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RF-09-22-2360Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 09/26/2022 Location Address Parcel Number 71 NE 97TH ST, Miami Shores, FL 33138 1132060131010 Contacts Permit NO.: RF-09-22-2360 Permit Type: Roof Work ClossiJication: Tile Permit Status: Approved Expiration: 03/27/2023 MYRON NOVAK Owner PIONEERSTAR CONSTRUCTION SERVICES Applicant 71 NE 97 ST, MIAMI SHORES, FL 33138 CORP JOSE ORTEGA 575 Tamiami Canal RD, Miami, FL 33144 Business: 3057883893 Jo3ortaga@aol.com CORP JOSE ORTEGA 575 Tamiami Canal RD, Miami, FL 33144 Business: 3057883893 Description: REROOF TILES CONCRETE Jo3ortaga@aol.com Fees Amount Application Fee - Other $50.00 CCF $17.40 UBPR Fee $2.00 UCA Fee $2.00 Education Surcharge $8.70 Permit Fee (Manual( $407.52 Total: $487.62 Valuation: $ 29,000.00 Total Sq Feet: 2,408.00 Inspection Requests: 305-762-4949 Payments Date Paid Amt Paid Total Fees $487.62 Credit Card 09/15/2022 $50.00 Credit Card 09/26/2022 $437.62 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. I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws and zoning. Futhermore, I authorize the above named contractor to do the work stated. O�(' iZ. uJC zed ature: Owner / Applicant / Contractor / Agent Date September 26, 2022 Page 2 of 2 Miami Shores Village ENTERED BUILDING PERMIT APPLICATION BUILDING PLUMBING ELECTRIC MECHANICAL Building Department SEP 15 qua 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Q Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20Z0 ' 741. Master Permit No. f F-0q- Z2. - � (,)0 Sub Permit ROOFING ❑ REVISION ❑ EXTENSION [-]RENEWAL ❑ CHANGE OF CANCELLATION Ej SHOP CONTRACTOR DRAWINGS JOB ADDRESS: -71 FlJ t7 '77 S / City: Miami Shores County: Miami Dade Zip: 33 / 3 S Folio/Parcel#: 11- 3206-013— 1011D Is the Building Historically Designated: Yes NO,evc Occupancy Type: Load: Construction Type: Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Yy R.O N L N O V i} IC Phone#: Add City:"/412% lkojzys State: iL Zip: 3313 p Tenant/Lessee Name: 14A- Phone#: ly Email: /v.4 CONTRACTOR: Company Name: &1 ee,-S74A- (,p//J7YUC7 /D✓) -e.-VIVJ Phone#: 305 Address: S--t S TR Mi R HZ CAn/ A L R-09 0. A47% C e- 3 3 / VV Email: � 03®11 9--rA 8.4 n4 I-O L . CrOM J Qualifier Name: OS2 e:>r4-e_qcz_ Phone#:305 3-SS-10673 State Certification or Registration #: CC C l 3 3 bS -4 Certificate of Competency #: -3 J 1i Z 6 (0 1 DESIGNER: Architect/Engineer: N 14- Phone#: AJ4 Address:—" 4A- City: Aj State: LJAt-Zip: N a Value of Work far this Permit: $ ZC1 • 00 0 • G Square/Linear Footage of Work: Z 4 0 0 Type of Work: ❑ Addition ❑ Alteration ❑ New 4 Repair/Replace ❑ Demolition Description of Work: Vr P-00 P T J L C S CCrJ C L gTC Specify color of color thru tile: TQr,,-awl - rt,4niraG.��tvn: &vwS 5{ 4: 7Us wn y � Submittal Fee $ Permit Fee $ 1 • S CCF $ 1-/ • 4 v CO/CC $ Scanning Fee $ I L1 (ilk !� DCA Fee $ 4 - S:% DBPR $ . Notary $ Technology Fee $ 4 $ • J Training/Education Fee $ jp• 7 C) Double Fee $ Structural Reviews $ P&Z Review $ 4;F�0_ Bond $ TOTAL FEE NOW DUE $ M -1 S T� (Revised04/05/2022) ENTERED Bonding Company's Name (if applicable) NO" E , Bonding Company's Address N ifs"' _� �� City N A2 State OU AU. Zip Mortgage Lender's Name (If applicable) N 4 Mortgage Lender's Address ri 7- City ✓I' - N 111� State IV la Zip 1 C-, 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 falth 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 O't-"/ "" �'v 6 %1 // ✓42 OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this (7> day ofSe(J+ .20 2Z by /3 day of Je/J-/ 20 ZZ-- by Ind 20 R 'U- . who is personally known to you Or�-dt who is personally known to me or who has produced U s N tZ0 -Sq3 - G �-tZ a��� me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Slgn: Cw.. Print: ry Seal: APPROVED BY (Revisedo4/o5/2022) identification and who did take an oath. NOTARY PUBLIC: M_ Sign: C,�r� 0 .W�,-Seal: Hoary Public stale of Florida Maria Celeste Reyes .rA Notary Pudic state a Honda My Commisaion HH 032751 Maria Celeste Reyes Explaa 081&,2024 g My Commission HH 032751 dr Expres 08/162024 Plans Examiner Zoning Structural Review Clerk Miami Shores Village -BUILDING DEPART TERED 10050 NE 2 Ave Miami Shores, FL 33138 5EP 15 2022 305-795-2204 www.msvfl.gov 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 Date: 10050 NE 2nd Ave Miami Shores, FI 33138 Re: Owner's Name: (A rm C, I U (71/A"y— Property Address: '71'1 A/T st V1/u awv 5 W rZ/J Roofing Permit Number: �✓�j 3� DearA�uilding Official: I HX ILO [ Dy6Va Gr— certify that I am not required to retrofit the roof to wall connections of my building because: ahe just valuation for the structure for purpose of ad valorem taxation is less than $300,000.00. Please attach proof of ad valorem taxation. ❑ 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) Zn 9 V rim (S-- /�cs✓�: C,(�- Signatu Print l4ame State of Florida, Miami Dade County The undersigned, being the first duly sworn, deposes and says that he/she is the owne for the above property mentioned. Sworn to and subscribed before me this 13 day of o r� v=< 20ZZ Nvm Notary Public, State of Florida at Large �fw • When the just valuation of the structure for purpose of ad valorem taxation is eq or more than $300,000.00, and the building was not constructed with FBC nor a SFBC. Then you must provide a building application from a General Contractor for Roof to Wall connection Hurricane Mitigation. For Forms and Applications click here: http://bidg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia miShoresVillage RevOI 142021 Owner affidavit of exemption Page 1 of 1 Address Owner Name Folio SEARCH: 71 nE 97 st PROPERTY INFORMATION Folio: 11-3206-013-1010 Sub -Division: MIAMI SHORES SEC 1 AMD Property Address 71 NE 97 ST Owner MYRON C NOVAK Mailing Address 71 NE 97 ST MIAMI SHORES, FL 33138-2330 PA Primary Zone 1100 SGL FAMILY - 2301-2500 SO Primary Land Use 0101 RESIDENTIAL -SINGLE FAMILY: 1 UNIT Beds / Baths I Half Floors Living Units Actual Area 3/2/0 2,117 Sq,Ft Suite D Living Area 1,690 Sq.Ft Adjusted Area 1,894 Sq.Ft Lot Size 11,500 Sq.Ft Year Built Multiple (See Building Info.) Featured Online Tools Comparable Sales PA Additional Online Tools Property Search Help Report Discrepancies Glossary Property Record Cards Property Taxes Report Homestead Fraud Special Taxing Districts and Other Non -Ad valorem Assessments Tax Comparison Tax Estimator TRIM Notice Value Adjustment Board ASSESSMENT INFORMATION Year 2022 2021 2020 Land Value $494,132 $345,138 $345,138 Building Value $170,362 $131,109 $131,376 Extra Feature Value $2,515 $2,549 $2,582 Market Value -�.,a:rxzzss;xs'..-: $667,009 $478,796 $479,096 c+rs�a:.KLgsurlsa+:xa.�cxr.^i:.z:rt:7r+�avrT.te:sa.�ax-.+-�sr..-,rzr�:na r.:assxx_y'.r�: Assessed Value sssns�;v�:::a:+r,a;sx.