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RF-19-2340Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 — -'-, - Q i—,L- Ift Iii-m % Issue Date:12/09/2019 Location Address Parcel Number 260 NE 99TH ST, Miami Shores, FL 33138 1132060134320 Contacts Permit NO.: RF-10-19-2340 Permit Type: Roof Work Classification: Flat Permit Status: Approved Expiration: 06/08/2020 Jorge Toledo Owner ADDERLY DEVELOPMENT INC Contractor 26099 TODD R ADDERLY 8255 W SUNRISE BLVD 119, PLANTATION, FL 33322 Business: 9544454078 adderlydev@yahoo.com Description: RE -ROOF FLAT Valuation: $ 4,200.00 Inspection Requests: 305-62-4949 Total Sq Feet: 600.00 Fees Amount Application Fee - Other $50.00 CCF $3.00 DBPR Fee $3.75 DCA Fee $2.50 Education Surcharge $1.00 Roofing Fee $200.00 Scanning Fee $9.00 Technology Fee $6.25 Total: $275.50 Payments Date Paid Amt Paid Total Fees $275.50 Credit Card 10/03/2019 $50.00 Cash 12/09/2019 $225.50 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing in is accurate and that all work will be done in compliance with all applicable laws regulating'const�uction and zoning. Futhermore,-'I'Sidthorize the above named contractor to do the work stated. Signature: / Applicant / Contractor / Agent Date December 09, 2019 Page 2 of 2 � nA h� vrPcd (0/"�/q 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 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC 0 ROOFING PLUMBING MECHANICAL PUBLIC WORKS VOOC ED 9 BY: y�F B'C 201 Master Permit No. 1{— t o-1 Gj I " Sub Permit No. ❑ REVISION ❑ EXTENSION DRENEWAL CHANGE OF 0 CANCELLATION 0 SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 260 NE 99 ST City Miami Shores County- Miami Dade Zip: .3 Folio/Parcel#: 11c3206 013 4320 Is the Building Historically Designated: Yes NO Occupancy Type:.)_ Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): JORGE TOLEDO, MAGALYS TOLEDO Phone#: 260 NE 99 ST City City: MIA SHORES State: FL Zip: 33138 Tenant/Lessee Name: Email: CONTRACTOR: Company Name: ADDERLY DEVELOPMENT INC 5079 N DIXIE HWY, # 258 Phone#: hone#: 954 445 4078 City: City: OAKLAND PK State: FL Zip: 33334 Qualifier Name: TODD ADDERLY Phone#: 954 445 4078 State Certification or Registration #: CCC 1327886 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ i 1 0 V Square/Linear Footage of Work: Q U Type of Work: ❑ Addition ❑ Alteration ❑ New ❑■ Repair/Replace ❑ Demolition Description of Work: RE ROOF FLAT Specify color of color thru tile: Submittal Fee $ �Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ — (Revised02/24/2014) CCF $_ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ P, 5 00 • Op TOTAL FEE NOW DUE $ �2—S -92g.S-b Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address Zip City State Zi Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature C7,Signature ���NER or AGENT CON A OR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 0 N n rn LL LL it O w N i LU � w O 0: U C- w day of SEPT $--G T6 20 19 , by who is personally known to 9 da of SEPT 20 19 by 6 v 1L who is personally known to O or who has produced as me or who has produced as 1' P "fie- GA R ifica ion and who did take an oath. �� �y ntification and who did take an o OGIP4 Oa`z� `a. �e MY coMMISSIQN # F TARY PUBLIC: ?os EXPIRES October 74fViRRY UBLIC: (a07)308.0.53 FfaWBNote Sarvka.ron• I: �— Sign: /�✓� Q it \�- CA \ ly �,/��,� \/1 Print: \sue f J � \ V Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 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' Vompensatlon insurance I`xemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Own r State of Florida County of Miami -Dade The foregoing was acknowledge before me this By' T6 l 'C do K GAIL ROBINSON MY COMMISSION # FF927240 EXPIRES October 14, 2019 WC/)34)E-0'S3 RmidaNOaryServke.com day of `D� , 20 r . who is personally known to me or has produced as identification. Notary. 6_ SEAL: 9/912019 Propertv Search Application - Miami -Dade Countv ""PERVY" ARRANER 0 F F I E 0 F T HE= F N U, r Summary Report Property Information Folio: 11-3206-013-4320 Property Address: 260 NE 99 ST Miami Shores, FL 33138-2435 Owner JORGE TOLEDO MAGALYS VITIELLO TOLEDO Mailing Address 260 NE 99 ST MIAMI SHORES, FL 33138 USA PA Primary Zone 1000 SGL FAMILY - 2101-2300 SO Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY: 1 UNIT Beds / Baths / Half 2/2/0 Floors 2 Living Units 1 Actual Area 2,969 Sq.Ft Living Area 2,312 Sq.Ft Adjusted Area 2,518 Sq.Ft Lot Size 14,375 Sq.Ft Year Built 1925 Assessment Information Year 2019 2018 2017 Land Value $431,422 $431,422 $431,422 Building Value $265,190 $149,613 $149,613 XF Value $36,964 $37,398 $37,833 Market Value $733,5761 $618,4331 $618,868 Assessed Value $733,576 $415,227 $406,687 Benefits Information Benefit Type 2019 2018 2017 Save Our Homes Cap Assessment Reduction $203,206 $212,181 Homestead Exemption $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 1 AMD PB 10-70 LOTS 4 & 5 & E1/2 OF LOT 6 BLK 32 LOT SIZE 125.000 X 115 OR 20474-4522 06 2002 4 Generated On : 9/9/2019 Taxable Value Information 2019 2018 2017 County Exemption Value $0 $50,000 $50,000 Taxable Value 1 $733,576 $365,227 $356,687 School Board Exemption Value $0 $25,000 $25,000 Taxable Value $733,576 $390,227 $381,687 City Exemption Value $0 $50,000 $50,000 Taxable Value $733,576 $365,227 $356,687 Regional Exemption Value $0 $50,000 $50,000 Taxable Value 1 $733,576 $365,227 $356,687 Sales Information OR Previous Price Book- Qualification Description Sale Page 12/11 /2018 $850,000 31267 Qual by exam of deed 2001 12/17/2009 $585,000 27129 Qual by exam of deed 4920 26652- Sales which are disqualified as a result of 11/17/2008 $114,239 1881 examination of the deed 20474- Sales which are disqualified as a result of 06/01/2002 $0 4522 examination of the deed The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp Version: 'Vv Miami hores illa e g 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 2n6 Ave Miami Shores, FI 33138 Re: Owner's Name: JORGE TOLEDO, MAGALYS TOLEDO Property Address: 260 NE 99 ST Roofing Permit Number. Date: 9/9/19 Dear Building Official: J a -e certify that I am not required to retrofit the roof to wall connections of my building because: uKhe 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 edition of the South Florida Building Code (1994 SFBC) Si 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 above property mentioned. Sworn to and subscribed before me this SEPT 9 2019 Notary Public, Sate of Florida at Large day of When the just valuation of the structure for purpose of ad valorem taxation is equal to or more than $300,000.00. e SFBC. Then you must provide a building application from a General Contractor for the Roof to Wall connection Hu ROg�Ns014 9 GO- coM1SS10bev 14 14 20�9 M �Xp RIGS 0rto- with FBC nor a '994 Revised on 5121120C9 r s 1 a DATE IMMIODtYYYY) ACORO CERTIFICATE 4F LIABILITY INSURANCE A,-.. ' T 1 r2020 11 / 14/2019 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. I IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poilcy(les) must have ADDITIONAL INSURED provislons or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER Lockton Companies w°NstET 8110 E Union Avenuc P► IAIE FAX Suite 700 W Denver CO 80237 s_---- -- - - - (303) 414-6000 __._.._...... INSURER SllAFFORDING COVERAGE MW # _ INSURER A: National Union Fire Ins Co Pitts. PA 19445 INSURED twsuRert a : New Hampshire Insurance Company 23841 1036748 PeopieKeady Flontin, Inc, -- 1015 A. Street INSURER c : Insurance Company of the State of PA 19429 PO Box 2910 INaURER b : American Hoine Assurance Company 19380 Tacoma, WA 98401 INSURERS: . 000988528----.—. __........._......._.........._............. .._ NSURER F . ___ .- ... .........- .�., nn�-, of\/lcin►I RIIrYAFO• ( Y'YYYYyy 4VVCRAVCJ vr..�..••vr.•a_.. v......•... a.•-.