RF-06-23-1507Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Issue Date:06/29/2023
Parcel Number
126 NE 103RD ST, Miami Shores, FL 33138 1132060131760
Contacts
Permit NO.: RF-06-23-1507
Permit Type:Roof
Work Classification: Flat
Permit Status: Approved
Expiration: 12/29/2023
REGINALD BOURDEAU MAXI RAYMOND Owner
126103 ST, MIAMI SHORES, FL 33138
XPERT ROOFING OF SOUTH FLORIDA Contractor
GIOVANNY PEREYRA
Business:7863651160 xpertroofing@hotmail.com
Description: FLAT RE -ROOF Valuation: $ 8,100.00
Total Sq Feet: 800.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$5.40
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$2.70
Permit Fee (Manual)
$80.00
Scanning Fee (Manual)
$12.00
Technology Fee (Manual)
513.00
Total:
$167.10
Payments
Date Paid
Amt Paid
Total Fees
$167.10
Credit Card
06/29/2023
$117.10
Credit Card
06/13/2023
$50.00
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 information is accurate and that all work will be done in compliance with all applicable laws
regulat'ng nstruction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Au ure: Ow er I Applicant / Contractor I Agent lbate
June 29, 2023 Page 2 of 2
iR-CExV ED
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 Q ROOFING
❑PLUMBING [:]MECHANICAL ❑ CHANGE OF
CONTRACTOR
JOBADDRESS: 126 NE 103 ST
JUN 13 2023
BY:
FBC 202e - -1-1"'
Master Permit No. WF-0%-Z3-ISO-7
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple T
e,,,,,.-126 NE 103 ST
MIAMI SHORES
Tenant/Lessee
Email:
MAXI RAYMOND
State: FL Zip: 33138
CONTRACTOR: Company Name: XPERT ROOFING OF SOUTH FLORIDA Phone#: 7863651160
Address: 9761 NW 57TH TERRACE DORAL FL 33178
Email: XPERTROOFING@HOTMAIL.COM
Qualifier Name: GIOVANNY PEREYRA Phone#: 7863651160
State Certification or Registration #: CCC1332334 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City: State: _Zip:
O_O
Value of Work for this Permit: $ S i lC�• Square/Linear Footage of Work: Boo SQ (:�F .
Type of Work: ❑ Addition ❑ Alteration
/' I--]NewRepair/Replace ❑ Demolition
Description of Work: �(a+ c-c- fooA- .
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 80.
co CCF $ '1 b CO/CC $
Scanning Fee $ ("Z' DCA Fee $ ?,-(P DBPR $ Z • dD Notary $
Technology Fee $ 1 3 .OD Training/Education Fee $
Structural Reviews $
2'Za
Double Fee $
P&Z Review $ Bond $
TOTAL FEE NOW DUE $A I I-7• 10
(Revised04/05/2022)
Bonding Company's Name (if applicable)
Bonding Company's Address
city State
Mortgage Lender's Name (if applicable) _
Mortgage Lender's Address
city
State
Zip
Zip
Application is hereby made to obtain a permit to do the work and Installations as indicated. I certify that no work or Installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: 1 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 certifled copy of the recorded notice of commencemeqlmust be posted at a job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the ab nce of such post n ice, the
inspection will not be approved and a reinspection fee will be charged.
Signature V R A V M 121YO
OWNER or AGENT
The foregoing instrument was acknowledged before me this
q day of , Une 201-5 by
PdXil V _. who is personally known to
me or who has produced as
Identification and who did take an oath.
NOTARY PUBLIC:
The foregoing lifstrument was ackn vledged before me this
q day of JUYI 20 '1 by
%IY7 X�YlYl�1 t [ 1'f 'rG, who is personally known to
me or who has produced' - as
identification and Yvho'did take -an oath.
NOTARY PUBLIC:
Sign: f -
Print: l
Seal:
B"L'A AEWEW
APPROVED BY APPROVED Plans Examiner Zoning
061142023 5:20:43 PM
Structural Review
(RevisedO4/05/2022)
OFFICE OF THE PROPERTY APPRAISER
10
Summary Report
Property Information
Folio:
Property Address:
Owner
11-3206-013-1760
126 NE 103 ST
Miami Shores, FL 33138.2329
REGINALD BOURDEAU
MAXI RAYMOND
MARIE D BOURDEAU
Mailing Address
20456 NW 8 CT
MIAMI, FL 33169 USA
1000 SGL FAMILY- 2101-2300 SO
PA Primary Zone
Primary Land Use
0101 RESIDENTIAL -SINGLE
FAMILY:1 UNIT
Beds I Baths I Half
2/ 1/ 0
Floors
1
Living Units
1
Actual Area
2,413 Sq.Ft
Living Area
1,446 Sq.Ft
Adjusted Area
1,807 Sq.Ft
8,475 Sq.Ft
Lot Size
Year Built
Multiple (See Building Info.)
Assessment Information
Year
2022
$364,486
2021
$254,163
2020
$254,163
Land Value
Building Value
$166,967
$125.767
$125,767
XF Value
$842
$842
$942
Market Value
$532,295
$380,772
$380,772
Assessed Value
$136,993
$133,003
$131,167
Benefits Information
Benefit
Type
2022
2021
2020
Save Our Homes
Assessment
$395,302
$247,769
$249,605
Cap
Reduction
Homestead
Exemption
$25,000
$25,000
$25,000
Second
Homestead
Exemption
$25,000
$25.000
$25,000
Note: Not all benefits are applicable to all Taxable Values (Le, County, School
Board, City, Regional).