^stsu-r.::_:-�c:r- :rcr..sraecu:�.�aez:ss: v::asro: ;::.r..Fez:�,rsms.r..•,:.:w4_n:zcrz::.-az:sc::rn::.�ttyr.-ac:.x:z�:.crax:.�uav:: $215,102 $208,837 uaer:. �•._.sz:a..tr,:s•.::•_�: $205,954 � P TAXABLE VALUE INFORMATION 2022 2021 2020 COUNTY Exemption Value $50,000 $50,000 $50,000 Taxable Value $165,102 $158,837 $155,954 SCHOOLBOARD Exemption Value $25,000 $25,000 $25,000 Taxable Value $190,102 $183,837 $180,954 CITY Exemption Value $50,000 $50,000 $50,000 Taxable Value $165,102 $158,837 $155,954 REGIONAL Exemption Value $50,000 $50,000 $50,000 Taxable Value $165,102 $158,837 $155,954 � P BENEFITS INFORMATION Benefit Type 2022 2021 2020 Save Our Homes Cap Assessment Reduction $451,907 $269,959 $273,142 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Miami Shores Village - BUILDING DEPARTMENT7ERED 10050 NE 2 Ave Miami Shores, FL 33138 1 5 2022 305-795-2204 www.msvfl.ciov SECTION R4402.13 HIGH VELOCITY HURRICANE ZONES— REQUIRED OWNERS NOTIFICATION FOR ROOFING CONSIDERATIONS R4402.13.1 Scope. As it pertains to the section, it is the responsibility of roofing contractor to provide the owner with the required roofing permit, and to explain to the owner the content of the 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 ant the contractor. The owner's initial in the designated space indicates that the item has been explained. 1. -&I/L/ Aesthetics -Workmanship: the workmanship provisions of Section R4402 are for the purpose of providing that the roof system meets the wind resistance and water instruction 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. alt, 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 to be performed. 4. Exposed Ceiling: 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 penetration of the underside of the decking may not be acceptable. This provides the option of maintaining the appearance. 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. Pounding can be an indication of structural distress and may require the review of a professional structural engineer. Pounding may shorten the life expectancy and performance of the new roofing system. Pounding conditions may not be evident until the original roofing system is removed. Pounding conditions should be corrected. RevOI 142021 Owners roofing consideration Page 1 of 2 Miami Shores Village - BUILDING DEPARTMENT 10050 NE 2 Ave Miami Shores, FL 33138 305-795-2204 www.msvfl.aov 6. —WALAverflow scuppers (wall outlets): It is required that rainwater flows off so that the roof is not overloaded from a buildup of water. Perimeter/edge wall or other roof extension may block this discharge if overflow scuppers (wall outlets) are not provided. It may be necessary to install overflow scuppers in accordance with the requirements of Sections R4402, R4403 and R4413. 7. -- Ventilation: Most roof structures should have some ability to vent natural airflow through the interior of the structure assembly (the building itself). The existing amount of attic ventilation shall not be reduced. It may be beneficial to consider additional venting which can result in extending the service life of t roof. Owner/ gent's Signature Date C actor Signature Date For Forms and Applications click here: http://bldg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=o&repo=Mia miShoresVillage ReV01 142021 Owners roofing consideration Page 2 of 2 I NTr, ,, 4... �D SEP 1 b ­/ Florida Building Code 7th Edition (2020) High Velocityetwr icane Zone Uniform Roofing Application Form for Miami -Dade County BY: Section A (General Information) Master Permit Number: Contractor's Name: IP104,e�erS14✓ Process Number: 6"nt4ruC40"1 Seyye, u S Job Address: :;�/ NC- 93-57-- A//Ojni SLioi-eJ• GL 3-a/3S ❑ Low Slope ROOF CATEGORY ❑ Mechanically Fastened Tile ❑ AsphCrry ❑ Metal Panel/ Shingles cROOF TYPE 1-1NecoOP11yr ❑ Maintenance Low Slope Roof Area (ft') Mortar / Adhesive Set Tile ❑ Wood Shingles / Shakes ROOF SYSTEM INFORMATION Reroofing ❑ Recovering Steep Sloped Roof Area (ft2) Total (ftz Z Vo 9) 25/01 Are there gas vents on the roof? 0 Yes ® No If Yes what type? O Natural © LPX Is there an existing rooftop Solar System? O Yes ®No If yes will it be reinstalled? ©Yes O No Section B (Roof Plan) Sketch Roof Plan: Illustrate all levels and sections, roof drains, scuppers, overflow scuppers and overflow drains. Include dimensions of sections and levels, clearly identify dimensions of elevated pressure zones and location of parapets. Shores Village Building Department 3 Dept. Date ng Dept. Date act to compliance with all Federal, and County ryes and regulations. Its _-'-.-' _'-_�_' - -_'-_---~ } | { �� / �� � . " r] �� ---~'~~-� Florida Building Code 7th Edition (2020) High Velocity Hurricane Zone Uniform Roofing Application Form for Miami -Dade County Section D (Steep Sloped Roof System} Roof System Manufacturer: G d W N SUICD/A./A PA0 (,.bc Product Control Number: 2 [ -- a VZO • Minimum Design Wind Pressures, From Applicable RAS 127 Table or Calculations: Zone1: 3 V Zone 2e: V Zone2n: 101) Zone 2r: Zone 3e: ,�Q Zone 3r: 116, Slope.Range: *? 2:12 to _< 4:12 Roof Shape: Q All Hip Roof Deck Type: O>4:12to56:12 0>6:12to:512:12 0 Gable Roof or Partial Gable/Hip Roof Underlayment Type: Q AJ7H P Z Z 6 aj0r:,d Roof Slope: : 12 Insulation: A, Fire Barrier: N A4- Ridge Ventilation? Fastener Type & Spacing:IVY 1GS P"�t S N w 1"1 G L Cap Sheet Type: 50he, a�/f'�j-� p/ Cap Sheet Attachment: Mean Roof Height: Roof Covering: j7uww Aawr T/ C r Drip Edge Type & Size: aACA 24 e Florida Building Code 7th Edition (2020) High Velocity Hurricane Zone Uniform Roofing Application Form for Miami -Dade County Section E (Tile Calculations) For Moment based the systems, choose Method 1. Compare the values for Mrwith the values from Mf. If the Mf values are greater than or equal to the Mr values for each area of the roof, then the tile attachment method is acceptable. Method 1* " Moment Based Tile Calculations per RAS 127" Enter positive uplift pressures when using this table ( Zone 1: x AO.313 - 4/0 ) - Mg: W Qf = Ma JG• Product Approval Mf.