•v.. . ---- - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR iiiE POLICY PER10D INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RES?EtT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT T ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN:R TYPE OF INSURANCE 1 i POLICY NUMBER POLICY M M P LI q X ! COtNMERCIAL GENERAL LIABUM N � `�' '16962343 711 %2019 i 7/12020 3,000,000 I DPREMISES (F.a —1S 3 ON NO +—1 CLAIMS•IJADE J OCCUR i on) son) MEO EXP pers S XXXXXXX i X_ SlRS1M_ — ' PERSONAL a Att1V INJURY $ 3000,000.,-- �' I GENT. AGGREGATE UMR APPLIES PER; i I ERAL AG.a"REGATE GENERAL — : 5009,000 -�— PRODUCTS - COMP!'OP AGG s 3,000,000 ~— —1 PRO- L POLICY ._....1 JECT L LOC OTHER: A AUTOMOBILE uAssJrY N N 2991935 OS 7/1/2019 7i1/2020 COMaLNED ya„�tSINGLE $ 3 000,000_. _....._... BODILY IN,AIRY (Per person) A .-.......� ANY ALI'1'O 2991936 MA) A 299)937 VA) lr l2o 19 71 t202a 7%1202a f XXXXXXX _.._.,..._. _ .......__ BODILY INJURY1PeraeudeM) S j{j(�(,�(�( OWNED I �' SCHEDULED i 17/U2019 .........' AUTOS HIREDS ONLY �-- NON -OWNED s XXXXXXX I rt _.......-4 AUT03 ONLY `� AUTOS ONLY I �w acydeMi --.-- S XXXXXXX A I UMBRELLA UAB �7(y OCCUR ; N N 28295164 ( 7112019 1 7:1/2020 � FACH OCCURRENCE s 25.000..0000 AGGREOATL A.25.000.000 EXCESS LIAB CLAIMS-MADei j s XXXXXXX ' OEO I � RErEN710N S !WORKERS COMPENSATION Y B AND EMPLOYERS•LIMLJTY Y/N 14649290, 14649284, 14649287 � 7r12019 7112020 1 L I000000......_._—. - C ANY PROPMETORMARTNERIEXECUTNE j Ali 14649293, 14649288, 14649286 7/1/2019 7/12020 n E.L. EACH ACCIDENT i4649296 17•I,�U19 17,1l2020 I— �........ O IOFF!CERMEM3EnexCWDED9 N :N/ (ManMtory In NNj I , { E.L. DISEASE - EA EMPLOYE _,_...._........_........ ....-s $ 1,000,000 :It yyness tit de ctlimr*N ur OPERATIONS uelrnw i r. , E.L. DISEASE • POLICY LIMIT A ' Fxcess Work Comp n : N 5565626-QSI 7,112a 19 7. IIZa20 S1R 5350,OtT0 crtch acciJcMt DESCRIPTION OF OPERATIONS I LOCATIONS! VENICL.E3 (ACORD TtH, Addtdonal RemsAu Schedule, m W be snaMwd If mare space Is required) The above coverages apply only to temPorary employees dispatched to do work on behalf of the Natned Insured. Waiver of Subrrogation applies on Genetic) Liability urld AVurkers Compensation if required by written contract. where permissible by )aw. trwra r c nva-mcn 16410957 Miami Shores village Bldg. Dept. 10050 NE 2nd Avenue Miatni 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 REPRUgNTAT" s ® f9B8-2 o ACORD CORPUARATION.IAll rights reserved. ACORO 25 (2016103) The ACORD name and logo are registered marks of ACORD Attachment Code: D563101 Master ID: 1036748. Certificate ID: 16410957 SCHEDULE OF NAMED INSUREDS TrueBlue, Inc, Affiliates' Centerline Drivers, LLC CLP Resources, Inc. Labor Ready, Inc. PeopleReady, Inc. PeopleReady Florida, Inc. Project Trade Solutions, LLC Spartan Staffing, LLC Spartan Staffing Puerto Rico, LLC TrueBlue, Inc. TrueBlue Enterprises, Inc. TrueBlue Energy and Industrial Services, LLC Venue Ready, LLC Job Rooster, Inc. Attachment Code: D550685 Certificate ID: 16410957 POLICY NUMBER: 6862343 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS COVERAGE PART SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION REQUIRING A WAIVER OF TRANSFER OF RIGHTS OF RECOVERY PURSUANT TO APPLICABLE WRITTEN CONTRACT OR AGREEMENT YOU ENTER INTO. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schelule above because of payments we make for injury or damage arising out of your ongoing operations of "your work" done under a contract with that person or organization and included in the "products-complet d operations hazard". This waiver applies only to the person or organization shown in the Schedule Zve. Attachment Code: D552813 Certificate ID: 16410957 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date Is indicated below. (The following "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 7/1/2019 forms a part of Policy No. 14649293 By: Insurance Co. of the State of PA. Premium INCLUDED 1 i We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement apOies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. i 0 Schedule THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. I This form is not app:icable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas. Utah, or Washington. ® people ready A TRUEfWC COMPANY Certificate of Insurance Request Form and Agriliement Customer Name ("Customer') Customer Number Customer Address 5079 N UWe Hwy Suite 25 AddedDevelooment Inc, ON988528 Entity or Entities Servicing Customer PeopleRead , Inc. Oakland Park FL 33334 Upper Tier Certifeate Holder Name Miami shores Vi:lage Bldng Department i Address 10050 NE 2nd Ave Miami Shores FL 33138 Certificate of Insurance Requirements • Workers' Compensation • General Liability • Automobile Liability • Umbrella Liability Additional Endorsements The following entities shall be named as Additional Insured as respects to General Liability Ongoing OperaL'ons: List of Additional Insureds Waiver of Subrogation applies to Workers' Compensation, General Liability Additional Notes or Requirements: Conditions a• This Certificate of Insurance Request Form ('Agreement") Is entered into between PeopleReady, Inc. ("Supplier") and Custo. Customer has requested that Supplier provide a Certificate of Insurance with the coverages and endorsements listed above; Supplier shall grant such endorsements as listed above but only on the conditions contained herein. Any modifications to this Agreement are void unless approved by Supplier. The undersigned are expressly authorized to sign this Agreement for and on behalf of the Customer and Supplier. b Without the prior written agreement of Supplier, Customer will not entrust Suppiier's Temporary Associates ("TAs") with the cAm of unattended premises, custody of control of cash, credit cards, valuables or other similar property. Nor shall Customer allow Swpplier's TAs to operate machinery, equipment or motor vehicles Without the prior written permission of Supplier in each occasion. c. Suppliers obligation to Indemnity and defend shall in no event provide indemnity or defense for the negligent acts or omissions of Customer, its agents, or employees, or Customers obligation to provide adequate supervision for the TAs. A d• Customer agrees that such endorsements Indicated on the Certificate of Insurance and any related endorsements shall only ektend to provide coverage to Customer to the extent the underlying liabilities, costs claims, attomeys' fees, or expenses collectively "L lIabilities- arise from the negligence of Supplier supplied TAs, and shalt not provide any defense or coverage to the extent such liablibes arise from the negligent or willful acts of Customer, its agents or employees. I e. Any endorsement provided to Customers upper tier contractors or owners shall only apply to the extent Customer is contractu,lly obligated to provide such endorsement from Supplier to its upper tier contractors or owners. Acknowledged and Agreed Customer: By: (Print Name ,q, v(U tvl Lo SMure:(,�--' /ZA floe: VDate: 2-02'� By: (Prnt Name) Visweswari Cherukuh Signature: (Title: (Dbte: (Contracts Services Assistant 11412019 ACORD,M- -CERTIFICATE PRODUCER A MAPLES INSURANCE AGENCY 1051 E SAMPLE ROAD DATE (MMIDDIYY) OF LIABILITY INSURANCE 11/06/19 POMPANO BCH, FL 33064 Phone 9549468940 Fax 9549468942 INSURED ADDERLY DEVELOPMENT,INC 8255 WEST SUNRISE BLVD #19 PLANTATION, FL 33322 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 I NAIC # —INSURER A: HUDSON SPECIALTY INSURER B: - - II NSURER I — INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 ADVIL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD- TYPE OF INSURANCE I POLICY NUMBER _DA__T_ E(MMIDDNY) DATE(jM/DD1YY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE I 1,00 DAMAGE TO RENTED — 000 eCOMMERCIAL GENERAL LIABILITY JHBD-10030367-1 11/08/19 11/08/20 PREMISES occurence 100,000 ❑❑ CLAIMS MADE ©OCCUR ME EXP (Aone person) 5,000 � � ny _ A El ❑ { PERSONAL h ADV INJURY 1,000,000 I ❑ GENERAL AGGREGATE 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:- i PRODUCTS _COMP/OP AGG _ 1,000.000 e POLICY ❑ PROJECT ❑ LOC ��- AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ❑ ANY AUTO I (Ea_accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per person) _ ❑ HIRED AUTOS BODILY INJURY j ❑ NON OWNED AUTOS I (Per accident) ❑ -- - - II PROPERTY DAMAGE —i--.._..