Short Legal Description
1534165342
MIAMI SHORES SEC 1 AMD PB 10-70
W1/2 LOT 10 & LOT 11 BLK 13
LOT SIZE 75.000 X 113
OR 14840-1140 1290 1
Generated On : 6/1/2023
Taxable Value Information
2022
2021
2020
County
Exemption Value
$50,000
$60,0001
$50,000
Taxable Value
$86,993
$83,0031
$81,167
School Board
Exemption Value
$25.000
$25,000
$25,000
Taxable Value
1 $111,9931
$108,003
$106,167
City
Exemption Value
$50,000
$50,000
$50,000
Taxable Value
1 $86,9931
$83,0031
$81.167
Regional
Exemption Value
$50,000
$50,000
$50,000
Taxable Value
$86,9931
$83,003
$81,167
Sales Information
Previous
OR Book.
Sale
Price
Page
Qualification Description
07/05/2022
$210,400
33282-
Affiliated parties
1266
21743-
Sales which are disqualified as a result
06/01/2003
$0
2263
of examination of the deed
12101/1990
$83,500
14840
Sales which are qualified
1140
10101/1984
$75,000
12300-
Sales which are qualified
2195
The Once 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 Countv assumas no liability. see full disclaimer and User Ameement at httn://w ..miamidadn.nov/info/disciaimor.aso
BUILDING BREW
APPROVED I.NARANJO
Florida Building Code 7th Edition (2020) 06114120235:17:49PM
High Velocity Hurricane Zone Uniform Roofing Application Form for Miami -Dade County
Section A (General Information)
Master Permit Number: Process Number:
Contractor's Name: XPERT ROOFING OF SOUTH FLORIDA
Job Address: 126 NE 103rd St, Miami Shores, F133138
ROOF CATEGORY
19 Low Slope ❑ Mechanically Fastened Tile ❑ Mortar / Adhesive Set Tile
❑ Asphaltic Shingles ❑ Metal Panel/ Shingles ❑ Wood Shingles/ Shakes
ROOF TYPE
❑ New Roof ❑ Repair ❑ Maintenance Reroofing ❑ Recovering
ROOF SYSTEM INFORMATION
Low Slope Roof Area (ftz) SteeSloped Roof Area (ftZ) gO�Total (ftZ)
iI PC
Are there gas vents on the roof? 0 Yes QIo If Yes what type? 0 Natural 0 LPX
Is there an existing roof top Solar System? 0 Yes 00 If yes will it be reinstalled? 0 Yes �Ao
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.
CITY
COPY
/ZG NF149-iT.
1: Flat roof only.
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.clov
AFFIDAVIT OF COMPLIANCE WITH ROOF TO WALL CONNECTION
HURRICANE MITIGATION RETROFIT FOR EXISTING SITE -BUILT SINGLE
FAMILY RESIDENTIAL STRUCTURES PURSUANT TO SECTION 553.844 F.S.
To: Miami Shores Village Building Department
10050 NE 2nd Ave
Miami Shores, FI 33138
Re
Owner's Name: MAXI RAYMOND
Date: 6 i 3
Property Address:126 NE 103rd St, Miami Shores, FL 33138
Roofing Permit Number:
Dear Building Official:
I GIOVANNY PEREYRA certify that I have improved the roof to wall
connections of the ref enced property as required by the Manual of Hurricane Mitigation
Retrofits for xisting a -Built Single Family Residential Structures as adopted by the Florida
Building C missio y Rule 9B-3.047 F.A.C.