- (Zone 2e• Y x A .313 Mg: g = Mr2e 16 • t� Product Approval Mf: Z% s• S ( Zone 2n: j 0 x A f '5 - •g0 )-Mg: •9 f = Mr2e Z(► gay Product Approval Mf: t/� • ( Zone 2r: 1018 x A A. = 33•" ) - Mg:G. 9 9 = Mr2r Product Approval Mf- (Zone 3e: ) 0 U x A l3 =93.SO ) - M91.49 = Mr3eLM L Product Approval Mf: QJ ( Zone 3r: 1100 x AD•3r; _ �%a�b )- Mg: &.fl = Mr3 35zgq..Product Approval Mf: qs• S ao Ice Tile attachment method.A,-edo" AL7 Alternate Tile attachment method: 07 For Uplift Based tile systems use Method 3. Compare the values for F' with the values for Fr. If the F' values are greater than or equal to the Fr values for each area of the roof, then the the attachment method is acceptable. Method 3* "Uplift Based Tile Calculations per RAS 127" (Zone 1: x L = x W = ) - (w) x cos 9 } = Fri Product Approval F': (Zone 2e: x L = x W = ) - (w) x cos a ) = Free Product Approval F': (Zone 2n: x L = x W = ) - (w) x cos 9 ) = Fr2„ Product Approval F: (Zone 2r. x L = x W = ) - (w) x cos 9 ) = Fr2r Product Approval F': (Zone 3e: x L = x W = ) — (w) x cos 13 ) = Fr3e Product Approval F': (Zone 3r: x L = x W = ) — (w) x cos 0 ) = For Product Approval *Method 2 "Simplified Tile Calculations" only applicable in Broward County. Where to obtain Information - Description Symbol Where to Find Design Pressure Zones 1, 2e, 2n, 2r,3e, 3r From the applicable Table In RAS-127 or be an engineering analysis prepared by a PE based upon ASCE 7 Mean Roof Height • H Job Site Roof Slope 8 Job Site Aerodynamic Multiplier A Product Approval / Notice of Acceptance Restoring Moment due to Gravity Mg Product Approval / Notice of Acceptance Attachment Resistance Mf Product Approval / Notice of Acceptance Required Moment Resistance Mr Calculated Minimum Attachment Resistance F' Product Approval / Notice of Acceptance Required Uplift Resistance Fr Calculated Average Tile Weight w Product Approval / Notice of Acceptance Tile Dimensions L=Length W= Width Product Approval / Notice of Acceptance All calculations must be submitted to the Building Official at the time of permit application. MIAMI D '® MIAMI-DADE COUNTY PRODUCT CONTROL SECTION DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) 11805 SW 26 Street, Room 208 BOARD AND CODE ADMINISTRATION DIVISION Miami, Florida 33175-2474 T (796)315-2590 F (786)315-2599 NOTICE OF ACCEPTANCE (NOA) www.mianddade.eov/oera Crown Building Products of Florida LLC 6018 HWY 72 Arcadia, FL. 34266 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 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: Tuscany Roof Tile 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 tiled 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 revises NOA 20-1105.07 and consists of pages I through 8. The submitted documentation was reviewed by Alex Tigers. NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 1 of 8 ROOFING ASSEMBLY APPROVAL Category: Roofing Sub Catezorv: Roofing Tiles Material: Concrete 1. SCOPE This approves a roofing system using Tuscany Roof Tile manufactured by Crown Building Products of Florida LLC in Arcadia, Fl. as 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 Crown Tuscany Roof Tile L = 17.0" W = 13.0" 0.50" thick nominal 2.3" high Test Product Specifications Description TAS 112 Low profile interlocking, concrete roof tile. For Type — lb direct deck, batten nail -on, mortar or adhesive set Class III applications Trim Pieces Length: varies TAS 112 Width: varies varying thickness 2.1 PRODUCTS MANUFACTURED BY OTHERS Pradiiet Name Polyset AH-160 TILE BOND TM Roof Tile Adhesive Product Description Two component polyurethane foam adhesive. Accessory trim, concrete roof pieces for use at hips, rakes, ridges and valley terminations manufactured for each tile profile. Single component polyurethane foam roof tile adhesive. Touch `N Seal StormBone One One component polyurethane Component Polyurethane Roof Tile foam adhesive. Adhesive "Tile Tite" Roof Tile Mortar Bonsai Roof Tile Mortar "Quikrete" Roof Tile Mortar, FL-15 Premixed, pre -bagged roof tile mortar. Premixed, pre -bagged roof tile mortar. Premixed, pre -bagged gray roof tile mortar. Manufacturer (With Current NOA) ICP Adhesives and Sealants, Inc. DuPont de Nemours, Inc. DAP Foam, Inc. Bermuda Roof Co. Inc. Bonsai American, Inc. The Quikrete Companies, Inc. NOA No.: 21-0420.10 MIAMM MDE COUNTY Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 2 of 8 2.2 MANUFACTURING LOCATION 2.2.1. Arcadia, Ft. 2.3 SUBMITTED EVIDENCE: Test Aaency Test Identifier Redland Technologies 7161-03 Appendix III Letter P0631.01 P0402 The Center for Applied Engineering, Inc. Celotex Corporation Testing Services Walker Engineering, Inc. American Test Lab of South Florida NEMO ETC, LLC PRI Construction Materials Technologies 94-083 94-084 25-7094-(1, 4 & 7) 25-7183-(1,2 & 7) 25-7214-(2 & 6) 25-7487-(1) 25-7496 (2 & 3) 25-7804-5 528454-2-1 520109-2 Calculations Calculations Calculations Calculations Calculations Calculations Calculations Evaluation Calculations Evaluation Calculations RT0908.02-14 RT09 l 2.02-14 RT1021.01-15 RT1211.01-15 RT1211.01-15 RTl 203.02-18 RT0531.02-19 4c-DPBS-20-LSOTM- 01.A-R 1 2002T0003.09 Test Name/Report PA 102 & PA 102(A) PA 108 (Nail -On) PA 108 (Mortar Set) Withdrawal Resistance Testing of screw vs. smooth shank nails PA 101 (Adhesive Set) PA 101 (Mortar Set) PA 102 PA 102 PA 102 PA 102 PA 102 PA 101 PA 101 25-7094 25-7496 25-7584 25-7804b-8 25-7804-4 & 5 25-7848-6 25-7183 Aerodynamic Multiplier Two Paddy Adhesive Set System TAS 112 Restoring Moment Aerodynamic Multiplier TAS 112 Restoring Moment Aerodynamic Multiplier TAS 112 TAS 112 TAS 101 TAS 101 Date Dec. 1991 Aug. 1994 July 1994 Sept. 1993 April 1994 May 1994 Oct. 1994 Nov. 1994 Feb. 1995 March, 1995 Sep. 1996 Sept. 1998 December 1998 February 1996 April 1996 December 1996 December 1996 December 1996 December 1996 March 1995 April 1999 April 1999 09/ 18/ 14 09/ 18/ 14 12/10/15 12/11/15 12/11/15 12/11/18 05/31/19 12/17/20 10/05/20 NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 3 of 8 3. LIMITATIONS: 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 accordance with TAS 106 may required, refer to applicable building code. 3.3 Applicant shall retain the services of a Miami -Dade County Certified Laboratory to perform quarterly test in accordance with TAS 112, appendix `A'. Such testing shall be submitted to the Building and Neighborhood Compliance Department — Product Control Section for review. 3.4 Minimum underlayment shall be in compliance with the applicable Roofing Applications Standards listed section 4.1 herein. 3.5 4/12 Minimum slope for mechanically attached tiles. 3.6 30/90 hot mopped underlayment applications may be installed perpendicular to the roof slope unless stated otherwise by the underlayment material manufacturers published literature. 3.7 This acceptance is for wood deck applications. Minimum deck requirements shall be in compliance with applicable building code. 4. INSTALLATION 4.1 Crown Tuscany Roof 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. Table 1: Average Weight (W) and Dimensions (I x w ) Tile Profile Weight-W (lbf) Length -I (ft) 1 Width-w (ft) 1 Fuscany Crown Roof Tile 10.0 1.42 1.08 Table 2: Aerodynamic Multipliers - A (ft3) Tile Profile A (ft3) Batten Application A (ft3) Direct Deck Application ITuscany Crown Roof Tile 0.289 0.313 Table 3: Restoring Moments due to Gravity - M9 (ft.