�------.._. ---t- - ... _..._(Per accident) GARAGE LIABILITY I AUTO ONLY - EA ACCIDENT ❑ ❑ ANY AUTO ,❑ L' EXCESS LIABILITY ❑ OCCUR ❑ ' ❑ DEDUCTIBLE ❑ RETENTION WORKERS COMPENSATION I EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNEI OFFICER I MEMBER EXCLUDI If yes, describe under SPECIAL PROVISIONS below OTHER THAN EAACC - AUTO ONLY: AGG EACH OCCURRENCE AGGREGATE ❑ WC STATU- ❑ OTH- TORY LIMITS ER _ E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT OTHER Ili DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFIED ROOFER CCC 1327886 Certified General Contractor - CGC 1506459 CERTIFICATE HOLDER INSURED COPY Village of Miami Shores Bldg Dept. 10050 NW 2 Ave, Miami Shores, FL. 3318 ACORD 25 (2001108) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER 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. AUTHORIZED REPRESENTATIVE J DE ROSA C ACORD CORPORATION 1988 Ai _A_CO_R_ Dr� C_E_RTIFICA_T_E OF_ LIABILITY INSURANCE E °AT11`/09/18 Y' PRODUCER A MAPLES INSURANCE AGENCY r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 1051 E SAMPLE ROAD POMPANO BCH, FL 33064 Phone 9549468940 -- Fax 9549468942 INSURED ADDERLY DEVELOPMENT, INC 8255 WEST SUNRISE BLVD # 119 PLANTATION, FL 33322 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 # wsURERA: HUDSON SPECIALTY INSURER B: INSURER C: INSURER D. - ;- - — - - --- --- - INSURER E:-------_ -- - _- — COVERAGES I INSURER F. I THE POLICIES OF INSURANCE LISTED 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 1 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IINSR ADUL i I POLICY EFFECTIVE POLICY EXPIRATION!I LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (Ally YY).. _ DATE (MMIDDIYY) LIMITS - -- GENERAL LIABILITY EACH OCCURRENCE 300, 000 © COMMERCIAL GENERAL LIABILITY HBD-10030367 ! rDX, �� � T— 11 /08/18 1 11 l08/19 PREMISES Ea occurence 100, 00� ❑ ❑ CLAIMS MADE Q OCCUR i MED EXP (Any one person) 5,0001 A ❑ ❑ I PERSONAL & ADV INJURY 300, 000 I ❑ GENERAL AGGREGATE 300,000 G-�EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG - 300, QO IJ POLICY ❑ PROJECT ❑ LOC iAUTOMOBILE LIABILITY _ 1 COMBINED SINGLE LIMIT -� ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS ❑ BODILY INJURY ❑ : SCHEDULED AUTOS (Per person) ❑ HIRED AUTOS -- j BODILY INJURY I ❑ NON OWNED AUTOS j ! (Per accident) ❑ - --- PROPERTY DAMAGE — + (Per accident) GARAGE, LIABILITY AUTO ONLY - EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC I ❑ i AUTO ONLY: AGG I EXCESS LIABILITY i EACH OCCURRENCE ❑ OCCUR ❑CLAIMS MADE II AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION - - WORKERS COMPENSATION AND I ❑ WC STATU- ❑ OTH-i EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR ! PARTNER! EXECUTIVE I E.L. EACH ACCIDENT OFFICER I MEMBER EXCLUDED? I E.L DISEASE - EA EMPLOYEE j It yes, describe under ! ---- - - - -- --- ---- L SPECIAL PROVISIONS below I E L. DISEASE - POLICY LIMIT ..-- - -- - ---------- - -� OTHER I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAL PROVISIONS CERTIFIED ROOFER LICENSE # CCC 1327886 CERTIFICATE HOLDER CANCELLATION INSURED COPY Miami Shores Village Bldg Dept. 10050 NE 2nd Ave Miami Shores, FL. 33138 -- -- — ACORD 25 (2001/0--8) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER 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. AUTHORIZED REPRESENTATIVE J DE ROSA 0 ACORD CORPORATION 1988 ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE (MM(DONYYY) 11 kb r TU2020 11/14/2019 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER LGckton Companies CONTACT MECT PNON£ �.. 8110 E Union Avenue Suite 700 E-MAIL ADDRESS: Denver CO 80237 (303) 414-6000 _ INSURE BRa AFFORDING COVERAGE i NAte s INSURER A: National Union Fire Ins Co Pitts. PA 19445 INSURED PeopieReady Florida, Inc. INSURCRs:New Ram shire TrisuranceCorrinany 13841 INSURER C : Insurance Company of the State of PA �19429 1036748 1015 A, Street INSURER O : Atncrican Hotne Assurance Company PO Box 2910 19380 _ .. Tacoma, OVA 98401 INSURER E :000988528 INSURER F r•MICOA(PCQ I"PRTIFICATF NIIMRFR• 1641(1Q57 REVISION NUMBER: I XXXXXXX 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 REOUIREMENT. 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 ----........._...LTR .._.........._.._.__. �- T _.,.. ---- -... TYPE QF INSURANCE �3-iDDL'BU9RI POLICY NUMBER _ _......._._. MMroCY EFFXP MWDD}YYYY -- L LIM11S A COMMERCIAL GENERAL LIABILITY N Y E 6862343 7/ 1 /2019 s 7d f2020 1 EACH OCCURRENCE 3 3 000 000 PREMI$Fci (Ea occurrence) i 3.000 0Q0 {i CLAIMS -MADE OCCUR MEO EXP (Any we Person) $ XXXX,XXX i{ i SIR S 1 i11 ! PERSONAL d ADV INJURY S 3,000,000______, GENL AGGREGATE LIMIT APPLIES PER. s GENERAL AGGREGATE S S 000 000 PRODUCTS • COMP}OP A045 $ 3 000�,000 jj POLICY _.y ' OC i 1.� • S ,... I i OTHER: i A I AUTOMOBILE L"ntrY 1 N N I 2WI935 (AOS) 7/1/2019 7;112020 IN SINGLE S 3000,000 (�.�'tts�rlp0_. A A 2991936(MA) X ( ANY AUTO 2991937(VA) 7,in019 7/1/2020 7rI/'_Ol9 7i/2020 _ ._. DQDILYINJURY{PerPeraon) $ %XXXXXX - _ ... 00DILYINJURV{Peracadanl} $xxxit XX ------- ... -......1 OWNED �" SCHEDULED ( AUTOS ONLY _ AUTOS ..' HIRED " NON -OWNED I e AMAGE 5 xy-xxxxx tP acrdant i AUTOS ONLY l.,-,,,.,.,j AUTOS ONLY I l S ]{XXxXxx A LX1 UMBRELLAUAB I X� OCCUR I N N 28295164 7'1J2u19 7 1i2020 EACH OCCURRENCE S 75,000,000 EXCESS LtA6 i` CLAIMS-MAChl ( 3 AGGREGATE S 25 000 0 DED i RETENT*DNi XXX}C.XXx WORKERS COMPENSATION 13 AND EMPLOYERS'LIABILITY Y 14649290.14649284, 14649287 X TH- 7/l/2019 7 Il2020 I �ATUTC_ LI;,R �..� ( Y/N '�ANYPROPRIETORPARTNER)EXECUTIVE NIA 146.19293, 14�9288, 14649286 14649296 7)l12014 7/1f202() IEL.CACHACCIDENT S l 00000 `!/1/2u19 711/2020---..— '-----..._--.-. D OFFICERAdEMBER EXCLUDED'+ NH) f ; E.L. DISEASE • £A EtdIPI.AYEt S In(},,(�Q�.......... :(Mandatary In - _... t.............._..._._........P 9 It YYaa, de-1110 oneer 1DERCRIPTION OF OPERATIONS below I I 1 IEL. dSEAeE • POLICY LIMIT I•y A Excess Nark Comp N I N 5565626-QSI l 7/1/2019 7; 112020 SIR 3350,000 cdch mcodcpp t DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 1a1, Additional Remarks SCMdula, may be attached If more spa" Is required) The above coverages apply only to temporary employces dispatched to do work on behalf of the Named Insured. Vdalver of Subrng:ttion applies on Generhl i.iability and Workers Cornpcnsaran if required by written contract, where permissible by law. I i 16410957 Miami Shores Village Bldg. Dept. 10050 NE 2nd Avenue Miatni Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE THE EXPIRATION DATE THEREOF, NOTICE WILL ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRe5ENTA� ELLED BEFORE DELIVERED IN — C 1968.20to- ACORD CORPtiRATION.'Ali rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ', Attachment Cade; D563101 Master ID: 1036748. Certificate ID: 16410957 SCHEDULE OF NAMED INSUREDS TrueBlue, Inc. Affiliates' Centerline Drivers, LLC CLP Resources, Inc. Labor Ready, Inc. PeopleReady, Inc. PeopleReady Florida, Inc. Project Trade Solutions, LLC Spartan Staffing, LLC Spartan Staffing Puerto Rico, LLC TrueBlue, Inc. TrueBlue Enterprises, Inc. TrueBlue Energy and Industrial Services, LLC Venue Ready, LLC Job Rooster, Inc. Attachment Cade; D55068r Certificate ID: 16410957 POLICY NUMBER. 6862343 COMMERCIAL GENERAL THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS COVERAGE PART SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION REQUIRING A WAIVER OF TRANSFER OF RIGHTS OF RECOVERY PURSUANT TO APPLICABLE WRITTEN CONTRACT OR AGREEMENT YOU El INTO. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations o} "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule aEbove. Attachment Code: D552813 Certificate ID: 16410957 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The fo!!owing "attaching clause" need to be completed only when this endorsement is issued to preparation of the policy). This endorsement, effective 12:01 AM 7/1J2019 forms a part of Policy No. 14649293 By: Insurance Co, of the State of PA. Premium INCLUDED We have the right to recover our payments from anyone liable for an injury covered by this policy. We wN not enforce our right against the person or organization named In the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement froin us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Tennessee, Texas, Utah, or Washington. people ready A TRUEaLUE COMPARY Certificate of insurance Request Form and Agreement Customer Name ("Customer") Customer Number Customer Address 5079 N Dixie Hwy Suste 258 Addarly Develooment Inc. 000988528 II Entity or Entities Servicing Customer PeopieRead , Inc. Oakland Park FL 33334 Upper Tier Certifcate Holder Name Miami shores ViJage Bidng Department Address 10050 NE 2nd Ave State. Zip (Miami Shores FL 331 Certificate of Insurance Requirements • Workers' Compensation • General Liability • Automobile Liability • Umbrella Liability Additional Endorsements The following entities shall be named as Additional Insured as respects to General Liability Ongoing Operations: List of Additional Insureds Waiver of Subrogatlon applies to Workers' Compensation, General Liability I Additional Notes or Requirements: 1 Terms and Conditions a. This Certificate of Insurance Request Form ("Agreement") is entered into between PeopleReady, Inc. ("Supplier") and Customler. Customer has requested that Supplier provide a Certificate of Insurance with the coverages and endorsements listed above; Supplier shall grant such endorsements as listed above but only on the conditions contained herein. Any modifications to this Agreement are void unless approved by Supplier. The undersigned are expressly authorized to sign this Agreement for and on behalf of the Customer and Supplier. b. Without the prior written agreement of Supplier, Customer will not entrust Suppiler's Temporary Associates ("TAV) with the care of unattended premises, custody or control of cash, credit cards, valuables or other similar property. Nor shall Customer allow SLpplier's TAs to operate machinery, equipment or motor vehicles Without the prior written permission of Supplier in each occasion. c, Supplier's obligation to indemnify and defend shall in no event provide indemnity or defense for the negligent acts or omission of Customer, its agents, or employees, or Customer's obligation to provide adequate supervision for the TAs. d. Customer agrees that such endorsements indicated on the Certificate of Insurance and any related endorsements shall only a tend to provide coverage to Customer to the extent the underlying liabilities, costs claims, attomays' fees, or expenses collectively "Lbilities" arise from the negligence or Supplier supplied TAs, and shall not provide any defense or coverage to the extent such liabilities,, arise from the negligent or willful acts of Customer, its agents or employees. (( e. Any endorsement provided to Customer's upper tier contractors or owners shall only apply to the extent Customer is contractually obligated to provide such endorsement from Supplier to its upper tier contractors or owners. Acknowledged and Agreed IS 1J. "TPA � By: (Print Name)} Visweswari Cherukuri Services Assistant l� CITY of HOLLYWOOD 0 NA TREASURY SERVICES DIVISION LOCAL BUSINESS TAX PEOPLEREADY FLORIDA,INC PO BOX 2910 TACOMA, WA 98401. Please contact us with any changes or corrections to your information. CUSTOMER SERVICE: Should you have any questions regarding Local Business Tax or need to update information related to your Business Tax Account, please contact us by phone at 954-921-3225,', businesstax@hollywoodfi.org or in person at City Half, Room 103, 2600 Hollywood Blvd. Please ser correspondence to: City of Hollywood, Treasury Services Division, Attn: Business Tax, Room 103, PC Hollywood, FL 33022-9045. / correct any by email at d all written Box 229045, PURSUANT TO STATE LAW, LOCAL BUSINESS TAX IS LEVIED FOR THE PRIVILEGE OF DOING BUSINESS WITHIN A CITY'S LIMITS, AND IS NON -:REGULATORY IN NATURE. ISSUANCE OF A LOCAL BUSINESS TAX RECEIPT BY: THE CITY OF HOLLYWOOD DOES NOT MEAN THAT THE CITY HAS DETERMINED THAT THE EXISTING OR PROPOSED USE OF A LOCATION IS LAWFUL. ISSUANCE OF A LOCAL BUSINESS TAX RECEIPT DOES NOT LEGALIZE OR CONDONE THE NATURE OF THE BUSINESS BEING CONDUCTED IF CONTRARY TO ANY LOCAL, STATE OR FED IRAL LAW OR REGULATION, THIS IS NOT A BILL. DO NOT PAY. i BELOW IS YOUR LOCAL BUSINESS TAX RECEIPT. PLEASE DETACH AND POST THIS LOCAL BUSINESS TAX RECEIPT IN A CONSPICUOUS PLACE AT YOUR PLACE OF BUSINESS. I i i.r.y,7F E ys N� FLORIDA �U4'(IIIAY� 2019/2020 LOCAL BUSINESS TAX RECEIPT Business Name: PEOPLEREADY FLORIDA)INC Account Registration DBA: Expirati i Business Location: 2843 HOLLYWOOD BLVD Business Category: SERVICE/OTHER BUSINESS Classification: Employment Agency Tax Basis: OVER 50 WORKERS ##: 89049820.2020 Date: 9/30/2020 Tax Rate: $571.00 Miami Shores (­-,�-)r1T,t,._"ir, 0 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATECERTIFIED CONTRACTOR:, A __COPY OF QUALIFIEP;S STATE- LICENCES B COPY OF LOCAL BUSINESS TAX RECEIPT C . _......._..._.COPY OF LIABILITY INSURANCE' 10050 I.E. Miami Shores, F Tel: (3C Fax: (3C COPY OF WORKERS COMPENSATION INSURANCE' (GVorkers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER, B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICE14SE OR MIAMI DADE COU CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE' (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and ,YOUR INSURANCE COMPANY CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number, BUSINESS NAME: BUSINESS ADDRESS: CITY STATE BUSINESS PHONE: FAX NUMBER (_LL - —) _2? CELL PHONE -Zc QUALIFIER'S NAME QUALIFIER'S LIC NUMBER: V illage rtment 2nd Avenue onda 33138 5)7952204 5) 756 6972 MUNICIPAL Affidavit) , .. 0 .... 0 a 6 * Florida Building Code Edition 2017 High Velocity Hurricane Zone • Uniform Roofing Application Form Section A (General Information) Master Permit No. Process No. \�\ �! f/�(�"C 4- C [ tvi Z� L Contractor's Name: /'t V �� ✓' D l�e 2 Job Address: ROOF CATEGORY / R Low Slope ❑ Mechanically Fastened Tile ❑ Mortar/Adhesive Set Tile , .....• ❑ Asphaltic Shingles ❑ Metal Panel/ Shingles ❑ Wood Shines% Shakes ",,,, • ❑ Prescriptive BUR-RAS 150 Y + ROOF TYPE • ' ' ❑ New Roof ❑ Reroofing ❑ Recovering ❑ Repair ©Mikenance . ROOF SYSTEM INFORMATION • ' Low Slope Area (SF) Steep Sloped Roof Area (SF) Total Area i4v • Florida Building Code 6th Edition (2017) High -Velocity Hurricane Zone Uniform Permit Application Form Section C (Low Sloped Roof Svstem Fill in Specific Roof Assembly Components Fastener Spacing for Anchor/Base Sheet and Identify Manufacturer Attachment (If a component is not used, identify as 'NA') System Manufacturer. GAF Field: e oc @ Lap, # Rows @ 9 • oc NOA No.: 18-0919.07 Perimeter. e ' oc @ Lap, #Rows 4 @ 6 ' oc Comer. 6 ' oc @ Lap, # Rows 4 @ 6 ' oc Design Wind Pressures, From RAS 128 or Calculations: 42.8 71.7 108.0 Number of Fasteners Per Insulation Pmax1: Pmax2: Pmax3: Board Max. Design Pressure, From the Specific NOA <--------- --- N/A ------------- > System: 52.5 Field ___ Perimeter Corner Deck' Type: PLYWOOD Gaugerrhickness: 5/8" MINIMUM Slope: 1 /4":12 1 PLY GAFGLAS #75 BASE SHEET Anchor/Base Sheet & No. of Ply(s): Anchor/Base Sheet Fastener/Bonding Material: 11 GAUGE ANNULAR RS NAILS & 1-5/8" TINCAPS Insulation Base Layer: _ NIA_ Base Insulation Size and Thickness: N/A Base Insulation Fastener/Bonding Material: NIA Illustrate Components Noted and • • Details as Applicable: • • • • • • Woodblocking, Gutter, Edge • �TarminavArt,• • • Stripping, Flashing, Continuous► eEleat, Cant• • - Strip, Base Flashing, Coar4te►+. Flashing, - Coping, Etc. 0000 . 00041 Indicate: Mean Roof Height, •Rarepet Height,.. • Height of Base Flashing, Conuwjwg Material, . Material Thickness, Fastener.npo,' Fastdw*.: Spacing or Submit ManufactuEggs pptalls that. Comply with RAS 111 and Chaoter*16.* • Top Insulation Layer: N/A Top Insulation Size and Thickness: N/A GAF MINERAL SURFACED CAP SHEET Top Insulation Fastener/Bonding Material: j -- 3x3 26 ga poly N/A f ply4wlck strips J 2 PLIES PLY 4 Base Sheet(s) & No. of Ply(s): NIA 75 BASE SHEET Base Sheet Fastener/Bonding Material: N/A PLYWOOD 518" MINIMUM Ply Sheet(s).