: NOA No.: Design Wind Pressures, From RAS 128 or Calculations: Pmax1: Pmax2: Pmax3: Max. Design Pressure, From the Specific NOA System: Deck: Type: Gauge/Thickness: Slope: Anchor/Base Sheet & No. of Ply(s): Anchor/Base Sheet Fastener/Bonding Material: Insulation Base Layer: Base Insulation Size and Thickness: Base Insulation Fastener/Bonding Material: Top Insulation Layer: Top Insulation Size and Thickness: Top Insulation Fastener/Bonding Material: Base Sheet(s) & No. of PIy(s): Base Sheet Fastener/Bonding Material:. Ply Sheet(s) & No. of°PIy(s): Ply Sheet Fastener/Bonding Material: Top Ply: Top Ply Fastener/Bonding Material: Surfacing: Fastener Spacing for Anchor/Base Sheet Attachment Field: " oc @ Lap, # Rows @ " oc Perimeter: " oc @ Lap, # Rows Comer: " oc @ Lap, # Rows Number of Fasteners Per Insulation Board Field: Perimeter Comer @ "oc Illustrate Components Noted and ,Details as Applicable: Woodblocking, Gutter, Edge Termination, Stripping, Flashing, Continuous Cleat, Cant Strip, Base Flashing, Counter- Flashing, Coping, Etc. Indicate: Mean Roof Height, Parapet Height, Height of Base Flashing, Component Material, Material Thickness, Fastener Type, Fastener Spacing or Submit Manufacturers Details tihai Comply with RAS 111 and Chap 4 16.. . •••• •... . . . • . . • 1 1 • • . • .. ev FT. arapat• . • p . Height • . 1 • • . . • ... . . . . Mean Roof Height Florida Building Code Edition 2010 High Velocity Hurricane Zone Uniform Permit Application Form Section D (Steep Sloped Roof System) Roof System Manufacturer: ---(464-1-r-: Product Approval Number: 1 1 - CO1..1 % 0 Minimum Design Wind Pressures, If Applicable (From RAS 127 or Calculations): P1: ' 9. e P2: 1 S' (C' P3: HUD . L Maximum Design Pressure --">s Product Approval Specific System: _ ' Method of Tile Attachment:*1L1, 1 74' �(e Roof Slope: : 12 Steep Sloped System Description Deck Type: Wcot • --- Type Underlayment: Insulation: Ridge Ventilation? . • .... . . . .. . Fire Barrier: i • . • . . • .... .... .• • . • Fastener Type & Spacing: Adhesive Type: Mean Roof Height: l 1/41 FS '�1►15 590714i Tolybam - Wo1Tero Type Cap Sheet: Roof Covering: Type & Size Drips Edge: �3 241 Florida Building Code Edition 2010 High Velocity Hurricane Zone Uniform Permit Application Form Section E (Tile Calculations) For Moment based tile systems, choose either Method 1 or 2. Compare the values for Mrwith the values from M,. If the Mr values are greater than or equal to the Mr values, for each area of the roof, then the tile attachment method is acceptable. AAMethod 1 "Moment (P1:„T?�� ZxX •Zee = /3B )-Mg: (P2: -756 x), -26Z = 2rp ) - Mg: (P3: '1/6-2- x Z8 2. .32-9 ) - Mg: Based Tile Calculations Per RAS 127" 4-65-= Mr, -7./ " Product Approval M, 41S 6.6 = Mr2 /S. Z Product Approval M, yS.s fez S= M3 96,.43- Product Approval Mt / • '' Method 2 "Simplified Tile Calculation Per Table Below" Required Moment of Resistance (Mr) From Table Below Product Approval M, M, Required Moment Resistance* Description Symbol Mean Roof Height -0. Roof Slope j 15' 20' 25' 30' H 40' Roof Slope 2:12 34.4 36.5 38.2 39.7 Restoring Moment due to Gravity 42.2 Product Approval 3:12 32.2 34.4 36.0 37.4 Calculated 39.8 F' 4:12 30.4 32.2 33.8 35.1 W 37.3 Tile Dimensions 5:12 28.4 30.1 31.6 32.8 34.9 6:12 26.4 28.0 29.4 30.5 32.4 .•4 7:12 24.4 25.9 27.1 28.2 : • • .30.0 •' *Must be used in conjunction with a Ilst of moment based tile systems endorsed by the • •.• • Broward County Board of Rules and Appeals. • •• • • • •• • • ••.• •••• For Uplift based tile systems use Method 3. Compare the values for F' with thevsfues for • •••• • Fr. If the F' values are greater than or equal to the Fr values, for each area of tbetpof, then: • • • the tile attachment method is acceptable. • • • • •••• . . • • • Method 3 "Uplift Based Tile Calculations Per RAS 127" • • (P1: x 1: _ _x w:= ) - W: x cos 0: - = Fri Product Aporove • (P2: x 1: _ _x w:= ) - W: x cos 0: - = Fre Product Apedlral F' _ • • • • (P3: x 1: = _x w:= ) - W: x cos 0: = Fr3 Product Approval F' • Where to Obtain Information Description Symbol Where to find Design Pressure P1 or P2 or P3 RAS 127 Table 1 or by an engineering analysis prepared by PE based on ASCE 7 Mean Roof Height H Job Site, Roof Slope 0 Job Site Aerodynamic Multiplier A Product Approval Restoring Moment due to Gravity M, Product Approval Attachment Resistance M, Product Approval Required Moment Resistance M, Calculated Minimum Attachment Resistance F' Product Approval Required Uplift Resistance F, Calculated Average Tile Weight W Product Approval Tile Dimensions I =length w = width Product Approval All calculations must be submitted to the Building Official at the time of permit application.. SECTION R4402.13 HIGH VELOCITY HURRICANE ZONES REQUIRED OWNERS NOTIFICATION FOR ROOFING CONSIDERATIONS R4402.13.1 Scope. As it pertains to this section, it is the responsibility of the roofing contractor to provide the owner with the required roofing permit, and to explain to the owner the content of this section. The provisions of Section R4402 govern the minimum requirements and standards of the industry for roofing system installations. Additionally, the following items should be addressed as part of the agreement between the owner and the contractor. The owner's initial in the adjacent box indicates that the' item has been explained. �J 1. Aesthetics -Workmanship: The workmanship provisions of Section R4402 are for the purpose of providing that the roofing system meets the wind resistance and water intrusion performance standards. Aesthetics (appearance) are not a consideration with respect to workmanship provisions. Aesthetic issues such as color or architectural appearance, that are not part of a zoning code, should be addressed as part of the agreement between the owner and the contractor. 