-lbf) Tile Profile 2" • 12" 3" • 12" 493: 12" 5" • 12" 6" • 12" 791• 12" or greater Tuscany Crown Roof Tile Battens Direct Deck Battens Direct Deck Battens Direct Deck Battens Direct Deck I Battens Direct Deck Battens Direct Deck N/A 7.06 L N/A 6.99 6.88 6.88 1 6.73 6.74 6.57 6.57 1 6.39 6.39 NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 4 of 8 Table 4: Attachment Resistance Expressed as a Moment - Mf (ft.-Ibf) for Mechanically Attached Systems Tile Profile Fastener Type Direct Deck (min 15/32" plywood) Direct Deck (min. 19/32" plywood) Battens Tuscany Crown Roof 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 Table 5: Attachment Resistance Expressed as a Moment - Mf (ft.-Ibf) for Mechanically Attached Systems Tile Fastener Type Direct Deck Direct Deck Battens Profile (min 15132" (min. 19/32" plywood) plywood) Tuscany Crown Roof Tile 2-10d Ring Shank Nails' 43.0 67.6 50.9 1 Installation with a 4" the headlap and fasteners are located a min. of 2'/2" from head of tile. Table 6: Attachment Resistance Expressed as a Moment Mf (ft: Ibf) for Two Patty Adhesive' Set Systems Tile Profile Tile Application Minimum Attachment Resistance Tuscany Crown Roof Tile TILE BONDTm Roof Tile Adhesive 352 ICP Adhesives Pol set® AH-160 26.13 Touch 'N Seal StormBond® (one component) 864 1 See manufactures component approval for installation requirements. 2 Medium paddy weight of 16 grams per paddy of TILE BONDTM Roof Tile Adhesive 3 Medium paddy weight of 8 grams per paddy of Po) set® AH-160 4 Medium paddy weight of 8 grams between tile and underlayment, paddy weight of 5 grams on overlap of the of Touch 'N Seal StormBond ® one component) MIAODADE COUNTY NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 5 of 8 Table 7: Attachment Resistance Expressed as a Moment - Mf (ft-lbf) for Single Patty Adhesives Set Systems Tile Profile Tile Application Minimum Attachment Resistance Tuscany Crown Roof Tile TILE BONDTm Roof Tile Adhesive 676 Pol set AH-160 86.67 Polyset AH-160 45.58 5 See manufactures component approval for installation requirements 6 Medium paddy weight of 16 grams of TILE BONDT"' Roof Tile Adhesive 7 Large paddy weight of 54 grams of Pol set® AH-160. 8 Medium paddy weight of 24 grams of Pol set®AH-160 Table 8: Attachment Resistance Expressed as a Moment - Mf (ft.-Ibf) for Mortar Set Systems Tile Profile Tile Application Attachment Resistance Tuscany Crown Roof Tile Mortar SeV 20.6 9 Seespecific mortar manufacturers Notice of Acceptance APPROVED NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 6 of 8 5. LABELING 5.1 All tiles shall bear the imprint or identifiable marking of the manufacturer's name or logo as detailed below, or following statement: "Miami -Dade County Product Control Approved". r LABEL FOR CROWN TUSCANY ROOF TILE) (LOCATED ON THE UNDERSIDE OF TILE) NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09/02/21 Page 7 of 8 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. I' V" 11 AN PROFILE DRAWING TUSCANY CROWN TuscANY ROOF TILE END OF THIS ACCEPTANCE NOA No.: 21-0420.10 Expiration Date: 01/29/25 Approval Date: 09102/21 Page 8 of 8 OM-2 MIAMI-DADE COUNTY PRODUCT CONTROL SECTION 11805 SW 26 Street, Room 208 DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) Miami, Florida 33175-2474 BOARD AND CODE ADMINISTRATION DIVISION T (786)315-2590 F (786) 315-2599 NOTICE OF ACCEPTANCE (NOA) w .miamidade.eov/economy ICP Adhesives and Sealants, Inc. 12505 NW 44`' Street Coral Springs, FL. 33065 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 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: Polyset° AH-160 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 NOA 20-1124.07 and consists of pages 1 through 11. The submitted documentation was reviewed by Alex Tigera. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 1 of 11 ROOFING COMPONENT APPROVAL: Category: Roofing Sub Category: Roof file adhesive Materials: Polyurethane SCOPE: This approves Polyset® AH-160 as manufactured by ICP Adhesives and Sealants, Inc. as described in this Notice of Acceptance. For the locations where the design pressure requirements, as determined by applicable building code, do not exceed the design pressure values obtained by calculations in compliance with Roofing Application Standard RAS 127. For use with approved flat, low, and high profile roof tile systems using Polyset' AH-160. PRODUCTS MANUFACTURED BY APPLICANT: Product Dimensions Test Product Descriution Specifications Polyset°AH-160 N/A TAS 101 Two component polyurethane foam adhesive ICP Adhesives Foam N/A Dispensing Equipment Dispenser RTF1000 ICP Adhesives ProPack® N/A Dispensing Equipment 30&100 PRODUCTS MANUFACTURED BY OTHERS: Any Miami -Dade County Product Control Accepted Roof Tile Assembly having a current NOA which list attachment resistance values with the use of Polyset` AH-160 roof tile adhesive. MANUFACTURING LOCATION: Tomball, TX. PHYSICAL PROPERTIES: ProRerty Test Results Density @ 730F ASTM D1622 2.1 lbs./ft.3 Compressive Strength ASTM D 1621 18 PSI Parallel to rise 14 PSI Perpendicular to rise Tensile Strength ASTM D 1623 29 PSI Parallel to rise Water Absorption ASTM D2842 0% Moisture Vapor Transmission ASTM E96 2.3 Perms Dimensional Stability ASTM D2126 +0.07% Volume Change @ -40° F., 2 weeks +6.0% Volume Change @158°F., 100% Humidity, 2 weeks Closed Cell Content ASTM D6226 94% Note: The physical properties listed above are presented as typical average values as determined by accepted ASTM test methods and are subject to normal manufacturing variation. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 2 of 11 EVIDENCE SUBMITTED: Test Agency Test Identifier Test Name/Report Date Center for Applied Engineering #94-060 TAS 101 04/08/94 257818-IPA TAS 101 12/16/96 25-7438-3 SSTD 11-93 10/25/95 25-7438-4 25-743 8-7 SSTD 11-93 11 /02/95 25-7492 SSTD 11-93 12/12/95 Miles Laboratories NB-589-631 ASTM D 1623 02/01/94 Polymers Division Ramtech Laboratories, Inc. 9637-92 ASTM E 108 04/30/93 Southwest Research Institute 01-6743-011 ASTM E 108 11/16/94 01-6739-062b[l] ASTM E 84 01/16/95 Trinity Engineering 7050.02.96-1 TAS 114 03/14/96 P36700.04.12 ASTM D 1623 04/18/12 P39740.02.12 TAS 101 02/21/12 TAS 123 Celotex Corp. Testing Services 528454-2-1 TAS 101 10/23/98 528454-9-1 528454-10-1 520109-1 TAS 101 12/28/98 520109-2 520109-3 520109-6 520109-7 520191-1 TAS 101 03/02/99 520109-2-1 NEMO ETC, LLC 4p-ICP-20-SSLAP-0 LB Physical Properties l 1 /1 l /20 LIMITATIONS: 1. Fire classification is not part of this acceptance. Refer to the Prepared Roof Tile Assembly for fire rating. 2. PolyseO AH-160 shall solely be used with flat, low, & high the profiles. 3. Minimum underlayment shall be in compliance with the Roofing Application Standard RAS 120. 4. Roof Tile manufactures acquiring acceptance for the use of Polysee AH-160 roof tile adhesive with their tile assemblies shall test in accordance with TAS 101. 5. 