& No. of Ply(s):2 PLIES GAFGLAS PLY IV FELT Ply Sheet Fastener/Bonding Material: HOT ASPHALT Top Ply: GAF MINERAL SURFACED CAP SHEET Top Ply Fastener/ Bonding Material: HOT ASPHALT Surfacing: N/A FT. 6 Parapet Height ral® Mean Roof Height losses • • '.•••• :.•••. lose• • • 1 • . • • • • • MIAMI-DARE DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) BOARD AND CODE ADMINISTRATION DIVISION NOTICE OF ACCEPTANCE (NOA) GAF 1 Campus Drive Parsippany, NJ 07054 MIAMI-DADE COUNTY PRODUCT CONTROL SECTION 11805 SW 26 Street, Room 208 Miami, Florida 33175-2474 T (786)315-2590 F (786) 31525-99 www.miamidade.eov/economy 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 RER - Product Control Section to be used in Miami Dade County and other areas where allowed by the A;iJ4jty Having Jurisdiction (AHJ). • This NOA shall not be valid after the expiration date stated below. The Miami -Dade Z011tyProduct•0•- Control Section (In Miami Dade County) and/or the AHJ (in areas other than Miami 132d2 County) • reserve the right to have this product or material tested for quality assurance purposes. rf thiaproduMor•• material fails to perform in the accepted manner, the manufacturer will incur the expe>:s�r Q�`pch testing • and the AHJ may immediately revoke, modify, or suspend the use of such product or rpgtef0 with4tll' c jurisdiction. RER reserves the right to revoke this acceptance, if it is determined by Mia"oDade County Product Control Section that this product or material fails to meet the requirements of the applicabk building code. This product is approved as described herein, and has been designed to comply with the Florida Builrr]•i>:g bode including the High Velocity Hurricane Zone of the Florida Building Code. DESCRIPTION: GAF Conventional Built -Up Roof Systems for Wood Decks. LABELING: Each unit shall bear a permanent label with the manufacturer's name or logo, city, state and following statement: "Miami -Dade County Product Control Approved", unless otherwise noted herein. RENEWAL of this NOA shall be considered after a renewal application has been filed and there has been 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 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 NOA renews and revises NOA No. 14-1030.01and consists of pages 1 through 27, The submitted documentation was reviewed by Jorge L. Acebo. C •DADE COUNTY ,..I1 r NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 1 of 27 ROOFING SYSTEM APPROVAL Cateeory: Roofing Sub -Category: BUR Material: Fiberglass Deck Type: Wood Maximum Design Pressure: -97.5 psf. TRADE NAMES OF PRODUCTS MANUFACTURED OR LABELED BY APPLICANT: TABLE 1 Test Product Product Dimensions Specification Description GAFGLAS® Ply 4 39.37" (1 meter) ASTM D2178 Smooth surfaced asphaltic ply sheet reinforced Wide with fiberglass mat. ; .0. • • • • ; • Tri-Ply® Ply 4 39.37" (1 meter) ASTM D2178 Smooth surfaced asphalticplr.sheet rei#i£onced ....:. Wide with fiberglass mat. • • • • • • 0 0 • ...... GAFGLAS® 39.37" (1 meter) ASTM D2178 iit Smooth surfaced asphalt.pl;.sheet reinforced .....6 FlexPly 6 Wide with fiberglass mat. .... •. • . •.... GAFGLAS®#75 39.37" (1 meter) ASTM D4601 Smooth asphaltic base or*40P. 9y sheet reinforced••.'• Base Sheet Wide with fiberglass mat. : ' : . . ...... Tri-Ply®#75 Base' 39.37" (1 meter) ASTM D4601 Smooth asphaltic base orSC/rQy sheet reinforced;""; Sheet Wide with fiberglass mat. ' GAFGLAS® 480 39.37" (1 meter) ASTM D4601 Smooth asphaltic base or base/ply sheet reinforced UltimaT' Base Sheet Wide with fiberglass mat. GAFGLAS® 39.37" (1 meter) ASTM D4897 Smooth surfaced asphaltic perforated venting base Stratavent® Wide sheet reinforced with fiberglass mat. Perforated Venting Base Sheet GAFGLAS® 39.37" (1 meter) ASTM D4897 Smooth surfaced asphaltic nailable venting base StrataventoNailable Wide sheet reinforced with fiberglass mat. Bottom side Venting Base Sheet surfaced with granules. Ruberoid® 20 39.37" (1 meter) ASTM D6163 SBS polymer -modified asphalt base or Smooth Wide anchor sheet reinforced with a fiberglass mat. Ruberoid® Mop 39.37" (1 meter) ASTM D6164 Smooth surfaced mop applied SBS base or Smooth wide anchor sheet reinforced with a polyester mat. Ruberoid® Mop 39.37" (1 meter) ASTM D6164 Smooth surfaced mop applied SBS base or anchor Smooth 1.5 wide sheet reinforced with a polyester mat. Ruberoid' Mop 39.37" (1 meter) ASTM D6164 Smooth surfaced mop applied SBS base or Plus Smooth wide anchor sheet reinforced with a polyester mat. Ruberoid® HW 25 39.37" (1 meter) ASTM D6163 $mooth surfaced torch applied SBS base or anchor Smooth wide sheet reinforced with a fiberglass mat. QNOA No.: 18-0919.07 MIAMI•DADE COUNTY Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 2 of 27 TRADE NAMES OF PRODUCTS MANUFACTURED OR LABELED BY APPLICANT: TABLE 1 Test Product Product Dimensions Specification Description Ruberoid® HW 39.37" (1 meter) ASTM D6164 Smooth surfaced torch applied SBS base or anchor Smooth GAFGLAS® Mineral Surfaced Cap Sheet Tri-Ply® BUR Granule Cap Sheet GAFGLAS® EnergyCapT" Mineral Surfaced Cap Sheet Topcoat® Surface Seal SB Topcoat® Membrane Topcoat® MB Plus wide sheet reinforced with a polyester mat. 39.37" (1 meter) ASTM D3909 Granule surfaced asphaltic cap sheet reinforced Wide with fiberglass mat. 39.37" (1 meter) Wide 39.37" (1 meter) Wide ASTM D3909 Granule surfaced asphaltic cap sheet reinforced With fiberglass mat. ASTM D3909 5 or 55 gallons ASTM D6083 1, 5 or 55 gallons ASTM D6083 5 or 55 gallons Proprietary Granule surfaced asphaltic cap sheet r* infor@ed with fiberglass mat. Cap: sheet is factory boated . with TOPCOAT® Energ}��Q e..ElastegVrjF• ....:. Coating. 0 00:0 Solvent -based thermopla,0100*0 � jybber • .... • sealant designed to proter t,444restore aged >;oof ,,.,,' surfaces and to increase roofreflectivliy.'.: ...... Water -based elastomeric Foa;n- j • Water based, low VOC primer designed Jo Diock asphalt bleed -through. Topcoat® FireOutT" 5 or 55 gallons Proprietary Low VOC, water based fire barrier coating. Fire Barrier Coating VersaShield' Fire- 12" x 100' rolls ASTM D226 Non -asphaltic, fiberglass reinforced underlayment Resistant Roof and/or fire barrier Deck Protection VersaShield' Solor" 42" roll wide, 100 ASTM D146, Non -asphaltic, fire resistant fiberglass Fire -Resistant Slip ft. D828, D4869, underlayment Sheet D6757 Topcoat® 1, 5 gallons or TAS 139 Solvent -based elastomeric sealant. F1exSealT" 1 qt. tube MIAMI•DADE CNOA No.: 18-0919.07 OUNTY Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 3 of 27 APPROVED INSULATIONS: Product Name EnergyGuardT" Polyiso Insulation EnergyGuard'" Tapered Polyiso Insulation EnergyGuardT" Ultra Polyiso Insulation EnergyGuard' RA Polyiso Insulation EnergyGuardT" RA Composite Polyiso Insulation EnergyGuardi" RH Polyiso Insulation EnergyGuardT" RH Tapered Polyiso Insulation EnergyGuardT" RN Polyiso Insulation EnergyGuardT" Perlite Roof Insulation EnergyGuard" Perlite Recover Board TABLE 2 Manufacturer Product Description (With Current NOA) Polyisocyanurate foam insulation GAF Polyisocyanurate foam insulation GAF Glass -faced polyisocyanurate foam insulation GAF Polyisocyanurate foam insulation GAF • ...... Polyisocyanurate foam insulation with high GAV '. 