GIOVANNY PEREYRA
re / Print Name
State of Florida Miami Dade County
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 01 :. ' day of J t 1fle, 20 12 b
Notary Nblic, State of Florida at Large
For Forms and Applications click here:
http://bldg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01 142021 Affidavit of Compliance with roof to wall Page 1 of 1
JUAN J. SANTANDREU P.E BUILDING REVIEW
P.E.. # 67241 APPROVED I.NARANJO
7135 SW 44 Street Miami, Florida 33155 06/14/2023 5:18:13 PM
Ph.305-412-7361
1 Monday, June 12, 2023
CONTRACTOR: XPERT ROOFING
JOB ADDRESS: 126 Northeast 103rd Street, Miami Shores, FL
LOW PITCH ROOFS FASTENERS CALCULATIONS
Description
Flat Roof
Roof Mean Heght: 10.0 ft
NOA No: 18-0919.12
Roof System Manufacturer: GAF
Deck Type: Wood No Insulated
BaseSheet & Fastener Type: 1 Ply #75 Base Sheet fastener with 1-1/4 RSN
and Tin Cap
System Type: E(i)151
Maximum Design Preassure from the specific NOA: -52.50 psf
Scope of Activity & Findings:
Minimum Design Wind Uplift Preassure from (RAS 128) Exposure "C"
Zone 1'= -37.0 psf @ 9 in o/c on laps and 2 equal rows
9 in
Zone 1 = -64.0 psf @ 71n o/c on laps and 2 equal rows
7 in
Zone 2 = -84.0 psf @ 5 in o/c on laps and 2 equal rows
5 in
Zone 3 = -115.0 psf @ 4 in o/c on laps and 2 equal rows
4 in
lap: 4 In
Net width(ft)= Nw = 2.95 in
Net length (ft) Nl = (100) Ln= 33.93 in
(to make one square)
Nw
Rs = 11.79 in
Number of fastener per square
Side laps row = fl: = 45 fasteners/sq
Center row = fc: = 90 fasteners/sq
Total 136 fasteners/sq
Ft 12 x per fasteners FT:= 100 FT= 0.74
Total
Fy= 52.5 * FT Fy = 38.69 Ibf
General Equation:
FS=Fy x 144/P x Rs
Results:
JUAN J. SANTANDREU P.E
P.E.. # 67241
7135 SW 44 Street Miami, Florida 33155
Ph.305-412-7361
Zone F= fa:= Fy * 144 fa= 13 in
(Field * Rs)
Zone 1= fa= Fy * 144 fa= 7 in
(Perimeter * Rsf)
Zone 2 fa= Fy * 144 fa= 5 in
(Comer * Rsp)
Zone 3 fa= Fy * 144 fa= 4 in
(Comer * Rsc)
ZONE DIMENSIONS:
Perimeter zone (P2) Width: 6.00 ft
Comer zone (P3) Length: 6.00 ft (P3) Width: 2.00 ft
JUAN J. SANTANDREU P.E
P.E. # 67241
BUILDING REVIEW
APPROVED 1. NARANJO
06/14/2023 5:18:24 PM
Florida Building Code 7th Edition (2020)
High Velocity Hurricane Zone Uniform Roofing Application Form for Miami -Dade County
Section C (Low Sloped Roof Systems)
Fill in Specific Roof Assembly Components and Identify
manufacturer
(If a component is not used, identify as "NA")
System Manufacturer: GAF
Product Approval # 18-0919.12
Design Wind Pressures, from RAS 128 or Calculations:
Zone 1': 3'11 Zonal: U 4 Zone 2: aL4
Zone3: -(1p7
Max. Design Pressure, from the specific product
approval system: -52.5
Deck,-.. PYLWOOD
Gauge / Thickness: 5/8
Slope: 0.50
Anchor/ Base Sheet & No. of Ply(s): N/A
Anchor/ Base Sheet Fastener/ Bonding Material:
Insulation Base Layer: N/A
Base Insulation Size and Thickness: N/A
Base Insulation Fastener/ Bonding Material:
N/A
Top Insulation Layer:
Top Insulation Size and Thickness: N/A
Top Insulation Fastener/Bonding Material:
N/A
Base Sheet(s) & No. of Ply(s): GAF GLASSBASE 75R(1)
Base Sheet Fastener/ Bonding Material:
1 1/4" Rs NAIL & TIN CAP 15/8
Ply Sheet(s) and No. of Ply(s): GAF RUBEROID 20 (1) PLY
Ply Sheet Fastener/ Bonding Material:
HOT MOP ASPHALT
Top Ply; GAF MINERAL CAP SHEET
Top Ply Fastener/ Bonding Material:
HOT MOP ASPHALT
Surfacing:
Fastener Spacing for Anchor/Base Sheet Attachment:
Zone 1' "cc@Laps, R Rows @ "oc
Zone 1 " cc @ Laps, # Rows 2 @ , "oc
Zone 2 5 oc @ Laps # Rows �±'tC @ 5 "cc
Zone "cc@Laps, It Rows @ L"oc
Number of Fasteners Per Insulation Board
Zone I': N/A Zonel: N/A Zone 2: N/A Zone 3: N/A
Illustrated Components Noted and Details as Applicable:
Woodblocking, Gutter, Edge Termination, Stripping, Flashing,
Continuous Cleat, Cant Strip, Base Flashing, Counterflashing,
Coping, Etc.
Indiute: Mean Roof Height, Parapet Height, Height Base Flashing,
Component Material, Material Thickness, Fastener Type, Fastener
Spacing or Submit Manufactures Details that Comply with RAS III
and Chapter 16.
N/A
FT.
GAFGLASSSASE 754 It)
P; impel
GAF RUBEROID 20(1)
Iluullu
GAF MINERAL CAP SHEET
14
t r'r
518 PLYWOOD
Moan
Roof
3"FACE 26 GA DRIP EDGE
Height
TGFU.R 1306 - Roofing Systems
Page 5 of 48
Cap Shoop —TYPO G3'GAFGIAS® Minrnl SurtacM Cap Shmt' or "TriAlyO BUR Grnmue Cap Sheet" Or'GAFGlAS% EAw9yCOP'"
Mineral -Surfaced Cap Shear, k* adhered with has n oOn9 asphalt.
Coating (Optional)( — -United Coatings"' TOPCOAT(D EoargyCPtaw Aaof Cutting" or "TOPCOAT%MB Mus Coating" Or'Lkltd
Coatings"' Roar Mate Me Plus Roar Coating" applied at a rate of 2-031.1100.10.