2. Renailing Wood Decks: When replacing roofing, the existing wood roof deck may have to be renailed in accordance with the current provisions of Section R4403. (The roof deck is usually concealed prior to removing the existing roof system.) 3. Common Roofs: Common roofs are those which have no visible delineation between neighboring units (i.e. townhouses, condominiums, etc.) In buildings with common roofs, the roofing contractor and/or owner should notify the occupants of adjacent units of roofing work to be performed. 4. Exposed Ceilings: Exposed, open beam ceilings are where the underside of the roof decking can be viewed from below. The owner may wish to maintain the architectural appearance, therefore, roofing nail penetrations of the underside of the decking may not be acceptable. This provides the option of maintaining this appearance. 3 5. Ponding Water: The current roof system and/or deck of the building may not drain well and may cause water to pond (accumulate) in low-lying areas of the roof. Ponding cap be•an indieltjor:of structural distress and may require the review of a professional structural engineer. Pjgl-Riirjg may §11Qrren • the life expectancy and performance of the new roofing system. Ponding conditions•rray•not bepyidert . • until the original roofing system is removed. Ponding conditions should be correctecj. •• • J{ 1; .... ..•• J 6. Overflow scuppers (wall outlets): It is required that rainwater flow off Sp.trat the rdt;f jg bt overloaded from a build up of water. Perimeter/edge walls or other roof extensions maylalpclI this discige • • if overflow scuppers (wall outlets) are not provided. It may be necessary to install.4ge.lbw scupass in accordance with the requirements of Sections R4402, R4403 and R4413. • • • • • 4 7. Ventilation: Most roof structures should have some ability to vent natural air}low thr66011 tile . interior of the structural assembly (the building itself). The existing amount of attic ventitation shall.nat.he reduced. It may be beneficial t� consider additional venting which can result in extending the service.life bf the roof. Exception: Attic spaces, designed by a Florida' licensed engineer or register: architec is eliminate the attic venting, ve 0 shall not be required. PA) 6.7:' - • r s T nature • ' wner's/AIis Signature 06/02/ Date Property Address Permit Number DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) BOARD AND CODE ADMINISTRATION DIVISION NOTICE OF ACCEPTANCE (NOA) Polyglass USA Inc. 150 Lyon Drive Fernley, NV 89408 MIAMI-DADE COUNTY PRODUCT CONTROL SECTION 11805 SW 26 Street, Room 208 Miami, Florida 33175-2474 T (786) 315-2590 F (786) 315-2599 www.miamidade.2ov/ecodomv SCOPE: This NOAis being issued under the applicable rules and regulations governing the use of construction materials. The documentation submitted has been reviewed and accepted by Miami -Dade County RER - Product Control Section to be used in Miami Dade County and other areas where allowed by the Authority Having Jurisdiction (AHJ). This NOA shall not be valid after the expiration date stated below. The Miami -Dade County Product Control Section (In Miami Dade County) and/or the AHJ (in areas other than Miami Dade County) reserve the right to have this product or material tested for quality assurance purposes. If this product or material fails to perform in the accepted manner, the manufacturer will incur the expense of such testing and the AHJ may immediately revoke, modify, or suspend the use of such product or material within their jurisdiction. RER reserves the right to revoke this acceptance, if it is determined by Miami -Dade County Product Control Section that this product or material fails to meet the requirements of the applicable building code. This product is approved as described herein, and has been designed to comply with the Florida Building Code including the High Velocity Hurricane Zone of the Florida Building Code. DESCRIPTION: Polyglass Polystick Underlayments .... . • LABELING: Each unit shall bear a permanent label with the manufacturer's name or logo, oity, state Andefollowing • statement: "Miami -Dade County Product Control Approved", unless otherwise noted herejp, • • • • • • •. • • • RENEWAL of this NOA shall be considered after a renewal application has been filed an I. ere has baon'no change, • in the applicable building code negatively affecting the performance of this product. •••• •••• • • ... • •' TERMINATION of this NOA will occur after the expiration date or if there has been a reivi§ oJI or c• hange in the • •• materials, use, and/or Manufacture of the product or process. Misuse of this NOA as an eddois'setnent of any product,..:., for sales, advertising or any other purposes shall automatically terminate this NOA. Failure to eomplywrt.h any section • of this NOA shall be cause for termination and removal of NOA. • • • • •• •• • •• • } •.