0. density fiberboard or permalite ...... .... ..... . Polyisocyanurate foam insulation 0 • • • • 0 GAF"". .... .... ...... ' ..... ...... . . ..... Polyisocyanurate foam insulation .. .. GAF .. .. ...... . ...... Polyisocyanurate foam insulation . . . . GA;***** .. . . .. ..... . • Perlite insulation board .... GAF Perlite recover board Securock' Gypsum -Fiber Roof Gypsum board Board Securock® Glass -Mat Roof Glass faced gypsum board Board Structodek® High Density Fiber High density fiberboard Board Roof Insulation DensDeck® Prime Roof Board Gypsum board DensDeck® Roof Board Gypsum board APPROVED GAF United States Gypsum Corp. United States Gypsum Corp. Blue Ridge Fiberboard, Inc. Georgia-Pacific Gypsum LLC Georgia-Pacific Gypsum LLC NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 4 of 27 APPROVED FASTENERS: Fastener Product Number Name 1. Drill-Teci" 412 Fastener 2. Drill-Teci" 14 Fastener 3. Drill-Teci" ASAP 3S 4. Drill-Teci°' 3" Steel Plate 5. Drill-Teci" 3" Standard Steel Plate 6. Drill-Teci" AccuTraco Flat Plate 7. Drill-Teci" AccuTrac® Recessed Plate 8. Drill-Tec 3 in. Ribbed Galvalume Plate (Flat) TABLE 3 Product Description Phillips head, modified buttress thread, pinch point, carbon steel fastener for use in steel or wood decks. With CR-10 coating. Available with a pinch point or drill point. Truss head, self -drilling, pinch point, high thread fastener for use in steel, wood or concrete decks. Drill -Tee " 412 Fastener with Drill-Teci'" 3" Standard Steel Plate, Round Galvalume® steel stress plate with reinforcing ribs and recessed for use with Drill-Teci"' fasteners. Galvalume' coated steel stress plate for use with approved Drill-Teci" fasteners. A2-SS aluminized steel plate for use with Drill-Teci" fasteners. Galvalume® steel plate with recess for use with Drill- Teci" fasteners. Round Galvalume® plated steel stress plate with reinforcing ribs for use with Drill-Teci" fasteners. Dimensions #12x8"max length, #3 Phillips head. Manufacturer (With Current NOA) GAF #14 x 16" Cidu:. max. length,, .'. Goes:' 09 0• 43 Phillips .*see• head. ...... • .... ...... ..••.• See •••• Ci"A•1 0, • "" Goes ""' components .. . • .. .. • • • • . • 3" Round ...... GA)~ • . . . . 000000 • • • • • • • • 00:0.0 3" Round GAF 3" square; GAF 017" thick 3" square; GAF 017" thick 3" Round GAF MIAMI•DADE NOA No.: 18-0919.07 COUNTY • , , Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 5 of 27 EVIDENCE SUBMITTED: Test Aeency Factory Mutual Research Corp. UL LLC PRI Construction Materials Technologies, LLC Test Identifier Description Date 3014547 4470 05/22/03 3029832 4470 05/11/07 3033135 4470 11/24/08 3034312 4470 04/09/09 3036980 4470 08/14/09 3038278 4470 11/18/11 3040738 4470 11/16/10 3041769 4470 05/26/11 3042887 4470 11/14/11 3042905 4470 01/10/12 3046081 4470 % .4?C 13/13 3046388 4470 •�. 09/24/12 *•e:s 3047636 4470 goose* •„JOJ08/13...„• ODOA8.AM 4470 ... %. 07/09/99, OD1A8.AM 4470 eggs ••"7/29/94:0gsg� OY9Q5.AM 4470 o••••• 0•0ON1/9800••0 1B9A8.AM 4470 ••••••e • A9:04/97•ggg. 2B8A4.AM 4470 gog s •' OT02/97• g g •:' 3B9Q1.AM 4470 :**:•: bl/08/98 g• 3D4Q2.AM 4470 go : • • 4f30/97: g gg g: 797-03221-267 4470 •..• . OP/27/07;".': 797-03825-267 4470 •.:O-7i21/08 797-10228-267 4470 01/23/15 R1306 UL 790 08/21/18 GAF-122-02-01 TAS 139 05/07/06 GAF-270-02-02 ASTM D226 11/15/10 GAF-276-02-OlRev ASTM D6083 12/16/10 GAF-276-02-02 ASTM D226 11/15/10 GAF-306-02-01 ASTM E96 07/07/11 GAF-314-02-01 ASTM D2178 08/23/11 GAF-315-02-01 ASTM D2178 08/23/11 GAF-369-02-01 ASTM C1289 10/22/12 GAF-417-02-01 ASTM C1289 05/28/13 GAF-464-02-01 ASTM C1289 10/22/12 GAF-464-02-01 ASTM C1289 02/06/14 GAF-499-02-01 ASTM D6083 03/12/14 GAF-500-02-01 ASTM D6083 03/12/14 GAF-549-02-01 TAS 114 08/08/14 GAF-549-02-02 TAS 114 08/08/14 GAF-559-02-01 TAS 117(B) 09/30/14 GAF-559-02-04 ASTM D 1876 10/01/14 GAF-559-02-05 ASTM D 1876 10/15/14 GAF-559-02-06 TAS 114(H) 10/02/14 GAF-559-02-07 ASTM D 903 10/02/14 GAF-559-02-08 ASTM D 903 10/02/14 NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 6 of 27 EVIDENCE SUBMITTED: (CONTINUED) Test AlZency Test Identifier PRI Construction Materials GAF-559-02-09 Technologies, LLC GAF-559-02-11 . GAF-559-02-12 GAF-559-02-13 GAF-559-02-14 GAF-559-02-15 GAF-559-02-16 GAF-559-02-18 GAF-559-02-19 GAF-628-02-01 IRT of S. Fl. 02-005 02-014 Trinity I ERD Dynatech Engineering Corporation Atlantic & Caribbean Roof Consultants, LLC C8500SC.11.07 G30250.02.10-3-R2 G31360.03.10 G33470.01.11 G34140.04.11-2 G34140.04.11-4-R2 G34140.04.11-5-R3 G36780.07.11-R1 G40630.01.14-1 G40630.01.14-2A G4063 0.01.14-2A-1-R 1 G43610.01.14 G6850.08.07-1 SC6870.08.14-R1 SC9700.08.15-R1 SC 10680.05.16 SC13105.03.1.7-R1 #4482.02.95-1 11-053 Description ASTM D 903 TAS 114 TAS 114 TAS 114 TAS 114 TAS 114 TAS 114 TAS 114 TAS 114 ASTM C 1289 TAS 114 ••• TAS 114 • • • TAS ASTM D390191 ASTM D6104••- ASTM D61.64:••: ASTM D61.6'3 • • ASTM D641)1 • ASTM D48,q7 4470-TAS flA• ASTM D6163 ASTM D6164 ASTM D6164 ASTM D3909 ASTM D3909 ASTM D3909 ASTM D2178 ASTM D6163 ASTM D6164 TAS 114 TAS 114 Date 10/02/14 10/14/14 10/14/14 10/15/14 10/15/14 10/15/14 10/15/14 10/15/14 04/16/15 05/31/16 • %bll118/02 •••••• :-155=/02 •, osos some.. 1 i/3 0/07 • • ••96f0.3/15 'W31/10 ••�••• .•ll/lb/11 ••••• *64715111 •e••%• • 06/A4/15 •eme;e :0e6)MI15 e e 03/018/11 :••••0 •Q k6/14 01/07/14 04/10/14 01/22/14 08/13/07 09/04/14 8/31/2015 5/10/2016 3/23/2017 09/01 /95 08/12/11 NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 7 of 27 Membrane Type: BUR Deck Type 1: Wood, Non -insulated Deck Description: 19/32" or greater plywood or wood plank decks secured 6 in. o.c. at panel end and intermediate supports with 8d ring shank nails to supports spaced 24 in. o.c. at max. System Type E(1): Anchor sheet mechanically attached to roof deck. All General and System Limitations shall apply. Fire Barrier: Topcoat® FireOut" Fire Barrier Coating, VersaShield"DFire Resistant Roof Deck (optional) Protection, VersaShield® Solo" Fire -Resistant Slip Sheet installed per manufacturer's installation instructions. Base sheet: Fastening Option #1: Fastening Option #2: Ply Sheet: GAFGLAS'9' #80 Ultima'" Base Sheet, Stratavent" Nailable Venting Base Sheet, Ruberoid" 20 Smooth, Ruberoid SBS Heat -Weld Smooth or Ruberoid' SBS Heat-N4!eleli'C25 base..... sheet mechanically fastened to deck as described below; • • GAFGLAS' Flex Ply'" 6, c A F(-.r A e) Jq75 Rase Sheet Tri-PI"Wbase Slieet or an ••• Qi' the above anchor sheets attached to deck with approved annular jj,"shank n44:gnd tin ;••••; caps at a fastener spacing of 9" o.c. at the 4" lap staggered and %j p•rows I" p"In the..... field. •••••• • • ••;.•• (Maximum Design Pressure —52. 5 psf. See General LimitatioPW A). • • • • • • • • • .00 UAI'ULAS"' #80 Ultima " Base Sheet, Ruberoid'20 Smooth oCRubej'oid'"'Vop Smooth Do**:* attached to deck with approved 1'A" annular ring shank nails and inserted 31 steeT plate at a • fastener spacing of 9" o.c. at the 4" lap, and in two rows staggered•wit a fas:eiVmpacingof • 9" o.c. in the center of the membrane. 0000 (Maximum Design Pressure —60 psf. See General Limitation #7) One or more plies of GAFGLAS`k Ply 4, Tri-Ply" Ply 4 or GAFGLAS''' 480 Ultima Base Sheet adhered in a full mopping o approved asphalt applied within the EVT range and at a rate of 20-40 lbs./sq. installed per manufacturer's installation instructions. Cap Sheet: (Optional) One ply of GAFGLAS' Mineral Surfaced Cap Sheet, Tri-Ply® BUR Granule Cap Sheet or GAFGLAS'' EnergyCap� Mineral Surfaced Cap Sheet adhered in a full mopping of approved asphalt applied within the EVT range and at a rate of 20-40 lbs./sq. installed per manufacturer's installation instructions. Surfacing: Optional on granular surfaced membranes; required for smooth membranes. Chosen components must be applied according to manufacturer's application instructions. All coatings must be listed within a current NOA. 1. Gravel or slag applied at 400 lbs./sq. and 300 lbs./sq. respectively in a flood coat of approved asphalt at 60 lbs./sq. 2. Topcoat® Membrane or Topcoat® Surface Seal SB applied at 1 to 1.5 gal./sq. OR Topcoat® MB Plus applied at 0.5 to 0.75 gal./sq.(to be used as a primer) followed by Topcoat' Membrane applied at 0.5 to 0.75 gal./sq. 3. Fiber Aluminum Roof Coating. Maximum Design Pressure: See Fastening Options NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 21 of 27 WOOD DECK SYSTEM LIMITATIONS: 1 A slip sheet is required with GAFGLAS® Ply 4 and GAFGLAS® Flex Ply" 6 when used as a mechanically fastened base or anchor sheet. 2. Minimum ''/4" DensDeckT" Roof Board or Type X gypsum board is acceptable to be installed directly over the wood deck. GENERAL LIMITATIONS: 1. Fire classification is not part of this acceptance; refer to a current Approved Roofing Materials Directory for fire ratings of this product. 