10. Docks NC Incline: 112
or
'GAF 2•Pwt Roollng Adhesive-, applied as a nomnal 2•)/2 In. bawl with a mintmum vn-timerapeUR9 d 124m. crafty ULOwsmels
IofpeUon adhutve, sopped Par the marwlactume, Insulation HSWctlans.
Base Shauss —One ply Type G2-GAFGLASO 175 8rae Shear or'Trl-Ply® A75 Base ShaW or'GAFGtAS% 080 UWma'" Go" Shmt",
mechanically fastened.
Ply enter — One w Iwo Wes Type G) -GAFGL S%Ply 4- w'TA-PP/% 4- Or-GAFGIASS nU-Pie" 6' or Type OF'GAFGUS% a75
Base Shoat" cr'TrI 875 Base Shear Or "GAFGLASO 980 UhTne- BOW Sheol', fully adhered with hot Mine no"IL
Cap Sheet•. — Type 63'GAFGUS43) Mineral Surfaced Cap Shed' Or"Trl.Plye OUR Granuk Cap Sheer, fully adhered with hot roofing
asphalt.
Coating: —"Untied Coatings'" TOPCOAT® Env9yCate'" Roof Coating' or TOPCOAT%Me PIUs Coaling' or "Unitee Coatings`" final Mate
Me Plus Coaling" applied at a rate a( 2gal./10040.
17. Deck: C-15y32 Incline: 112
nbar or poylsoeyanurale mechanically, fastened or ad1wed vets,
ah"N..
Oens(ieck% Roolteofd" w "OemOackS Pd.. Aoofseawr or
Stales Gvosum Co-'SECUROCRGI Raul DoWT (Tyne FRX G) Or
Case She art — One ply Type G2-GAFGUS% A75 Base Shear er 74-My 075 gale Sued` Or'GAFOi S% O80 UIUma^ DOm Shan'.
mechanically Fastened.
Ply Shook:— One w two pits Type 61'GAFG SS Ply 4'or'TtlAly 4-of'GAFGUIS% Flu My W'w Typo GI'GAFGUS%e75 Dais
Shoal' or'Td•My B75 Case Sneer Or'GAFGL SS a80 U11ma'" Case Shcct', fully adhered with liol maling aspmk.
Op Sheet, —Typs G3'GAFGLAS% Mlnelal Surfaced Cap Sheol- to 4n•ply%BUR Granule Cap Shotl', fully adhered wish hot roeln,g
PsphalL
Coatingl—'UARed Coatings"' TOPCOAT% Energy[ot" Roar CoaUnp' or "TOPCOAT% MO Plus Coaling" or "United Coolings"' Root Note
Me Plus Cotting' opened at a rate or 2-pa1,1100•FL2.
18. Deck: NC Tnellna: I
IptiomOt—Ally Warmest peril( cfy gbuer ar gloss Fluor w Polyimcyanuratc, mechanically fasturn oradhered with
! M' or nPO LISP Adhesive M Low Tamp" w OMG Inc. *0��bond Fastening System", applied up Amino! 3/4•m. bead or
mOng Adhasiye", applied as a nominal I1y2-ln. bind with a maximum On•mmerspruing Or 12•In. or any lit Classified
wive, appeals par the manutactunn s lestallMion Irotmetleas.
— One ply'GAFGUS% SmatavenlS Perforated Venting Base Shed', loose laid or Type GZ'GAFGLAS% 975 Sam Shell' or
Me Plus: —'Cato applied
n,u, cnmpnw�-sac
MB Plus Roof Caalinp' applied at a raft of 2•gal./J00•R �.
19. Deck: C-15/37 2nc11ne: I
or
or
PolylSDpanurale mechanically fastened or adhered vnth
or
'SECUROCKOGIass•Hat ROO( Bawls' (Type SGMRX) meWnkofly tstene0 ar WlereO nlih OMG Inc. "Vylsond Fastening System'• of
any
UL Classified Insula hen adheshc with butt Joints in the barrier board Products staggered a minimum of 64n. tram plywood deck Jamie
Base Sheets — One ply MAFGUSO Slralevent% Nallable Venting One Shad' 0,'GAIGUS% Slydtevent% Pedwited venting use
Sheet", base laid or Type 62'GAFGUS%e75 Base Sheet' at'TO•Ply A75 Base Shur or'GAFGLAS% 400 Ultimo'• Base Sheet', fully
adhered with hot moMg njohSIL
Ply Sheets —One or two pies "RUSER010(9 Mop Smooth' of *RUSEROID% Mop Plus Smpeth" fully adhered wkh hot monn0 asphalt.
Membranet — "GAFGIASS Mineral Surfaced Cop Shaer' or'r+PlyO OUR Granule Cop SOW, fully adhered vAh hot roofing allphall.
Coating: — "United CODUngS" TOPCOAT% EntrgYcale" Bear Cowing' In'TOPCOAT% Me Plus Cooling' or 'United Camps'" Real time
MIS Plus Reef Coating- secured at a rate of 2•ga1410040.
I0. peak: C-15132 Incline: I
Rasa Sher: —One ply Type G " GLASO a75 Base Sheol or-Trl-Ply% a75 USe Sheet- mechanically fastened.
Insulation (Optional): —Any t6lr5, ,on: per to aw nd ROor or glass fiber or pNylsocya.0 ate, mechonl(aDy fastened
or hot mopped or adhered Win jenm Syspm'Or any ULOassmed lnsllauto AdheSlva.