• •. • ADVERTISEMENT: The NOA number preceded by the words Miami -Dade County, Florida, and followed by the expiration date may be displayed in advertising literature. If any portion of the NOA is displayed, then it shall be done in its entirety. INSPECTION: A copy of this entire NOA shall be provided to the user by the manufacturer or its distributors and, shall be available for inspection at the job site at the request of the Building Official. This revises NOA #12-0713.02 and consists of pages 1 through 9. The submitted documentation was reviewed by Alex Tigera. MIAMI•DADE COUNTY APPROVED NOA No.: 14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 1 of 9 ROOFING COMPONENT APPROVAL Category: Sub -Category: Material: Roofing Underlayment SBS , APP Self -Adhering Modified Bitumen PRODUCTS DESCRIPTION: Product Polystick MTS Manufacturing Location #2 Polystick MTS Plus Manufacturing Location #2 Polystick IR -Xe Manufacturing Location #1 & #2 •••• • • P. ?Iystick Tt.J'>;11.ts. TSurface Print•rig} Manufacturing Dimensions Roll: 65'8" x 3'3-3/8" 60 mils thick Roll: • 65'87 x 3'33/8" 60 mils thick Roll: 65' x 3'33/8" Or 65' x 3' 60 mils thick '' • Roll: • 65' x 3'33/8" LVFation„ • • • • 80 mils thick #1•&•#2 •••• •r.♦ •••- • •••o•♦ • • • •••• •• •• Pttlystick TU $ , Roll: Tibb1ifactur4 Lit anon: .'32'10" x 3'33/8" • ••; • . • • t30 mils thick :47••• i •.• • • •• • • • • • • Polystick Tile Pro Manufacturing Location #2 Polystick Dual Pro Manufacturing Location. #2 MIAMI•DADE COUNTY APPROVED Roll: 61' x 3'33/8" 60 mils thick Roll: 61' x 3'33/8" 60 mils thick Test. Specification TAS 103 TAS 103 ASTM D 1970 TAS 103 and ASTM D 1970 Product Description A homogeneous, rubberized asphalt waterproofing membrane, glass fiber reinforced with polyolefinic film on the,upper surface for use as an underlayment for metal roofing, roof tile, slate tiles and shingle underlayment. A•homogeneous, rubberized asphalt waterproofing membrane, glass fiber reinforced with polyolefinic film on the upper surface for use as an underlayment for metal roofing, roof tile, slate tiles and shingle underlayment. A fine granular/sand top surface self -adhering, APP polymer modified, fiberglass reinforced, bituminous sheet material for use as an underlayment in sloped roof assemblies. Designed as an ice & rain shield. A rubberized asphalt self -adhering, glass- fiber/polyester reinforced waterproofing membrane. Designed as a metal roofing and roof tile underlayment. TAS 103 and ASTM A rubberized asphalt waterproofing membrane, D 1970 glass-fiber/polyester reinforced, with a granular surface designed for use as a tile roof e underlayment. TAS 103 and ASTM D 1970 A rubberized asphalt self -adhering, glass fiber/polyester reinforced waterproofing membrane. Designed as a metal roofing and roof tile underlayment. TAS 103 and ASTM A rubberized asphalt self -adhering, glass - D 1970 fiber/polyester reinforced waterproofing membrane. Designed as a metal roofing and roof tile underlayment. NOA No.: 14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 2 of 9 PRODUCTS DESCRIPTION: Product Polystick TU Max Manufacturing Location #2 Elastoflex S6 G Dimensions Roll: 65'8" x 3'3-3/8" 60 mils thick Test Product Specification Description TAS 103 and ASTM A rubberized asphalt self -adhering, polyester D 1970 reinforced waterproofing membrane. Designed as a a roof tile underlayment. , Roll: TAS 103 and ASTM Polyester reinforced, SBS modified bitumen 32' 10" x 3' 3-3/8" D6164 membrane with a burn off polyethylene or sanded back face and a granule top surface. For use in roof tile underlayment systems. MANUFACTURING PLANTS: 1.Hazelton, PA 2.Winter Haven, FL EVIDENCE SUBMITTED: Test Agency Trinity ( ERD PRI Asphalt Technologies Momentum Technologies, Inc. MIAMI•DADE COUNTY APPROVED Test Identifier P10870.09.08 -R1 P10870.04.09 P33360.06.10 P33370.03.11 P33370.04.11 P36900.09.11 P37300.10.11 P40390. 08.12-1 P40390.08.12-2 P40390.10.12 P37590.07.13-1 P45270.05.14* P46520.10.14 P44360.10.14 P43290.10.14 PUSA-035-02-01 PUSA-055-02-02 PUSA-089-02-01 JX20H7A RX I 4E8A DX23D8B DX23D8A Test Name/Report TAS 103 TAS 103/ASTM D4798 & G155 ASTM D1970 TAS 103: ASTM D 1623 TAS l'03/ASTM D4798 & G155 TAS 110/ASTM D4798 88 D1970 TAS 103 & TAS 110' • • ASTM D 1623 • ASTM D 1970 • • • • ASTM D6164 •....' TAS 103, TAS 110 & ASTM• D1623 •• •• ASTM D1623 . • • • TAS 103 & TAS 1 10 •' ASTM D 1970 & TAS JVD TAS 103 TAS 103 TAS 103/ASTM D4798 & G155 TAS 103/ASTM D4798 & G155 TAS 103/ASTM D4798 & G155 TAS 103/ASTM D4798 & G155 TAS 103/ASTM D4798 & G155 Date 12/04/08 04/13/09 07/01/10 03/02/11 04/26/11 .49/01/11 '..410019/11` .•1,8406/12 •' 08707/12' ..)9/03/11 •.. D002/13,.... •0.5412/14.