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. NOA No.: 22-0411.02 MlAMI O WE COUNTY � Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 3 of 11 INSTALLATION: 1. Polyset' AH-160 may be used with any roof tile assembly having a current NOA that lists attachment resistance values with the use of Polyset' AH-160. 2. Polysee AH-160 shall be applied in compliance with the Component Application section and the corresponding Placement Details noted herein. The roof tile assembly's adhesive attachment with the use of Polyset" AH-160 shall provide sufficient attachment resistance to meet or exceed the resistance value determined in compliance with Miami -Dade County Roofing Application Standards RAS 127. The adhesive attachment data is noted in the roof tile assembly NOA. 3. Polysee AH-160 and its components shall be installed in accordance with Roofing Application Standard RAS 120, and ICP Adhesives and Sealants, Inc.'s Operating Instruction and Maintenance Booklet. 4. Installation must be by a Factory Trained 'Qualified Applicator' approved and licensed by ICP Adhesives and Sealants, Inc. ICP Adhesives and Sealants, Inc. shall supply a list of approved applicators to the authority having jurisdiction. 5. Calibration of the ICP Adhesives Foam Dispenser RTF 1000 dispensing equipment is required before application of any adhesive. The mix ratio between the "A" component and the "B" component shall be maintained between 1.0-1.15 (A): 1.0 (B). 6. PolyseO AH-160 shall be applied with ICP Adhesives Foam Dispenser RTF1000 or ICP Adhesives ProPack8 30 & 100 dispensing equipment only. 7. Polysee AH-160 shall not be exposed permanently to sunlight. 8. Tiles must be adhered in freshly applied adhesive. Tile must be set within 1 to 2 minutes after Polyse& AH-160 has been dispensed. 9. Polysete AH-160 placement and minimum patty weight shall be in accordance with the 'Placement Details' herein. Each generic tile profile requires the specific placement noted herein. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 4 of 11 Table 1: Adhesive Placement For Each Generic Tile Profile Tile Profile Placement Detail Minimum Paddy Contact Minimum Paddy Gram Area Weight Eave Course - Flat, Low, High All Eave Course 17-23 sq. inches 45-65 Profiles Flat, Low, High Profiles # 1 17-23 sq. inches 45-65 Flat Profile #2 10-12 sq. inches 30 Low Profile #2 12-14 sq. inches 30 High Profile #2 17-19 sq. inches 30 Flat, Low, High Profiles #3 Two Paddys: 8-9 sq. inches at 12 grams per paddy head of tile 9-11 sq. inches at overlap Two -Piece Barrel (Cap Tile) Two Piece 2 Beads (1 each longitudinal 17 grams per bead edge) 20-25 sq. inches each bead Two Piece Barrel (Pan Tile) Two Piece 65-70 sq. inches 34 grams under pan LABELING: All approved products listed herein shall be labeled and shall bear the imprint or identifiable marking of the manufacturer's name or logo and following statement: "Miami -Dade County Product Control Approved" or the Miami - Dade County Product Control Seal as shown below. MIAMMADE COUNTY BUILDING PERMIT REQUIREMENTS: As required by the Building Official or applicable building code in order to properly evaluate the installation of this system. MI MMDADE COUNTY NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 5 of 11 ADHESIVE PLACEMENT DETAIL # I Nail through plastic cement Paddy (Beneath Tile) (when required) Undvlayment R\\ loin. may, Battensoptional ° agS Eave Course in Fascie Eave Closure Nail through plastic cement (when required) Tile)I Eave Closure Fattia Nall through plastic ce (when required) Paddy (Beneath Tile) 1 Underlayment wygt;:,r l01n.a 2 in.wide Battens /optional tygy� Y Eaveeourse " Fascia Weephole 101n. 2In. Eaveclosure Orip edge Flat/Low Profile Tile 1. Starting at the cave course, apply a minimum 2" (50.8 Tom) x 10" (254 mm) x 1" (25.4 Turn) foam paddy onto the underlayment positioned as shown, under the strengthening rib closest to the overlock of the tile being set. 2. Continue in same manner. Insure approximately 17 (109.7 cm2) — 23 (148.4 cm2) square inch adhesive contact with the underside of the tile. Medium Profile / Double Pan Tile 1. Starting at the eave course, apply a minimum 2" (50.8 mm) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the tie being set. 2. Continue in same manner. Insure approximately 17 (109.7 cm) — 23 (148.4 cm2) square inch adhesive contact with the underside of the tile. High Profile / Single Pan Tile 1. Starting at the cave course, apply a minimum 2" (50.8 Tom) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the file being set. 2. Continue in same manner. Insure approximately 17 (109.7 cm2) — 23 (148.4 cm2) square inch adhesive contact with the underside of the tile. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 6 of 11 ADHESIVE PLACEMENT DETAIL ## 2 Nall through plastic cemant Paddy Monteath Tile) (when required) Underlayment It 71n.21n. Battens optional ° Eave Course otoin. z in Ease Closure plasticcement Battens Paddy Eave Unsure Fascia Flat/Low Profile Tile 1. Starting at the cave course, apply a minimum 2" (50.8 mm) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the strengthening rib of the file closest to the overlock of the tile being set. Insure approximately 17 (109.7 cm2) — 23 (148.4 cm) square inch adhesive contact with the underside of the tile. 2. At the second course, apply a minimum 2" (50.8mm) x 7" (177.8 mm) x 1" (25.4 nun) foam paddy onto the underlayment positioned as shown under the strengthening rib closest to the overlock of the tile being set. 3. Continue in same manner. Insure approximately 10" (64.5 cm2) - 12 (77.4 cm2) square inch adhesive contact with the underside of the tile. Medium Pro81e / Double Pan Tile Starting at the cave course, apply a minimum 2" (50.8 mm) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the tile being set. Insure approximately 17 (109.7 cm2) — 23 (148.4 cm2) square inch adhesive contact with the underside of the tile. 2. At the second course, apply a minimum 2" (50.8mm) x 7" (177.8 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the tile being set. 3. Continue in same manner. Insure approximately 12" (77.4 cm2) - 14 (90.3 cm2) square inch adhesive contact with the underside of the tile. (Instructions continued on next page) NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 7 of 11 ADHESIVE PLACEMENT DETAIL # 2 (CONTINUED Nail through plastic ce (whenrequired) Paddy(Beneath rile) Undedayment 7 in.. 2 in. Bmensoptional e , Eave Cours Fascia Weephole 10in 2In. Eeveclosure Dripedge High Profile / Single Pan Tile Starting at the eave course, apply a minimum 2" (50.8 mm) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the tile being set. Insure approximately 17 (109.7 cm') — 23 (148.4 cm2) square inch adhesive contact with the underside of the tile. 2. At the second course, apply a minimum 2" (50.8mm) x 7" (177.8 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown under the pan portion of the tile closest to the overlock of the tile being set. 3. Continue in same manner. Insure approximately 17" (109.7 cm') - 19 (122.6 cm) square inch adhesive contact with the underside of the tile. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 8 of 11 ADHESIVE PLACEMENT DETAIL # 3 NailthsollPplWaeenat (when regldntdt ❑oddyfbeUlee,ltow i aartero tlpdalal ° j • I Paticly(uncler tik) Single paddy y on top at the 7 un&rn� \ Singlepaddy on andedaM -ent •a4in. -• j; e ... °. 101na4 �2. quia BreClawne Flat M P. TUG Nail through plastic Cement 9agkpaddy under tile (when required, Paddy (between files) Ban ens Paddy sunder tile; opt anal t' • Single pad,! on top of toe4 Ain. t" 2:Ain.`, singglepaddyon undeNymeM�-" tin. - Ears Closure E"e Coutse-' raKla Medium Profile The 1. On the eave course only, apply a minimum 2" (50.8 mm) x 10" (254 mm) x 1" (25.4 mm) foam paddy onto the underlayment positioned as shown, under the strengthening rib for flat tile or under the pan portion of the tile for low or high profile tile closest to the Overlock of the tile being set. Leave approximately 4" (101.6 mm) up from the eave edge free of foam to prevent the expanded adhesive from blocking the weep holes. Insure approximately 17-23 in' (109.7-148.4 cmZ) of adhesive contact with the underside of the tile 2. Apply a 4" (101.6 mm) x 4" (101.6 mm) x 1" (25.4 mm) foam paddy onto the underlayment just below the second course line positioned foam paddy under the strengthening rib for flat tile, or under the pan portion of the tile, closest to the underlock for the second course file to be installed. Insure approximately 8-9 in- (51.6-58.1 cm) of adhesive contact with the underside of the tile. (Instructions continued on next page) NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 9 of 11 ADHESIVE PLACEMENT DETAIL # 3 (CONTINUED) Eanm eMioval Ea" Corse High ProtlleTile �GMAPPROVED Ewe do m Mipedge 3. Also apply a 2" (50.8 mm) x 4" (101.6 mm) x'/d' (19 mm) paddy on top of the eave course tile surface as shown, on top of the strengthening rib for flat tile or on top of the pan portion of the tile, closest to the underlock of the first course of tile. Install second course of tile. Insure approximately 9 (58.1 cm2) - 11 (71cm2) square inch adhesive contact with the underside of the tile at the overlap and 7 (45.2 cm') - 9 (58.1 cm') square inch adhesive contact with the underside of the tile at the head of the tile. Continue in same manner. NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 10 of 11 1) Place enough adhesive to achieve 6S to 70 sq. In contact with the pan tile. 2) Turn coven upside down. Place adhesive in to 1 in. from outside edge of cover tile. Then install the tiles Ensure 20 to 25 sq. in. contact area; � Underlayment Eave closure (matar shawnl Fascia Board ADHESIVE PLACEMENT DETAIL TWO PIECE BARREL Steep pitch applications (when required) &4' Remove top portion of the eave course cover tile. Abut to second course of pan tiles. Ensure eave and of pan and coiner tiles are Rush at cave line. Two Piece Barrel - High Profile Tile MIAMI-DADE COUNTY Two Piece Barrel (Cap and Pan) Tile 1. Starting at the eave course, apply a minimum 2" (50.8 mm) x 10" (254 mm) x I " (25.4 mm) foam paddy onto the underlayment positioned as shown under two adjacent pan tiles. Support eave tiles from rocking until adhesive has a chance to cure. 2. Continue in same manner bringing two pan courses up toward the ridge. Insure approximately 65 (419.4 CM2) — 70 (451.6 cm2) square inch adhesive contact with the underside of the pan tile. 3. Turn covers upside down exposing the underside of the tile. Apply a minimum 1" (25.4 mm) x 10" (254 mm) bead of adhesive directly on the inner edge of each side of the cover tile. Leave approximately 3/4" (19 mm) to 1 " (25.4 mm) from the outside edge of the tile, inward, free of foam to allow for expansion. 4. Turn cover tile over after foam is applied and place onto pan the course. Insure a minimum of 20 (129 cm2) - 25 (161.3 cm2) square inch contact area on each side of the cover tile to the pan tile. Continue in same manner. Trim away any cured exposed foam adhesive. Pointing of longitudinal edges of the cover tiles are considered optional. 5. When additional nailing is required, 2" (50.8 mm) x 4" (101.6 mm) milers or the tie wire system using galvanized, stainless steel, or copper wire and compatible nails may be used. END OF THIS ACCEPTANCE NOA No.: 22-0411.02 Expiration Date: 05/10/27 Approval Date: 05/05/22 Page 11 of 11 ND MIAMI-DADE COUNTY E PRODUCT CONTROL SECTION DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) 11805 SW 26 Street, Room 208 BOARD AND CODE ADMINISTRATION DIVISION Miami, Florida 33175-2474 T (786) 315-2590 F (786) 315-2599 NOTICE OF ACCEPTANCE (NOA) www.mtamidade.eov/economy Polyglass USA Inc. I I I I W. Newport Center Drive Deerfield Beach, FL 33442 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 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, 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 shal I 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 21-0602.14 and consists of pages 1 through 7. The submitted documentation was reviewed by Alex Tigera. NOA No.: 21-1217.02 Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 1 of 7 ROOFING COMPONENT APPROVAL Cateeory: Roofing Sub-Cateeory: Underlayment Material: SBS, APP PRODUCTS DESCRIPTION: Test Product Product Dimensions Specification Description Polystick IR-Xe 65' x 3' Or 33.4' x ASTM D 1970 A fine granular/sand top surface self -adhering, APP Manufacturing 35 polymer modified, fiberglass reinforced, bituminous sheet Location #1 & #2 60 mils thick material for use as an underlayment in sloped roof assemblies. Designed as an ice & rain shield. Polystick TU Max 65'8" x 3'3-3/8" TAS 103 A rubberized asphalt self -adhering, polyester reinforced Manufacturing 60 mils thick waterproofing membrane. Designed as a a roof tile Location #1 & 42 underlayment. Polystick TU P 32' 10" x 3'3 3/s" TAS 103 A rubberized asphalt waterproofing membrane, glass- ManuActuiing 130 mils thick fiber/polyester reinforced, with a granular surface Location 42 designed for use as a tile roof underlayment. Polystick TU Plus 65' x 3'3 3/8" TAS 103 A rubberized asphalt self -adhering, glass-fiber/polyester (Surface Printing) 80 mils thick reinforced waterproofing membrane. Designed as a metal Manufacturing roofing and roof tile underlayment. Location #1 & 42 Polystick MTS 6518" x 31321811 TAS 103 A homogeneous, rubberized asphalt waterproofing Manufactufing 60 mils thick membrane, glass fiber reinforced with polyolefrnic film Location #2 on the upper surface for use as an underlayment for metal roofing, roof tile, slate tiles and shingle