U.S. Skeet —Doe or Mort pile "mmFDOID320 Smoo 'A betord@20 Plus SmoMA" or'RUBEROLO% MW IS Smooth',
mechanically fastened t r 1 2& red wD , no• n aso e11.
Cap Sheet —Type G7 Mnerw u ace eat" reTrl•My%&IM1 Granule Cap Slttl"Or"GArGLAS% EnargyCop"
Mlnare65Urfwed Cup Sheer.
21. Dal NC Incline:2
82rder Board (Optional): — One or more layers minimum 1/4.1a. thick Georgia-Pacific Gypsum LLC "DensDeck% ILoolUoawl' or
"OrroCcon a Prime Noafbow l" or'DensOeckR DureGuand- Ruefboard' or minimum 1/4-In. thick United States Gypsum Co.
"SECUROCKS Roar Board- (Type FRX4) or'SECUROCKO Glass -Mot Roar BooW (Type SGMRY).
hitp://daiabase.ul.com/cgi-biTi/XYV/Icniplatc/LISEXT/I FRAME/sbowpage.html?name="f... 2/26/2018
Scanned with CamScanner
BUILDINGBEVIEW
APPROVED I.NARANJO
06114/2023 5:18:34 PM
BUILDING REVIEW
APPROVED 1. NARANJO
06114/2023 5:183B PM
MIAMt6ZE T4rAMi-DADE COUNTY
r I r ' "•' . PRODUCT CONTROLSECTION
11805 SW 26 Saul, Room 208
DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES (RER) Miami, Florida 33175-2474
BOARD AND CODE ADMINISTRATION DIVISION T (786)315-2590 F (796) 315-2599
NOTICE OF ACCEPTANCE (NOA) mlmnIdaaecnvheannmv
GAF
1 Campus Drive
Parsippany, NJ 07054
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: GAF Ruberoid® Modified Bitumen Roof System 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 aftcr a renewal applicatian 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, andlor 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. 15-1020-01 and consists of pages I through 67.
The submitted documentation was reviewed by Jorge L. Acebo.
', APPaOVED
NOA No.: 18-0919.12
Expiration Date: 11/06/23
Approvnl Data: 11/01/18
Page 1 of 67
ROOFING SYSTEM APPROVAL
Category:
Roofing
Sub-CateQory:
Modified Bitumen
Material:
APP/SBS
Deck TvQe_
Wood
Maximum Design Pressure:
-105 psf.
TRADE NAMES OF PRODUCTS MANUFACTURED OR LABELED BY APPLICANT:
TABLE 1
Test
Product
Prods
Dimensions
$necification
Description
GAFGLAS" Ply 4
39.37"
ASTM D2178
Smooth surfaced asphaltic ply sheet
(l meter) Wide
reinforced with fiberglass mat.
Tri-Ply* Ply 4 Ply Sheet
39.37"
ASTM D2178
Smooth surfaced asphaltic ply sheet
(I meter) Wide
reinforced with fiberglass mat.
GAFGLAS'
39.37"
ASTM D2178
Smooth surfaced asphaltic ply sheet
FlexPly 6
(1 meter) Wide
reinforced with fiberglass mat.
GAFGLAS* #75 Base Sheet
39.37"
ASTM D4601
Smooth asphaltic base or base/ply sheet
(I meter) Wide
reinforced with fiberglass mat.
Tri-Ply* #75 Base Sheet
39.37"
ASTM D4601
Smooth asphaltic base or base/ply sheet
(1 meter) Wide
reinforced with fiberglass mat.
GAFGLAS* #80 Ultima" Base
39.37"
ASTM D4601
Smooth asphaltic base or base/ply sheet
Sheet
(1 meter) Wide
reinforced with fiberglass mat.
GAFGLAS* Stratavent'
39.37"
ASTM D4897
Smooth surfaced asphaltic perforated
Perforated Venting Base Sheet
(I meter) Wide
venting base sheet reinforced with
fiberglass mat.
GAFGLAS* Stratavent'n'
39.37"
ASTM D4897
Smooth surfaced asphaltic nailable venting
Nailable Venting Base Sheet
(1 meter) Wide
base sheet reinforced with fiberglass mat.
Bottom side surfaced with granules.
Ruberoidg' HW 25 Smooth
39.37"
ASTM D6163
Smooth surfaced torch applied SBS base
(1 meter) Wide
or ply sheet reinforced with a fiberglass
mat.
Ruberoidx' HW Smooth
39.37"
ASTM D6164
Smooth surfaced torch applied SBS base
(1 meter) Wide
or ply sheet reinforced with a polyester
mat.
Ruberoid*' HW Granule
39.37"
ASTM D6164
Granule surfaced torch applied SBS cap
(I meter) Wide
sheet reinforced with a polyester mat.
Ruberoid' HW Granule FR
39.37"
ASTM D6164
Fire retardant granule surfaced heat -
meter) Wide
welded SBS cap sheet reinforced with a
polyester mat.
Ruberoid'O HW Plus Granule
39.37"
ASTM D6164
Granule surfaced torch applied SBS cap
(1 meter) Wide
sheet reinforced with a polyester mat.