•:•." �. • . .. • . • '10/03/14 :•.4W07/1•••' 4• • • 11:I17/1Q••••' . • . • • • 09/29/06 12/10/07 07/06/09 04/01/08 11/09/09 02/18/10 02/18/10 NOA No.: 14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 3 of 9 INSTALLATION PROCEDURES: Deck Type 1: Wood, non -insulated Deck Description: • Min. 19/32" plywood or wood plank,. System Type E(1) Anchor sheet mechanicallyfastened to deck, membrane adhered Anchor/Base Sheet: One or more plies of ASTM D 226 Type II or ASTM D 2626. Fastening: Per FBC 1518.2 & 1518.4 Nails and tin caps 12" grid, 6" o.c. at a minimum 4" head lap. (for base sheet only) Polystick membranes self -adhered. See General Limitations Below. Membrane: Surfacing: Deck Type 1: Deck Description: System Type E(2) Anchor/Base Sheet: Fastening: Membrane: Surfacing: Deck Type 1: Deck Description: • Svs tem TypeV) ,lrnchorBe;Shget: „Fastening: • • • •••• • • •�l �'heet• •••• .. ••... .CQAXional)• .:.. Membrane: • •Surfacing: . ••• • • • MIAMI.DADE COUNTY APPROVED Wood, non -insulated Min. 19/32" plywood or wood plank Anchor sheet mechanically fastened to deck, membrane adhered One or more plies of ASTM D 226 Type II or ASTM D 2626. Per FBC 1518.2 & 1518.4 Nails and tin caps 12" grid, 6" o.c. at a minimum 4" head lap. (for base sheet only) Elastoflex S6 G, hot asphalt applied. See General Limitations Below. Wood, non -insulated Min. 19/32" plywood or wood plank • Base sheet mechanically fastened deck, subsequent cap membrane self- adhered. Otie or more plies of ASTM D 226 Type II or ASTM D 2626. .•;�c,r.FBC 1518.2 & 1518.4 Nails and tin caps 12" grid, 6" o.c. at a minimum 4" head lap. (for • • •base sheet only), .13olystick MTS Plus, self -adhered with minimum 3" horizontal laps and minimum 6" vertical • •.lips. • Td 'stick TU Plus, self -adhered. •• . See•General Limitations Below. . • • • •• NOA No.:14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 4 of 9 INSTALLATION REQUIREMENTS: 1. 1 All nails in the deck shallbe carefully checked for protruding heads. Re -fasten any loose decking panels, and sweep the deck thoroughly to remove any dust and debris prior to application. 2. Place the underlayment over, metal drip edge in accordance with RAS,111. 3. Place the first course of membrane parallel to the eave, rolling the niembrane to obtain maximum contact. Remove the release film as the membrane is applied. All side laps shall be a minimum of 3-'Y2" and end laps shall be a minimum of 6". Roll the membrane into place after removing the release strip. Vertical strapping of the roof with Polystick is acceptable. Membrane shall be back nailed in accordance with applicable building code. r , 4. When applying the membrane in the valley, start at the low point and work to the high point, rolling the membrane from the center outward in both directions. 5. For ridge applications, center the membrane and roll from the center outward in both directions. 6. Roll or broom the entire membrane surface so as to have full contact with the surface, giving special attention to lap areas. 7. Flash vent pipes, stacks, chimneys and penetrations in compliance with Roof Assembly current Product Control Notice of Acceptance. 8. All protrusions or drains shall be initially taped witha 6" piece of underlayment. The flashing tape shall.be pressed in place and formed around the protrusion to ensure a tight fit. A second Layer of Polystick shall be applied over the underlayment. GENERAL LIMITATIONS: 1. Fire classification is not part of this acceptance. 2. Polystick MTS, Polystick MTS Plus, Polystick TU Plus, Polystick Tile Pro and Polystick Dual Pro may be used in asphaltic shingles, wood shakes and shingles, non-structural metal roofing, roof tile sxstems ae8 ituarry slate roof assemblies. Polystick TU P may be used in all the previous assemblies listed engpt metal r44i►g. • • Polystick IR -Xe may be used in all the previous assemblies listed except metal rooiatMgand rooftile's�stems • Polystick TU Max may be used in non-structural metal roofing and roof tile systemsf•tylastoflex S6 G maybe • used in roof the systems only. .•••• •• • • •• • • .... ..•. 3. Deck requirements shall be in compliance with applicable building code. •••• ..: • • • . 4. Polyglass Polystick membranes shall be applied to a smooth, clean and dry surface' F1•ie deck saaltbe free of" • irregularities.• 5. Polyglass Polystick membranes and underlayments shaltl"not be: adhered directly ovtr a.�ire-existing roof • membrane as a recover system. •. • • • • • 6. Polyglass Polystick membranes shall not be left exposed as a temporary roof for longer than the amount of days listed in the table below after application. Polyglass reserves the right to revise or alter product exposure times; not to exceed the preceeding maximum time limitations. Exposure Limitations (days) MTS IR -Xe Elastoflex S6 G TU Plus TU P Tile Pro Dual Pro TU Max MTS Plus Winter Haven, FL. 180 90 180 180 180 180 180 90 180 Hazelton, PA. N/A 90 N/A 180 'N/A N/A N/A N/A N/A 7. All products listed herein shall have a quality assurance audit in accordance with the Florida Building Code and Rule 9N-3 of the Florida Administrative Code. NOANo.: 14-0717.08 Expiration' Date: 09/13/16 Approval Date: 01/22/15 Page 5 of 9 8. In roof tile application, data for the attachment resistance of roof tiles shall be as set forth in the roof tile manufacturer's Notice of Acceptance. Polystick TU Plus, Polystick Tile Pro, Polystick TU Max or Elastoflex S6 G may be used in both adhesive set and mechanically fastened roof tile applications. Polystick Dual Pro is limited to mechanically fastened roof tile applications. Polystick MTS and Polystick MTS Plus are limited to mechanically fastened with the limitations outlined in Section 9. Polystick TU P may be used in mechanically fastened roof tile applications with the exception of mortar set tile applications. 