2. Insulation may be installed in multiple layers. The first layer shall be attached in compliance with Product Control Approval guidelines. All other layers shall be adhered in a full mopping of approved asphalt applied within the EVT range and at a rate of 20-40 Ibs,/sq., or mechanically attached using the fastening pattern of the top layer 3. All standard panel sizes are acceptable for mechanical attachment. When applied in approved asphalt, panel size shall be 4' x 4' maximum. 4. An overlay and/or recovery board insulation panel is required on all applications over closed cell Aeam.ie4igulations when the base sheet is fully mopped. If no recovery board is used the base sheet shall ;p.apj jied usipgispot 6 0 : mopping with approved asphalt, 12" diameter circles, 24" o.c.; or strip mopped 8" rib4gil, "three %Ws.bne at....;, each sidelap and one down the center of the sheet allowing a continuous area of ventiWiOL *Encircling of the . strips is not acceptable. A 6" break shall be placed every 12' in each ribbon to allow c q%voentilatiQn! irs.phalt application of either system shall be at a minimum rate of 12 lbs./sq. Note: Spot attaelled systems Shall be • •; • •. limited to a maximum design pressure of -45 psf. •' • •' • • • • • • 5. Fastener spacing for insulation attachment is based on a Minimum Characteristic Forcee(FYvalue of75'f6f. as tested in compliance with Testing Application Standard TAS 105. If the fastener value,* a3 field-to%ted,*Ve belor ..; 275 lbf. insulation attachment shall not be acceptable. • • • • • • 6. Fastener spacing for mechanical attachment of anchor/base sheet or membrane attachmaaf is.'based.on a minimum fastener resistance value in conjunction with the maximum design value listed within a specific systA,? 4hould the fastener resistance be less than that required, as determined by the Building Official, a revised fastener spacing, prepared, signed and sealed by a Florida Registered Professional Engineer, Registered Architect, or Registered Roof Consultant may be submitted. Said revised fastener spacing shall utilize the withdrawal resistance value taken from Testing Application Standards TAS 105 and calculations in compliance with Roofing Application Standard RAS 117. 7. Perimeter and corner areas shall comply with the enhanced uplift pressure requirements of these areas. Fastener densities shall be increased for both insulation and base sheet as calculated in compliance with Roofing Application Standard RAS 117. Calculations prepared, signed and sealed by a Florida registered Professional Engineer, Registered Architect, or Registered Roof Consultant (When this limitation is specifically referred within this NOA, General Limitation 49 will not be applicable.) 8. All attachment and sizing of perimeter nailers, metal profile, and/or flashing termination designs shall conform to Roofing Application Standard RAS 111 and applicable wind load requirements. 9. The maximum designed pressure limitation listed shall be applicable to all roof pressure zones (i.e. field, perimeters, and corners). Neither rational analysis, nor extrapolation shall be permitted for enhanced fastening at enhanced pressure zones (i.e. perimeters, extended corners and corners). (When this limitation is specifically referred within this NOA, General Limitation #7 will not be applicable.) 10. All products listed herein shall have a quality assurance audit in accordance with the Florida Building Code and Rule 61 G20-3 of the Florida Administrative Code. END OF THIS ACCEPTANCE MIAMI•DADE COUNTY NOA No.: 18-0919.07 Expiration Date: 11/04/23 Approval Date: 11/08/18 Page 27 of 27 ROOFING SYSTEMS I UL Product iQ Pagel of 4 TGFU.R1306 - ROOFING SYSTEMS Roofing Systems See General Information for Roofing Systems GAF •••• •••••• R1306 •• 1 CAMPUS DR •••••• •••• •••••• PARSIPPANY, NJ 07054 USA ...... .... .... . . "RUBEROID@ 20 Smooth" or "RUBEROID@ Mop Smooth" or "RUBEROIDp Mop Smooth 1.5" may be L;iljz�d�s an aTte0 0;? o Type • • • • G2 "GAFGLAS@ *75 Base Sheet" or "Tri-Ply@ #75 Base Sheet" or "GAFGLAS@ #80 Ultima— Base Sgee4'.t Ve sheets in arty of the••��•• following Classifications. . . , . . • Torch applied "RUBEROID@ HW" SBS roofing membranes may be used as alternates to "RUBER0IDnM8 jBS roofing Membranes •• in any appl'.cable Classification as follows: • • . . ...... ...... A. "RUBEROIDO HW Smooth" may be used as an alternate to "RUBEROtDO Map. Smooth" or "RUBEROID® Mop Smooth 1.5" 0000 B. "RUBEROIDO HW 25 Smooth" may be used as an alternate to "RUBEROIDO 20 Smooth" C. "RUBEROIDO HW Granule" may be used as an alternate to "RUBEROID® Mop Granule" D. "RUBEROIDO HW Plus Granule" may be used -as an alternate to "RUBEROID® Mop Plus Granule" E. "Ruberoid® HW Granule FR" may be used as an alternate to "Ruberoid® Mop Granule FR" F. "RUBEROID® HW Plus Granule FR" may be used as an alternate to "RUBEROID® Mop Plus Granule FR" G. "RUBEROIDO EnergyCap HW Plus Granule FR" may be used as an alternate to "RUBEROIDO EnergyCap Mop Plus Granule FR" https://iq.ulprospector.com/en/profile?e=148955 2/13/2019 ROOFING SYSTEMS I UL Product iQ Page 2 of 4 1/2-in. thick (minimum) gypsum board or 1/4-in. thick (minimum) Georgia-Pacific Gypsum LLC "DensDeckQ Roofboard" or "DensDeckQ Prime Roofboard" or "DensDeckQ DuraGuard'" Roofboard" or 1/4-in. thick (minimum) United States Gypsum Co. "SECUROCKQ Roof Board" (Type FRX-G) or "SECUROCKO Glass -Mat Roof Board" (Type SGMRX) may be used in any existing noncombustible deck Classification. When this is done, the resulting roofing system is acceptable for use over combustible (15/32-in. thick minimum) roof decks, However, the butt joints in the gypsum board and Georgia-Pacific Gypsum LLC "DensDeckQ Roofboard" or "DensDeckQ Prime Roofboard" or "DensDeckQ DuraGuard'" Roofboard" are to offset a minimum of 6-in. with the butt joints in the roof deck. If polystyrene is part of the roof system, it must be placed below the overlayment board. 1/4-in. thick (minimum) "SECUROCKO Roof Board" (Type FRX-G) and "SECUROCKO Glass -Mat Roof Board" (Type SGMRX) are limited to a maximum 3:12 slope when used over a combustible deck in a system with any UL Classified insulation except polystyrene. Multiple plies of Type G1 "GAFGLASO Ply 4" or "Tri-PlyO Ply 4" or "GAFGLASO Flex Ply 6" or "Tri-PlyO Ultra -Flexible Ply 6" may be adhered to Georgia-Pacific Gypsum LLC "DensDeckQ Roofboard" or "DensDeckQ Prime Roofboard" or "DensDeckQ DuraGuard'" Roofboard" in hot roofing asphalt. "GAFGLASO FlexPly— 6 5L" and "GAFGLASO FlexPly'" 6" may be used interchangeably in any roof covering system listed below, "EnergyGuard'" Ultra" is an acceptable alternate to "EnergyGuard'"" in any applicable Classification. "GAFGLASQ StrataventQ Nailable Venting Base Sheet" may be mechanically fastened or fully adhered with hot roofing asphalt over noncombustible decks and as a recover over existing roof systems. "EnergyGuard" Perlite Insulation" may be utilized as a cover board over "EnergyGuard'"" in any of t he following sitch'T; • • • Unless otherwise indicated, the roof insulation is mechanically fastened, fully adhered with hot roofing'EFsph;t or Ule ilea 41fjed • ', urethane insulation adhesive. Polystyrene referenced in any of the following Classifications include inSeMCV. *so* • • 6 6 •. Unless otherwise indicated, all insulations may be adhered with any UL Classified Insulation Adhesive pgrG4 manufa�tr;%r's ; • •' •; installation instructions (excluding "LRF Adhesive O") in any applicable Non -Combustible Roof Deck C%VWy cations. • • •. • • • • • "EnergyGuard'" Tapered" is an acceptable alternate to "EnergyGuard"', in any applicable ClassificatitR: * •; .' • ; ' • •"• •• •• •• •• "EnergyGuard'" Ultra Tapered" is an acceptable alternate to "EnergyGuardTM Ultra" in any applicable"..:;i.ation. • •••••• •� "EnergyGuard" NH Tapered" is an acceptable alternate to "EnergyGuard'" NH" in any applicable Classification. : • • • s • e* "EnergyGuardT' NH Ultra Tapered" is an acceptable alternate to "EnergyGuard'" NH Ultra" in any appllt8bleClassifi{at1QA! •• • "EnergyGuard'" Barrier Tapered" is an acceptable alternate to "EnergyGuard'" Barrier". "EnergyGuard'" NH Barrier