Ruberoid* HW Plus Granule
39.37"
ASTM D6164
Fire retardant granule surfaced torch
FR
(1 meter) Wide
applied SBS cap sheet reinforced with a
polyester mat.
NOA No.: 18-0919.12
}p=E W u� Expiration Date: 11/06/23
Approval Date: 11/01/18
Page 2 of 67
Membrane Type: SBS/SBS Cold Applied
Deck Type 1: Wood, Non -insulated
Deck Description: Min. 19/32" or greater plywood or wood plank secured 6 in. o.c. with 8d ring shank
nails to supports spaced 24 in. o.c. max.
System Type E(I):
Anchor sheet is mechanically attached to roof deck. (Non -insulated systems)
All General and System Limitations snot[ apply.
Fire Barrier:
FireOut'" Fire Barrier Coating, VersaShiclda Fire -Resistant Roof Deck Protection,
(optional)
VersaShield" Solo` Fire -Resistant Slip Sheet, DensDeck®Roof Board,
SECUROCK" Gypsum -Fiber Roof Board, or SECUROCK Glass -Mat Roof Board.
Base sheet:
GAFGLAS" #80 Ultima' Base Sheet, GAFGLAS" Stratavent" Nailable Venting
Base Sheet, Ruberoid® 20 Smooth, Ruberoid" HW Smooth or Ruberoid" HW 25
Smooth base sheet mechanically Fastened to deck as described below:
Fastening
GAFGLAS" Ply 4, Tri-Ply® Ply 4 Ply Sheet, GAFGLAS" FlexPly' 6, GAFGLAS"
Option #1:
#75 Base Sheet, Tri-Ply® #75 Base Sliest or any of above base sheets attached to
deck with approved annular ring shank nails and tin caps at a fastener spacing of 9"
o.c. at the lap staggered and in two rows 18" o.c. in the field.
Not for use with DensDcck or SECUROCK Fire Barrier
(Maxhnum Design Pressure —45 psf. See Gencral Linrilulion 119)
Fastening
GAFGLAS" Ply 4, Tri-Ply® Ply 4 Ply Sheet, GAFGLAS® FlexPly'" 6, GAFGLAS"
Sheet, Tri-Plye #75 Base Sheet or any of above base sheets attached to
Option #2:
#75 Base
deck with Drill-Tec' #12 Fastener or Drill-Tec' #14 Fastener and Drill-Tec"' 3"
Steel Plate, Dril l-Tece' AccuTrac" Fiat Plate or Drill-Tec"' AccuTrac" Recessed
Plate installed 12" o.c. in 3 rows. One row is in the 2" side lap. The outer rows are
equally spaced approximately 12" O.C. in the field of the sheet.
(Maximum Design Pressure 1S psf. See General Limitation #9)
Fastening
GAFGLAS® FlexPly- 6, GAFGLAS® 975 Base Sheet, Tri-Ply" 05 Base Sheet or
Option #3:
any of above bast sheets attached to deck with approved annular ring shank nails
and tin caps at a fastener spacing of 9" o.c. at the 4" lap staggered and in two rows
9" o.c. in the field.
Not for use with DensDeck or SECUROCK Fire Barrier
(Maximum Design Premcure —52.5 psf. See General Limitation #7)
Fastening
GAFGLASe' #75 Base Sheet, Tri-Ply" #75 Base Sheet or any of above base sheets
Option $14:
attached to deck with Drill-Tec'" #12 Fastener or Drill-Tece' #14 Fastener and Drill-
Tec'" 3" Steel Plate, Drill-Tec' AccuTrac® Flat Plate or Drill -Ted" AccuTrac®
Recessed Plate installed I T' o.c, in 4 rows. One row is in the 2" side lap. The other
rows are equally spaced approximately 9" 0.0. in the field or the sheet.
(Maxim ran Design Pressure —45 psf. See General Limitation 09)
Fastening
GAFGLAS® 4180 Ultima" Base Sheet, Ruberoid" 20 Smooth, Ruberoid"Mop
Option #5:
Smooth base sheet attached to deck approved annular ring shank nails and 3"
inverted Drill-Tec'" 3" Steel Plate at a fastener spacing of 9" o.c. at the 4" lap
staggered in two rows 9" in the field.
Not for use with DensDeck or SECUROCK Fire Barrier
(Maxinumr Design Pressure —60 psf. See General Limilolion #7)
NOA No.: 18-0919.12
Expiration Date: 11/06/23
Approval Date: 11/01/18
Page 51 of 67
Fastening
GAFGLAS" 075 Base Sheet, Tri-Ply® 475 Base Sheet or any of above base sheets
Option #6:
attached to deck with Drill -Teti" #12 Fastener or Drill -Teti" #14 Fastener and Drill -
Ted" 3" Steel Plate, Drill -Tee"' AccuTrac" Flat Plate or Drill -Tee!' AccuTraco
Recessed Plate installed 8" o.c. in 4 rows. One row is in the 2" side lap. The other
rows are equally spaced approximately 9" o.c, in the field of the sheet.