9a. The maximum roof slope for use as roof tile underlayment for (direct -to -deck) tile assemblies shall be as follows: (See Table Below) Tile Profile Polystick MTS Elastoflex S6 G Polystick TU Plus, TU P, Tile Pro, Dual Pro Polystick TU Max Polystick MTS Plus' „ '- Flat Tile Prohibited 4:12 No limitation No limitation 5:12 without battens s Profiled Tile Prohibited without battens , 4:12 No limitation No limitation 4:12 The above slope limitations can be exceeded only by using battens and counter battens in accordance with the Approved Tile System Notice of Acceptance and applicable Florida Building Code requirements. Battens are required for both loading and installation of tiles at all times. 'The following limitations shall be apply when using Polystick MTS Plus: • Slopes up to those shown in the table above will require stagging of tiles — two tiles laid perpendicular to slope followed by a maximum four tile stack parallel to the'slope, for a total of 6 tiles. (See Figure 1 below) • Battens shall be used for stagging of lugged tiles above 4:12 ••••13(11 -tens shall be used for stagging of flat tiles above 5:12 • • • . • •••• ' • •• . • • • •• • • •,• • •• • • • •••• ••.• • •• • •••• • • ••,•• • • • • • • • • • • • • • • • ••• • • •• • • • • •• t Figure 1: Stagging Method 9b. There shall be no roof slope limitation for the Polystick MTS Plus / Polystick TU Plus two-ply underlayment system when a applied using the stagging method outlined above. NOANo.: 1420717.08' Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 6 of 9 10. Care shouldbe taken during the loading procedure to keep foot traffic to a minimum and to avoid dropping of tile directly on the underlayment. Refer to Polyglass' Tile loading detail below for loading procedure for all underlayments except Polystick MTS which shall be loaded onto battens. .. 0 0. 0 N N e- Ibof Deck prepared with POLYSTICKTU Plus 6 Roofing Tiles (6 Max Per Stack) 12 11. Refer to prepared roofing system Product Control Notice of Acceptance for listed approval of this product with specific prepared roofing products. Polystick MTS, Polystick MTS Plus,"Polystick IR -Xe, Polystick TU Plus, Polystick TU P, Polystick TU Max, Polystick Dual Pro, Polystick Tile Pro or Elastoflex S6 G may be used with any approved roof covering Notice of Acceptance listing Polystick"MTS,"Polystick MTS Plus, Polystick IR -Xe, Polystick TU Plus, Polystick TU P, Polystick TU Max, Polystick Dual Pro, Polystick Tile Pro or Elastoflex S6 G as a component part of an assembly in the Notice of Acceptance. If Polystick°MTS, Polystick MTS Plus, Polystick IR -Xe, Polystick TU Plus; Polystick TU P, Polystick TU Max, Polystick Dual Pro, Polystick Tile Pro or Elastoflex S6 G are not listed, a request may be made to the Authority Having Jurisdiction (AI -IJ) or the Miami -Dade County Product Control Department for approval provided that appropriate documentation is provided to detail compatibility of the products, wind uplift resistance, and fire testing results. .,.. • • LABELING: • • • •• • ••••• .• •• • • • 1. All, membranes or packaging shall bear the imprint or identifiable marking of the manttfizlvtsrer's name or logo, .itx and state of manufacturing facility and the following statement: "Miami -Dade Countelloduct Cplitfdl.Approved" • or the Miami -Dade County Product Control Seal as shown below.• • •••• •••• ••.• • • • MIAMI-DADE COUNTY APPROVED BUILDING PERMIT REQUIREMENTS: • - •. •• •.•• • • • • • • • • • • • • • • • • • • •• • • ••• • • • • • Application• for buildingpermit shall be accompanied bycopies of the followin • • P Pg� 1. This Notice of Acceptance. 2. Any other documents required by the Building Official or applicable building code in order to properly evaluate the installation of this materials. MIAMI-DADE COUNTY APPROVED NOA No.: 14-0717.08 Expiration' Date: 09/13/16 Approval Date: 01/22/15 Page 7 of 9 POLYGLASS GENERAL APPLICATION GUIDELINES FOR POLYSTICK MEMBRANES: 1. Polyglass does accept the direct application of Polystick underlayment membranes to wood decks. Installers are cautioned to refer to applicable local building codes prior to direct deck installation to ensure this is acceptable. Please also refer to applicable Product Data Sheets of the corresponding products. 2. All rolls, with the exception of Polystick TU Plus should be back -nailed in selvage edge seam as per Polyglass Back Nailing Guide. Nails shall be, 11 gauge ring shank type, applied with a minimum 1" metal disk as required in Dade County or simplex type nail as otherwise allowable in other regions, at a minimum rate of 12" o.c. Polystick TU Plus should be back nailed in designated area marked "nail area, area para clavar" on the face of membrane, with the above stated nails and/or disks. The head lap membrane is to cover the area being back - nailed. (Please refer to applicable local building codes prior to installation.) 3. All seal lap seams (selvage laps) must be rolled with a hand roller to ensure full contact. 4. All fabric over fabric; and granule over granule end laps, shall have a 6" wide, uniform layer of Polyglass Polyplus 55 Premium Modified Flashing Cement, Polyglass Polyplus 50 Premium MB Flashing Cement, XtraFlex 50 Premium Modified Wet/Dry Cement, Polyglass PG500 MB Flashing Cement, applied in between the application of the lap. The use of mastic between the laps does not apply to Polystick MTS. 5. A makimum of 6'tiles per stack ar&allowed when loading tile on the underlayments. Refer to the Polyglass Tile Loading Guidelines. See General Limitations #9'and #10: ` 6. Battens and/or Counter -battens, as required by the tile manufacturers NOA's, must_be used on all projects for pitch/slopes of 7"112" or greater. It is suggested that on pitch/slopes in excess of 6 1/4"/12", precautions should be taken, such as the use of battens to prevent tile sliding during the loading process. P 7. Minimum cure time after membrane installation & before loading of roofing tiles is Forty -Eight (48) Hours. 