Tapered" is an acceptable alternate to "EnergyGuard'" NH Barrier". Minimum 1-in, thick "EnergyGuard'" Barrier" is an acceptable alternate to'"EnergyGuard— Ultra" in any applicable Classification. Minimum 1-in, thick "EnergyGuard'" NH Barrier" is an acceptable alternate to "EnergyGuard'" NH Ultra" in any applicable Classification. "Tapered EnergyGuard'" RA" may be substituted for "EnergyGuard'" RA" in any of the systems listed below that utilize "EnergyGuardT' RA". "EnergyGuard'" RA" may be perforated on one side for use as the contact side for BUR or modified bitumen membrane. ASPHALT FELT SYSTEMS WITH HOT ROOFING ASPHALT Type G2 asphalt glass mat base sheet ("GAFGLASO #75 Base Sheet" or "Tri-PlyO #75 Base Sheet" or "GAFGLASO #80 UltlmaTM Base Sheet") is a suitable alternate for Type G1 asphalt glass fiber ply sheet ("GAFGLASQ Ply 4" or "Tri-Ply@ Ply 4" or "GAFGLASO Flex Ply 6" or "Tri-PIyQ Ultra -Flexible Ply 6") in the Class A, B or C roof systems indicated below. The roof deck may first be covered with one ply Type G2 asphalt saturated glass mat base sheet "GAFGLASO StrataventO Nailable Venting Base Sheet" or "GAFGLASO StrataventO Perforated Venting Base Sheet". Perforated base sheets to be loose laid or fully adhered with hot roofing asphalt and nailable base sheets are to be mechanically fastened granule side down. As an option Type G2 asphalt glass mat base sheet ("GAFGLAS(D #75 Base Sheet" or "Tri-Ply@ #75 Base Sheet" or "GAFGLASQ #80 Ultima'" Base Sheet" or "GAFGLASO StrataventQ Nailable Venting Base Sheet") may be substituted for Type G1 asphalt glass fiber ply sheet ("GAFGLASO Ply 4" or "Tri-Ply@ Ply 4" or "GAFGLASQ Flex Ply 6" or "Tri-Ply@ Ultra -Flexible Ply 6") as the nailed base ply in the following systems. Bottom ply or base sheet may be fully adhered with hot roofing asphalt or mechanically fastened. Unless otherwise indicated, all insulations may be fully adhered with hot roofing asphalt or mechanically fastened. "GAFGLASO Flashing" or "RUBEROIDQ" may be used for flashing in any of the Class A, B or C systems listed below. https:Hiq.ulprospector.com/en/profile?e=148955 2/13/2019 ROOFING SYSTEMS I UL Product iQ Page 3 of 4 When "perlite" is referenced, this includes any UL Classified perlite insulation. Crushed stones or slag are suitable alternates for gravel in any of the Class A, B or C systems listed. Structural cement fiber building units are considered suitable to be included as a deck in the following Class A, B or C systems listed over C-15/32 or NC. The use of gypsum board under any of the following Class A, B or C systems does not adversely affect the rating. The use of 1/2-in. minimum thick gypsum board is an acceptable alternate for minimum insulation over C-15/32 thick roof decks. The use of polystyrene Insulation board between minimum 3/4-In. thick perlite board and deck with rosin paper (perlite/rosin paper/polystyrene/perlite) is a suitable alternate for polyisocyanurate board in the following Class A, B or C systems. Trumbull "Perma Mop" may be utilized with any of the following "Asphalt Felt Systems with Hot Roofing Asphalt". "GAFGLASO #80 Ultima" Base Sheet" may be used in any of the following systems. "GAFTEMP Permalite Recover Board" may be used in lieu of any perlite insulation in any of the following NC Classifications. Unless otherwise indicated, any of the "Asphalt Felt Systems with Hot Roofing Asphalt" may be surfaced with "United Coatings— FireShield MB Roof Coating" applied at a rate of 2-1/2 to 3-gal/100-ft2. Class A, B and C • • • • • • ...... Hot roofing asphalt, for use with glass felts or modified bitumen membranes. " ' •000""• ' • eo • Torch applied "RUBEROIDO Heat Weld" SBS roofing membranes may be used as alternates to "RUBBR"99mMop" SBS roofing membranes in any applicable Classification. ••.• ••.• •••• . • "RUBEROIDO HW 25 Smooth" may be used as an alternate to "RUBEROIDO Mop Smooth" or "RUBE59Ip•C4 clop Smooth 1.�". Class •. " .. •. 17 • •. • • • ..•.•• .. • ..... . 1. Deck: C-15/32 Incline: 3 ...... . Go ...... Barrier Board (Optional): — One or more layers minimum 1/4-in. thick Georgia -Phil lypsur LV; "DensDeckO Roofboard" or "DensDeckO Prime Roofboard" or "DensDeckO DuraGuardTM Roofbottd*or minimum 1/4-in. thick United States Gypsum Co. "SECUROCKO Roof Board" (Type FRX-G) or "SECUROCKO Glass -Mat Roof Board" (Type SGMRX). Vapor Barrier (Optional): — One or more plies "GAF® SA Vapor Retarder" self -adhered Insulation: — One or more layers perlite or wood fiber or glass fiber or polyisocyanurate or urethane or perlite/polyisocya nu rate composite or perlite/urethane composite or wood fiber/polyisocyanurate composite or phenolic, any thickness. Ply Sheet: — Three or more plies Type G1 "GAFGLAS0 Ply 4" or "Tri-Ply® Ply 4" or "GAFGLASO Flex Ply 6" or "Tri-Ply@ Ultra -Flexible Ply 6", fully adhered with hoot roofing asphalt. Surfacing: — Gravel. 2. Deck: C-15/32 Incline: 2 Barrier Board (Optional): — One or more layers minimum 1/4-in. thick Georgia-Pacific Gypsum LLC "DensDeckO Roofboard" or "DensDeckO Prime Roofboard" or "DensDeckO DuraGuardTM' Roofboard" or minimum 1/4-in. thick United States Gypsum Co. "SECUROCKO Roof Board" (Type FRX-G) or "SECUROCKO Glass -Mat Roof Board" (Type SGMRX). Insulation: — One or more layers perlite or wood fiber or glass fiber or polyisocyanu rate or urethane or perlite/polyisocya nu rate composite or perlite/urethane composite or wood fiber/polyisocyanurate composite or phenolic, any thickness. Ply Sheet: — Three or more plies Type G1 "GAFGLASO Ply 4" or "Tri-PlyO Ply 4" or "GAFGLASO Flex Ply 6" or "Tri-Ply® Ultra -Flexible Ply 6", fully adhered with hot roofing asphalt. https:Hiq.ulprospector.com/en/profile?e=148955 2/13/2019 ROOFING SYSTEMS I UL Product iQ Page 4 of 4 Cap Sheet: — Type G3 "GAFGLAS® Mineral Surfaced Cap Sheet" or "Tri-Ply® BUR Granule Cap Sheet" or "GAFGLAS® EnergyCapT" Mineral -Surfaced Cap Sheet", fully adhered with hot roofing asphalt. 3. Deck: NC Incline: 2 Barrier Board (Optional): — One or more layers minimum 1/4-in. thick Georgia-Pacific Gypsum LLC "DensDeck® Roofboard" or "DensDeck® Prime Roofboard" or "DensDeck® DuraGuardT" Roofboard" or minimum 1/4-in, thick United States Gypsum Co. "SECUROCK® Roof Board" (Type FRX-G) or "SECUROCK® Glass -Mat Roof Board" (Type SGMRX). Insulation (Optional): — One or more layers perlite or wood fiber or glass fiber or polyisocyanu rate or urethane or perlite/polyisocyanurate composite or perlite/urethane composite or wood fiber/polyisocya nu rate composite or phenolic, 2-in. maximum. Ply Sheet: — Two or more plies Type G1 "GAFGLAS® Ply 4" or "Tri-Ply® Ply 4" or "GAFGLAS® Flex Ply 6" or "Tri-Ply® Ultra -Flexible Ply 6", fully adhered with hot roofing asphalt. Cap Sheet: — Type G3 "GAFGLAS® Mineral Surfaced Cap Sheet" or "Tri-Ply® BUR Granule CagShegt" or "GAFGLAS® EnergyCap'11 Mineral -Surfaced Cap Sheet", fully adhered with hot roofing Asphalt. ••••�• 4. Deck: C-15 32 • / Incline: • . ...... . . . Slip Sheet (Optional : — Red rosin paper, nailed to deck. .... .... . . Insulation (Optional): — Any thickness perlite or wood fiber or glass fiber or polyisM, nurate�mecRanicall fastened or adhered with OMG Inc. "OlyBond Fastening System" or any UL Class ifie� ?ation 2 �e. Base Sheet: — One ply Type G2 "GAFGLAS® #75 Base Sheet" or "Tri-Ply® #75 Ba"$• @et" or "GAFGLAS® •� #80 UltimaT" Base Sheet" or "GAFGLAS® Stratavent® Nailable Venting Base Sheet" mecfianica0yfaltened. Ply Sheet: — One or more plies Type G1 "GAFGLAS® Ply 4" or "Tri-Ply® Ply 4" or GA f6Lj4S0 Fjex Ply 6" or;••••; "Tri-Ply® Ultra -Flexible Ply 6", fully adhered with hot roofing asphalt. Cap Sheet: — Type G3 "GAFGLAS® Mineral Surfaced Cap Sheet" or "Tri-Ply® BUR Granule Cap Sheet" or "GAFGLAS® EnergyCapT" Mineral -Surfaced Cap Sheet", fully adhered with hot roofing asphalt. Coating (O tional : — "United CoatingsT' TOPCOAT® EnergyCoteTm Roof Coating" or "TOPCOAT® MB Plus Coating" or "United Coatings' Roof Mate MB Plus Coating" applied at a rate of 2-gal./100-ft.2. https:Hlq.ulprospector.com/en/profile?e=148955 2/13/2019