(Maximum Design Pressure —75 psf. See General Limitation #7)
Ply Sheet:
(Optional) One or more plies GAFGLAS® Ply 4, Tri-Ply" Ply 4 Ply Sheet,
GAFGLASa F1exPly"6, GAFGLASa480 Ultims Base Sheet, Ruberoid' Mop
Smooth, Ruberoid* Mop Smooth 1.5, Ruberoid" Mop Plus Smooth or Ruberoid* 20
Smooth sheet adhered in a full mopping of approved asphalt applied within the EVT
range and at a rate of 20.40 lbs.lsq.
Membrane:
One or more plies of Ruberoida Mop Smooth, Ruberoid£ Mop Smooth 1.5,
Ruberoid* Mop Plus Smooth, Ruberoid" Mop Granule FR, Ruberoida Mop Granule,
Tri-Ply"' SBS Granule Cap Sheet, Intec Flex PRF, , Ruberoida Mop Plus Granule,
Rubomida 20 Smooth, Ruberoid® 30 Granule, Ruberoid* EnergyCap'" 30 Granule
FR, Ruberoida 30 Granule FR, Ruberoida 30 Plus Granule Fit, or Ruberoid* Mop
Plus Granule FR in adhered in a full mopping of approved asphalt applied within the
EVT range and at a rate of 20-40 lbs./sq.
Or
One or more plies of Ruberoida Mop Smooth, Ruberoid* Mop Smooth 1.5,
Ruberoid* Mop Plus Smooth, Ruberoida Mop Granule, Tri-Ply* SBS Granule Cap
Sheet, ]nice Flex PRF, , Ruberoida Mop Granule Fit, Ruberoida Mop Plus
Granule, Ruberoid* 20 Smooth, Ruberoid`° 30 Granule, Ruberoida EnergyCap' 30
Granule FR, Ruberoid* 30 Granule FR, Ruberoida 30 Pitts Granule FR, or
Ruberoid° Mop Plus Granule FR adhered in MatrixTM 102 SBS Membrane Adhesive
at an application rate of 1-2 gal./sq.
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.
I. 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. GAFGLAS" Mineral -Surfaced Cap Sbeet, 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 Ibs./sq.
3. TOPCOAT" Surface Seal SB or United Coatings' Surface Seal SB Roof Coating
applied in one or more coats at a minimum rate of 1.0 gal./sq. per coat.
OR
TOPCOAT" MB Plus or United Coatings"' Roof Mate MB Plus Coating
applied at a minimum rate of 1.0 gal./sq.(to be used as a primer) followed by
TOPCOAT" Membrane or United Coatings— Roof Mate TCM Coating
applied in one or more coats at a minimum rate of 1.0 gal./sq. per coat.
4. Fiber Aluminum Roof Coating.
Maximum Design
Pressure: See Fastening Options
NOA No.: 18-0919.12
Pn4tntor+oE couNn Expiration Date: 11/06/13
Approval Date: I1l01/18
Page 52 of 67
WOOD DECK SYSTEM LIMITATIONS:
I A slip sheet is required with GAFGLAS" Ply 4 and GAFGLAS® FlexPly' 6 when used as a
mechanically fastened base or anchor sheet.
2. Minimum''/." DensDecks' Roof Board or W' Type X gypsum board is acceptable lobe installed
directly over the wood deck.
GENERAL LIMITATIONS:
I. Fire classification is not part of this acceptance; refer to a current Approved Roofing Materials
Directory ror 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 lbs./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
foam insulations when the base sheet is fully mopped, if no recovery board is used the base sheet
shall be applied using spot cropping with approved asphalt, 12" diameter circles, 24" o.c.; or strip
mopped 8" ribbons in three rows, one at each side lap and one down the center of the sheet allowing
a continuous area of ventilation. Encircling of the strips is not acceptable. A 6" break shall be
placed every 12' in each ribbon to allow cross ventilation. Asphalt application of either system shall
be at a minimum rate of 12 lbs./sq. Note: Spot attached systems shall be limited tea maximum
design pressure of -45 Pat.
5. Fastener spacing for insulation attachment is based on a Minimum Characteristic Force (F') value of
275 Ibf., as tested in compliance with Testing Application Standard TAS 105. If the Fastener value,
as field-tested, are below 275 Ibf. insulation attachment shall not be acceptable.
6. Fastener spacing for mechanical attachment of anchor/base sheet or membrane attachment is based
on aminimum fastener resistance value in conjunction with the maximum design value listed within
a specific system. Should the fastener resistance be less than that required, as datemtined by the
Building Official, a revised fastener spacing, prepared, signed and scaled by a Florida Registered
Frisineer, Architect, or Registered Roof Consultant may be submitted. Said revised fastener spacing
shall utilize the withdrawal resistance value taken from Testing Application Standards'I'AS 105 and
calculations in compliance with Roofing Application Standard RAS 117.
7. Perimeter and comer areas shal I 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 scaled
by a Florida registered Professional Engineer, Registered Architect, or Registered Roof Consultant
(When tills limitation is specifically referred within this NOA, General Limitation #9 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 1 I I 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 comers). Neither rational analysis, nor extrapolation shall be permitted for
enhanced fastening at enhanced pressure zones (i.e, perimeters, extended corners and comers).