8. Polystick membranes may not be used in any exposed application such as crickets, exposed valleys, or exposed roof to wall details. •2••••Repat49f Pblysticic meibranes is to be accomplished by applying Polyglass Polyplus 55 Premium Modified • • Flashig.Gement:Polgglass Polyplus 50 Premium MB Flashing Cement, XtraFlex 50 Premium Modified • Wet/Dry'Cement!Pptyglass PG500 MB Flashing Cement to the area in need of repair, followed by a patch of the •Polystics'k material M1ik'e kind should beset and hand rolled in place over the area needing such repair. Patching memb��ri.,hall be•uriiimum of 6 inches in either direction. The repair should be installed in such a way so • • that water will rug ,pata lel to or over the top of all laps of the patch. • • • 'IA."'All self'adliered membranes must be rolled to ensure full contact with approved substrates. Polyglass requires a • u • minimum 0440 ltis gr aj weighted roller for the rolling of the field membrane. Hand rollers are acceptable for • •rollin'df Mtches or small areas of the roof. Brooming may be used where slope prohibits rolling. • • • '11. 'All appi;o •kad substrates should be dry, clean and properly prepared, before any application of Polystick membranes commences. An approved substrate technical bulletin can be furnished upon request. It is recommended to refer to applicable building codes prior to installation to verify acceptable substrates. 12. The Polyglass Miami -Dade Notice of Acceptance (NOA) approval for Polystick membranes can be furnished upon request by our Technical Services Department by calling 1 (800) 894-4563. NOA No.: 14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 8 of 9 • • 13. Questions in regards to the application of Polyglass products should be directed to our Technical Services Department at 1 (800) 894-4563. 14. Polyglass recommends that applicators follow good roofing practices and applicable procedures as outlined by the National Roofing Contractors Association (NRCA). PLEASE CHECK WITH LOCAL BUILDING CODES REGARDING LIMITATIONS OF SPECIFIC APPLICATIONS. LOCAL CODES MAY SUPERSEDE POLYGLASS REQUIREMENTS AND r RECOMMENDATIONS. END OF THIS ACCEPTANCE MIAMI-DADE COUNTY APPROVED .... . . . . .... .• . .. . .... . .. . . .. . • • • •••• •••• • •. • •• •.... • • • . • • • • • ..• • • ••• • .. } • .. • • • • NOA No.: 14-0717.08 Expiration Date: 09/13/16 Approval Date: 01/22/15 Page 9 of 9 141AMI.OADE COUNTY BUILDING AND NEIGHBORHOOD COMPLIANCE DEPARTMENT (BNC) BOARD AND CODE ADMINISTRATION DIVISION NOTICE OF ACCEPTANCE (NOA) Eagle Roofing Products LLC 1575 East C.R. 470 Sumterville, FL 33585 MIAMI-DADE COUNTY PRODUCT CONTROL SECTION 11805 SW 26 Street, Room 208 Miami, Florida 33175-2474 T (786) 315-2590 F (786) 315-2599 www.miamidade.aov/buildina/ SCOPE: This NOA is being issued under the applicable rules and regulations governing the use of construction materials. The documentation submitted has been'reviewed and accepted by Miami -Dade County BNC - Product Control Section to be used in Miami Dade County and other areas where allowed by the Authority Having Jurisdiction (AHJ). This NOA shall not be valid after the expiration date stated below. The Miami -Dade County Product Control Section (In Miami Dade County) and/or the AHJ (in areas other than Miami Dade County) reserve the right to have this product or material tested for quality assurance purposes. If this product or material fails to perform in the accepted manner, the manufacturer will incur the expense of such testing and the AHJ may immediately revoke,•modify, or suspend the use of such product or material within their jurisdiction. BNC reserves the right to revoke this acceptance, if it is determined by Miami -Dade. County Product. Control• • • • • Section that this product or material fails to meet the requirements of the applicable buiiding code • • • . This product is approved as described herein, and has been designed to comply witlttliFtorida Bdildlhg Cotlb' • • • • • • including the High Velocity Hurricane Zone of the Florida Building Code. DESCRIPTION: Malibu Concrete Tile .... . . .... . . .... • • . • .... .... •• LABELING: Each unit shall bear a permanent label with the manufacturer's namelonlsw, city, •state and following statement "Miami -Dade County Product Control Approved", unless otherwise rioted Deas id. • • • • . RENEWAL of this NOA shall be considered after a renewal application has been filed and therr;bs been no change m the applicable building code negatively affecting the performance of this product. TERMINATION of this NOA will occur after the expiration date or if there has been a revision or change in the materials, use, and/or manufacture of the product or process. Misuse of this NOA as an endorsement of any product, for sales, advertising or any other purposes shall automatically terminate this NOA. Failure to comply with any section of this NOA shall be cause for termination and removal of NOA. ADVERTISEMENT: The NOA