underlayment. Polystick MTS Plus 6518" x 31321811 TAS 103 A homogeneous, rubberized asphalt waterproofing Manu, factur ng 60 mils thick membrane, glass fiber reinforced with polyolefinic film Location #2 on the upper surface for use as an underlayment for metal roofing, roof tile, slate tiles and shingle underlayment. Elastoflex S6 G 32' 10" x 3'3 %" TAS 103 and Polyester reinforced, SBS modified bitumen membrane Manufacturing ASTM D 6164 with a sanded back face and a granule top surface. For Location #2 use in roof the underlayment systems. MANUFACTURING PLANTS: 1. Hazelton, PA 2. Winter Haven, FL NOA No.: 21-1217.02 Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 2 of 7 Test Agency Trinity I ERD NEMO I etc. LLC LABELING: EVIDENCE SUBMITTED Test Identifier Test Name/Report P40390.10.12 P37590.07.13-1 P45270.05.14 P46520.10.14 P44360.10.14 P43290.10.14-R1 PLYG-SC7550.03.15 PLYG-SC 10130.06.16-3 PLYG-S C 1013 0.06.16 -1 PLYG-SC 10130.09.16 PLYG-SC 13035.08.17 PLYG-SC15855.05.20 A 4j -PLYG-21-S SUDL-03.A ASTM D 1970 ASTM D6164 TAS 103, TAS 110 & ASTM D1623 ASTM D1623 TAS 103 & TAS 110 ASTM D 1970 & TAS 110 TAS 103 & ASTM D4798 TAS 103 & TAS 110 ASTM DI 970 & TAS 110 ASTM D1623 TAS 103 & ASTM D4798 TAS 103 & TAS 110 ASTM D1970 Date 10/03/12 07/02/13 05/12/14 10/03/14 10/07/14 10/17/14 03/24/15 06/27/16 06/27/16 09/22/16 10/32/17 05/29/20 10/29/21 1. All membranes or packaging shall bear the imprint or identifiable marking of the manufacturer's name or logo, city and state of manufacturing facility and the following statement: "Miami -Dade County Product Control Approved" or the Miami -Dade County Product Control Seal as shown below. BUILDING PERMIT REQUIREMENTS: Application for building permit shall be accompanied by copies of the following: 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. NOA No.: 21-1217.02 Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 3 of 7 INSTALLATION PROCEDURES: Deck Type 1: Wood, non -insulated Deck Description: Min. 19/32" plywood or wood plank System Type E(1): Anchor sheet mechanically fastened 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) Membrane: Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS or Polystick MTS Plus, self -adhered. Surfacing: See General Limitations Below. Deck Type 1: Wood, non -insulated Deck Description: Min. 19/32" plywood or wood plank System Type E(2): Anchor sheet mechanically fastened 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) Membrane: Elastoflex S6 G, hot asphalt applied Surfacing: See General Limitations Below. Deck Type l: Wood, non -insulated Deck Description: Min. 19/32" plywood or wood plank System Type E(3): Base sheet mechanically fastened to deck, subsequent cap membrane self- adhered. Anchor/Base Sheet: One or more plies of ASTM D 226 Type TT 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) Ply Sheet: Polystick MTS Plus, self -adhered with minimum 3" horizontal laps and minimum 6" vertical laps. Membrane: Polystick TU Plus, self -adhered. Surfacing: See General Limitations Below. NOA No.: 214 217.02 rt�►rn•u�►uE Cout�mr Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 4 of 7 INSTALLATION REQUIREMENTS: 1. All nails in the deck shall be carefully checked for protruding heads. Re -fasten any loose deck panels, and sweep the deck thoroughly to re move 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 membrane to obtain maximum contact. Remove the release film as the membrane is applied. All side laps shall be a minimum of 3" and end laps shall be a minimum of 6". Roll the membrane into place alter removing the release strip. Vertical strapping of the roof with Polystick is acceptable. Membrane shall be back nailed in accordance with applicable building code. 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 with a 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 TU Plus may be used in asphaltic shingles, wood shakes and shingles, non-structural metal roofing, adhered roof tile using ICP Adhesive Polyset RTA-1, mechanically fastened roof tile systems and quarry slate roof assemblies. Polystick MTS may be used in asphaltic shingles, wood shakes and shingles, non-structural metal roofing, mechanically fastened roof the systems and quarry slate roof assemblies. Polystick MTS Plus, may be used in asphaltic shingles, wood shakes and shingles, non-structural metal roofing, mechanically fastened roof tile systems and quarry slate roof assemblies. Polystick TU P may be used in asphaltic shingles, wood shakes and shingles, mechanically fastened roof tile systems and quarry slate roof assemblies. Polystick IR-Xe may be used in asphaltic shingles, wood shakes and shingles, and quarry slate roof assemblies. Polystick TU Max may be used in non-structural metal roofing, adhered roof tile using ICP Adhesive Polyset RTA-1 or ICP Adhesives Polyset AH-160, and mechanically fastened roof tile systems. Elastoflex S6 G may be used in adhered roof tile using ICP Adhesive Polyset RTA-1 or ICP Adhesives Polyset AT-160, and mechanically fastened roof file systems. 3. Deck requirements shall be in compliance with applicable building code. 4. Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS and Polystick MTS Plus shall be applied to a smooth, clean and dry surface. The deck shall be free of irregularities. 5. Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS and Polystick MTS Plus shall not be adhered directly over a pre-existing roof membrane as a recover system. 6. Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS and Polystick MTS Plus 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. NOA No.: 21-1217.02 Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 5 of 7 7. 8. Exposure Limitations (Days) Polystick MTS Polystick iR-Xe Elastolex S6 G Polystick TU Plus Polystick TU P Polystick TU Max Polystick NITS Plus Winter Haven FL 180 90 180 180 180 180 180 Hazelton PA N/A 90 N/A 180 N/A 180 1 N/A 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. When loading roof tiles on roof tile underlayment for (direct -to -deck) tile assemblies, the maximum roof slope shall be as follows: (See Table Below) Tile Polystick Elastotex Polystick TU Plus, Polystick Polystick System (E3) Profile MTS S6 G Polystick TU P TU Max MTS Plus MTS Plus with TU Plus Flat Tile Prohibited 4:12 6:12 6:12 5:12 6:12 without battens Profiled Prohibited 4:12 6:12 6:12 4:12 6:12 Tile without battens The above slope limitations can be exceeded only by using battens in accordance with the Approved Tile System Notice of Acceptance and applicable Florida Building Code requirements. When battens are required, they shall be utilized during loading and installation of tiles. 