number preceded by the words -Miami -Dade County, Florida, and followed by the expiration date may be displayed in advertising literature. If any portion of the NOA is displayed, then it shall be done in its entirety. • INSPECTION: A copy of this entire NOA shall be provided to the user by the manufacturer or its distributors and shall be available for inspection at the job site at the request of the Building Official. This renews NOA #06-0526.09 and consists of pages 1 through 7. The submitted documentation was reviewed by Alex Tigera. NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 1 of 7 • ROOFING ASSEMBLY APPROVAL Category: Sub Category: Material: Roofmg Roofing Tiles Concrete 1. SCOPE: This approves a system using Eagle Roofing Products Malibu Concrete Roof Tile, as manufactured by Eagle Rooting Products LLC in Sumterville, FL. and described in Section 2 of this Notice of Acceptance. For locations where the pressure requirements, as determined by applicable Building Code does not exceed the design pressure values obtained by calculations in compliance with RAS 127 using the values listed in section 4 herein. The attachment calculations shall be done as a moment based system. 2. PRODUCT DESCRIPTION: • Manufactured by Applicant Dimensions Malibu Concrete Tile 1= 17" w = 12'A" %2" thick Trim Pieces 1= varies w = varies varying thickness Test Product Specifications Description TAS 112 Low profile, interlocking, high pressure extruded concrete roof tile equipped with three nail hole and dolt* roll ribs • For direct deck or battebbd >tail -on, tfiMar or adhesive set applic&fiini. • • • • TAS 112 Accessory trim, coaorete roof pieces for • use at hips, rakes, ridges and vail1y terminations. MablilEll4bured forWach tile profile. .. .. .... • •. . • . • . • • • .• • • •.. • . . . NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 2of7 2.1 EVIDENCE SUBMITTED: Test Aeency PRI Construction Materials Technologies Redland Technologies Redland Technologies Redland Technologies The Center for Applied Engineering, Inc. The Center for Applied Engineerings Inc. Redland Technologies Redland Technologies Professional Service Industries, Inc. The Center for Applied Engineering, Inc. The Center for Applied Engineering, Inc. The Center for Applied Engineering, Inc. The Center for Applied Engineering, Inc. The Center for Applied Engineering, Inc. The Center for Applied Engineering, Inc. :FD4wEDI Test Identifier PRI06178 7161-03 Appendix III 7161-03 Appendix II P0402 94-060B 94-084 P0631-01 Letter Dated Aug. 1, 1994 224-47099 25-7094-1 25-7094-7 25-7094-4 Project No. 307025 Test #MDC -76 25-7183-1 25-7183-2 Test Name/Report TAS 112 Static Uplift Testing TAS 102 & TAS 102(A) Wind Tunnel Testing TAS 108 (Nail -On) Withdrawal Resistance Testing of screw vs. smooth shank nails Static Uplift Testing TAS 101 (Adhesive Set) Static Uplift Testing TAS 101 (Mortar Set) Wind Tunnel Testing TAS 108 (Mortar Set) Wind Tunnel Testing TAS 108 (Nail -On) Physical Propertieg.. • : TAS 112 • Static Uplift Testing. • TAS 102 •••••• (4" Headlap, Nails, Direct Deoly Mew Construction)D • • • • Static Uplift Testing • TAS 102 . (4" Headlap, Nails, Battens) : Static Uplift Testing TAS 102 (4" Headlap, Nails, Direct Deck, Recover/Reroof) Wind Driven Rain TAS 100 Static Uplift Testing TAS 102 (2 Quik -Drive Screws, Direct Deck) Static Uplift Testing TAS 102 (2 Quik -Drive Screws, Battens) Date 08/23/06 Dec. 1991 Dec. 1991 Sept. 1993 March, 1994 May 1994 July 1994 Aug. 1994 •Sept. 1994• • .. . • . 1994, . Oct. 1994 • •... . . • 'Oct:1994 Oct. 1994 Feb. 1995 Feb. 1995 . NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 3 of 7 The Center for Applied 25-7214-2 Engineering, Inc. 25-7214-6 Celotex Corporation Testing Services Walker Engineering, Inc. Walker Engineering, Inc. Walker Engineering, Inc. Walker Engineering, Inc. Walker Engineering, Inc. 528454-2-1 520109-2 Evaluation Calculations Evaluation Calculations Evaluation Calculations Evaluation Calculations Evaluation Calculations Walker Engineering, Inc. Calculations Walker Engineering, Inc. Calculations Static Uplift Testing TAS 102 (1 Quik -Drive Screw, Direct Deck) (1 Quik -Drive Screw, Battens) Static Uplift Testing TAS 101 Two Patty Adhesive Set System 25-7183 25-7094 25-7496 25-7584 25-7804b-8 25-7804-4 & 5 25-7848-6 Aerodynamic Multiplier Restoring Moment Due to Gravity . . March, 1995 Sep. 1998 Dec. 1998 April 1999 March 1995 February 1996 April 1996 December 1996 Sep. 2006 Sep. 2006 •0000 . 3. LIMITATIONS: 0000 0• 3.1 Fire classification is not part of this acceptance.• • . 3.2 For mortar or adhesive set tile applications, a static field uplift test in a000rdance witk.FAS 106 may required, refer to applicable building code. •••• •••• 3.3 Applicant shall retain the services of a Miami -Dade County Certified f.4198f&ory to p}fdrm quarterly test in accordance with TAS 112, appendix 'A'. Such testing`sa:0e submftted to the Building Code Compliance Office for review. 3.4 Minimum underlayment shall be in compliance with the applicable RoofingApp1KMfddsr . Standards listed section 4.1 herein. '...: .... . 3.5 30/90 hot mopped underlayment applications may be installed perpendicular to th.. robf slope unless stated otherwise by the underlayment material manufacturers published literature. 3.6 This acceptance is for wood deck applications. Minimum deck requirements shall be in compliance with applicable building code. • . . • • • • . • • NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 4 of 7 • • • 4. INSTALLATION 4.1 Eagle Roofing Products LLC Malibu Concrete Tile and its components shall be installed in strict compliance with Roofing Application Standard RAS 118, RAS 119 and RAS 120. 4.2 Data For Attachment Calculations Malibu Tile Tile Profile Table 2: Aerodynamic Multipliers - ?. (ftt (ft') (ft) Batten Application Direct Deck.Applicatio 0.305 I, 0.282 ( Table 1: Average Weight (W) and Dimensions (I x w ) Tile Profile Weight -W (Ibf) Length-1(ft) Width -w (ft) Malibu Tile 9.5 1.417 1.04 7":12" or g� r Malibu Tile • Malibu Tile Tile Profile Table 2: Aerodynamic Multipliers - ?. (ftt (ft') (ft) Batten Application Direct Deck.Applicatio 0.305 I, 0.282 ( • . • • • . .... .... le 4: chment Resistance Expressed as a Moment ..My(ft-Ibf) • • • • for Nail -On Systems •• • • • Table 3�(testoring Moments due to Gravity - Mlb_.__-� Tile Profile Fastener Type . . 3":12" 4":12" 5":12" 6":12" 7":12" or g� r Malibu Tile • 27.8 Battens Di Deck Battens Direct Deck Battens Direct Deck. Battens Direct Battege .Direct . 6.30 6`6,5 i 6.21 6.54 6.08 6.41 5.93 , 5.77.. 8.08 i I, 47.1 • . • • • . NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 5of7 . ... . . 0410 .... .... le 4: chment Resistance Expressed as a Moment ..My(ft-Ibf) • • • • for Nail -On Systems •• • • • . ° •_ T Tile Profile Fastener Type . . Direct Deck (min 15132" plywood) Direct D4415;:. (min. 19132"• : plywood) . 4141 .. . daitens • • 41 .41. • • . Malibu Tile 2-10d Ring Shank Nails 27.8 37.4 • • ' 28.8 1-10d Smooth or Screw Shank Nail 8.8 11.8 4.1 2-10d Smooth or Screw Shank Nails 16.4 21.9 7.1 1 #8 Screw 25.8 25.8 22.9 2 #8 Screw 47.1 47.1 49.1 1-10d Smooth or Screw Shank Nail (Field Clip) 24.3 24.3 24.2 1-10d Smooth or Screw Shank Nail (Eave Clip) 19.0 19.0 22.1 2-10d Smooth or Screw Shank Nails (Field Clip) 35.5 35.5 34.8 2-10d Smooth or Screw Shank Nails (Eave Clip) 31.9 31.9 32.2 2-10d Ring Shank Nails' I 43.0 1 67.5 1 50.9 1 installation with a 4" tile headiap and fastemers are located a min. of 2W from head of tile. NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 5of7 . ... . . 0410 Table 6: Attachment Resistance Expressed as a Moment M1 (ft -WO for Two Patty Adhesive Set Systems Tile Profile Tile Application Minimum Attachment Resistance Malibu Tile Adhesive 26.14 2 See manufactures component approval for installation requirements. 3 flexible Products Company TileBond Average weight per patty 11.4 grams. Polyfoam Product, Inc. Average weight per patty 8 grams. Table 6: Attachmen esistance Expressed as Moment - Mr (ft-Ibf) for S n le Patty Adhesive Set Sys s Tile Profile Tile Application Minimum Attachment Resistance Malibu Tile Polyfoam PolyProTM 86.61' --I- -rPolyfoam PolyfoamPolyProT .rs45:5°') 4 Large paddy placement of 54g ms of PolyPro"'.- ;, 4 Medium paddy placement of 2 rams of PotyPro"'. 5. LABELING : . . All tiles shall bear the imprint or identifiable marking of the manufacttfreri frame or lo&o. (See Detail Beiow)s or following statement "Miami -Dade County Product Control approved". .. . • ••• . . . .. • Elerit-7" FLORIDA MALIBU CONCRETE ROOF TILE LABEL) SUMTERVILLE. PLANT (LOCATED ON UNDERSIDE OF TILE) NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 6 of 7 • .• • . . Table 7: Attachme t Resistance Exp for Mortar Set as a Moment - Mr(ft-Ibf) tams • • • • Tile Profile :Attachment • • • • e • • •• AUsistanc• plication Malibu Tile Mortar Set ...:4.60 .... ...•. - . 5. LABELING : . . All tiles shall bear the imprint or identifiable marking of the manufacttfreri frame or lo&o. (See Detail Beiow)s or following statement "Miami -Dade County Product Control approved". .. . • ••• . . . .. • Elerit-7" FLORIDA MALIBU CONCRETE ROOF TILE LABEL) SUMTERVILLE. PLANT (LOCATED ON UNDERSIDE OF TILE) NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 6 of 7 • .• • . . 6. BUILDING PERMIT REQUIREMENTS: 6.1 Application for building permit shall be accompanied by copies of the following: 6.1.1 this Notice of Acceptance. 6.1.2 Any other documents required by Building Official or Applicable building code in order to properly evaluate the installation of this system. PROFILE DRAWING ... . . .... • • • • MALIBU CONCRETE ROOF TILE END OF THIS ACCEPTANCE .. . .... • . . . • NOA No.:11-0321.01 Expiration Date: 10/05/16 Approval Date: 05/12/11 Page 7of7 Miami Shores Village Building Department 10050•N.E.2nd Avenue Miami Shores, Florida 33138 Tel (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation 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. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker coinpensation injuries of any person allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE. READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner YY A Print Name: 2404) L t cer�--0 Signature, (� State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this 4112X • ELLIOT SOTO * MY COMMISSION # a 107020 EXPIRES:August 5, 2015 ed Ttn Budget Notary Services day of By 7 d .., 'Nos NI' ' (SEAL) �f Type of Identification produ d State of Florida) County of Miami -Dade ) Sworn to and subscribed be day of ?° By re4e this ELLIOT SOTO * Y COMMISSION # EE 107020 EXPIRES: August 5, 2015 Bonded Thru Budget Notary Services (SEAL) Type of Identification prod' ced