9. Care should be 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 — two tiles laid perpendicular to slope followed by a maximum four tile stack parallel to the slope, for a total of 6 tiles — for all underlayments except Polystick MTS which shall be loaded onto battens. Allis Fbpf Deck prepared worn POLYSTfCK TU Ru 10. Refer to prepared roofing system Product Control Notice of Acceptance for listed approval of this product with specific prepared roofing products. Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS, Polystick MTS Plus or Elastoflex S6 G may be used with any approved roof covering Notice of Acceptance listing Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS, Polystick MTS Plus or Elastoflex S6 G as a component part of an assembly in the Notice of Acceptance. If Polystick IR-Xe, Polystick TU Max, Polystick TU P, Polystick TU Plus, Polystick MTS, Polystick MTS Plus or Elastoflex S6 G are not listed, a request may be made to the Authority Having Jurisdiction (AHJ) or the Miami -Dade County Product Control Section for approval provided that appropriate documentation is provided to detail compatibility of the products, wind uplift resistance, and fire testing results. NOA No.: 21-1217.02 MIAMI•DADE COUNTY Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 6 of 7 POLYGLASS GENERAL APPLICATION GUIDELINES FOR POLYSTICK MEMBRANES PLEASE CHECK WITH LOCAL BUILDING CODES REGARDING LIMITATIONS OF SPECIFIC APPLICATIONS. LOCAL CODES MAY SUPERSEDE POLYGLASS REQUIREMENTS AND RECOMMENDATIONS. 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 V metal disk as required in Miami -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 50, XtraFlex 50 Premium Modified Wet/Dry Cement or Polyglass PG 500 applied in between the application of the lap. The use of mastic between the laps does not apply to Polystick MTS. 5. A maximum of 6 tiles per stack are allowed when loading tile on the underlayments. Refer to the Polyglass Tile Loading Guidelines. See General Limitations #8 and #9. 6. Battens and/or Counter -battens, as required by the tile manufacturers NOA, must be used on all projects for pitch/slopes of 7/12" or greater. It is suggested that on pitch/slopes in excess of 6'/"/12", precautions should be taken, such as the use of battens to prevent the sliding during the loading process. 7. Minimum cute 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. 9. Repair of Polystick membranes is to be accomplished by applying Polyglass POLYPLUS 50, XtraFlex 50 Premium Modified Wet/Dry Cement or Polyglass PG 500 to the area in need of repair, followed by a patch of the Polystick material of like kind should be set and hand rolled in place over the area needing such repair. Patching membrane shall be a minimum of 6 inches in either direction. The repair should be installed in such a way so that water will run parallel to or over the top of all laps of the patch. 10. All self -adhered membranes must be rolled to ensure full contact with approved substrates. Polyglass requires a minimum of 40 lbs for a weighted roller for the rolling of the field membrane. Hand rollers are acceptable for rolling of patches or small areas of the roof. Brooming may be used where slope prohibits rolling. 11. All approved 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) 8944563. 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 RECOM ErH WATIONS. END OF THIS ACCEPTANCE NOA No.: 21-1217.02 Expiration Date: 09/13/27 Approval Date: 09/08/22 Page 7 of 7 Data CERTIFICATE OF LIABILITY INSURANCE 8/24/2022 Producer: Plymouth Insurance Agency 2739 U.S. Highway 19 N, Holiday, FL 34691 (727) 938-5562 Thls Certificate Is Issued as matter of Information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or attar the coverage afforded by the policies below, Insurers Affording Coverage NAIC # insured: South East Personnel Leasing, Inc. & Subsidiaries Insurer A: Uon Insurance Company 11075 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurers: nwrerc: Insurer D: Insurer E: Covers es e po les Insurance listed below have been issued to the insured named above or no policy period n Ing any requirement tenor con on- of any contract or other owns with respect to which IMs certificate nay be issued or may "nuiln, the Insurance 9"W by the policies described heroin ie subjectto all the tears, exclusion, and condidons of such Policies. Aggregate limits shown my have scan rodumd by paid claims, INSR LTR ADDL INSRD Type of Insurance Policy Number Policy Effective Date (MMIDDIM Policy Expiration Dale(MM/DD/YY) Limits ENERAL LIABILITY Each occurrence Commercial General Liability Claims Made13 Occur Damage to rod premises (EA mma occunence) Mad Exp 6 Personal Adv Injury eneral aggregate limit applies per: Polity ❑ Project ❑ LOC General Aggregate Products. ComyOp Agp UTOMOBILE LIABILITY Combined Single Limit (EA Accident) Any Aura Bodily Injury All Owned Autw (Per Person) Scheduled Autosas Bodily Injury Hired Autos (Per Accident) NonAmletl Autos Property Damage (PerA ideng E%CESSIUMBRELLALIABILITY EachOc mmce Aggregate Occur ❑Claims Made seem Deductible A Workers Compensation and Employers' Liability Any proprietodpanner/executive officer/member WC 71949 01/01/2022 01101 /2023 X I WC Stetu- to Limns CTH- ER E.L. Each Accident $1,004000 E.L. Disease - Ea Employee s1.00o.nn0 excluded? NO If Yes, describe under special provisions below. E.L. Disease - Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Bast Company rated A 6caallont . AMR till 1261seems Descriptions of Operations/LOCations/Vehlcles/Exclusions added by Endorsement/Special Provisions: Cllcnt ID: 52-71-344 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company": Gold Star Miami Corp Coverage only applies to Injuries Incurred by South East Personnel Leasing, Inc. & Subsidiaries acute employee(s), while working In: FL. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937.2138 or emall ceruflcams011onlnsurancemmpany.com Project Name: 71 Ne VWSiRiiT, MERMI, R ISSUE 08-24-22 (To) • Da CERT FICATE OLDER CANCELLATION PIONEERSTAR CONSTRUCTION SERVICES CORP. ate r , e issuing Insured any of the shwa dea30 da policies bo cancelled before the expiraholder haired Insurer Will endeavor to mall 30 days written notice to the certificate holder nametl ro the left but failure ro do so shall Impose no obligation or liability of any kind upon the insurer, its agents or representatives. of 575 TAMIAMI CANAL ROAD MIAMi, FL 33144 Notice to Owner — Workers' Com Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 sation 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' 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: Owner State of Florida County of Mianti-Dade 1 The foregoing was acknowledge before me this 13 day of 5 ep 20 2't2 By M 3 Q_O � 1J 0\14 JC1-- who is personally known to me or has produced 3_G7--0ofas identification. Notary: SEAL: yx* Notary Public State of Flonde P. I t Maria Celeste Reyes _ _