(When this limitation is specifically referred within this NOA, General Limitation N7 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
NOA No.: I8-0919.12
tcwoeeoucurr Expiration Date: 11/06/23
' Approval Date: 11/01/18
Page 67 of 67
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.aov
BUILDING REVIEI9
APPROVED I.NARANJO
SECTION R4402.13 06f142023517:20PM
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.M A_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.
�P 2. M_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. M /- Common roofs: Common roofs are those which have no visible delineation
Y 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. '4 0- 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.M - 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
GQ
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.aov
BUILDING REVIEW
APPROVED 1. NARANJO
0614 2026 5:17 35 PM
M R— Overflow 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. —k4 12- Ventilation: Most roof structures should have
airflow through the interior of the structure assembly (the
amount of attic ventilation shall not be reduced. It may be
venting which can result in extending the service life of t
'2A V,(qQ1V Q osroino2a
O�wwner//Agent's Signature Date
rS
vent natural
The existing
consider additional
06/01 /2023
Date
For Forms and Applications click here: /
http://bidg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01142021 Owners roofing consideration Page 2 of 2
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl. ov
BUILDING REVIEW I
APPROVED I.NARANJO
OWNERS'S AFFIDAVIT OF EXEMPTION :D,4202351NOPIJ
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 2"d Ave
Miami Shores, FI 33138
Date: 06/01/2023
Re: Owner's Name: MAXI RAYMOND
Property Address:126 NE 103rd St, Miami Shores, FL 33138
Roofing Permit Number:
Dear Building Official:
I MAXI RAYMOND certify that I am not required to retrofit the roof
Fall connections of my ouiming necause:
e just valuation for the structure for purpose of ad valorem taxation is less than
,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)
MAX/ )2PyA4014_;)
Signature
State of Florida, Miami Dade County
MAX]RAYMOND
Print Name
The undersigned, being the first duly sworn, deposes and says that hd/sh`e1isthe owner for the
above property mentioned. Sworn to and subscribed before me tA&A_ " day of
JUNE 2023 =
Notary Public, State of Florida at Large
%oe fo
• When the just valuation of the stru e for p of ad valarem.;taxatioh is equal to
or more than $300,000.00, and the building was not constructed with FBC nor a 1994
SFBC. Then you must provide a building application from a General Contractor for the
Roof to Wall connection Hurricane Mitigation.
For Forms and Applications click here:
http://bldg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01 142021 Owner affidavit of exemption Page 1 of 1
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LICENCES
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE*
D. COPY OF WORKERS COMPENSATION INSURANCE*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit)
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 LICENSE OR MIAMI DADE COUNTY MUNICIPAL
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 Contractor Affidavit)
*YOUR INSURANCE COMPANY MUST ISSUE A 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: XPERT ROOFING OF SOUTH FLORIDA
BUSINESS ADDRESS: 9761 NW 57TH TERRACE
DORAL
BUSINESS PHONE: ( 786 ) 365-1160 FAX NUMBER ( )
CELL PHONE( 786 ) 365-1160 QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER: CCC1332334
STATE FL ZIP`i7
GIOVANNY PEREYRA
Ron DeSantis, Governor
STATE OF FLORIDA
Melanie S. Griffin, Secretary
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
THE ROOFING CONTRACTOR HEREIN IS CERTIFIED UNDER THE
PROVISIONS OF CHAPTER 489, FLORIDA STATUTES
PEREYRA, GIOVANNY A
XPERT ROOFING OF SOUTH FLORIDA CORP
9761 NW 57 TERRACE
DORAL FL 33178
LICENSE NUMBER: CCC1332334
EXPIRATION DATE: AUGUST 31, 2024
Always verify licenses online at MyFloridaLicense.com
IF
Do not alter this document in any form.
F=#• i it
❑' if rii,r_'�
This is your license. It is unlawful for anyone other than the licensee to use this document.
Local Business Tax Receipt
Miami -Dade County, State of Florida
THIS IS NOT A BILL - DO NOT PAY
7292922
BUSINESS NAME/LOCATION
XPERT ROOFING OF SOUTH
FLORIDA CORP
9761 NW 57TH TER
DORAL, FL 33178-2669
OWNER
XPERT ROOFING OF SOUTH
FLORIDA CORP
r./n r.InVANNY PFRFYRA .IR PRFR
Worker(s) 1
�LBTJ
EXPIRES
SEPTEMBER 30, 2023
Must be displayed at place of business
Won
Pursuant to County Code
Chapter SA - Art. 9 & 10
W .I
SEC. TYPE OF BUSINESS PAYMENT RECEIVED
196 SPECIALTY BUILDING BY TAX COLLECTOR
CONTRACTOR 45.00 09/29/2022
CCC1332334 INT-22432556
RECEIPT NO.
RENEWAL
7582313
This Local Business Tax Receipt only confirms payment of the Local Business Tex. The Recolpt is not a license,
permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sac Sa-276.
MIAMEDaoE For more information, visit www.miamidade aov/texcollector
C
AcoRv® CERTIFICATE OF LIABILITY INSURANCE
��
DATE (MM/DDIYYYYj
06/14/2023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements .
PRODUCER
City Coast insurance, Inc.
8785 SW 165 Avenue, Ste 200-2006
Miami, Florida 33193
CONTACT
NAME: Christine Serra
PHONE 786-347-2727 FAX 786-502-2153
AIC Nol.
ADDRESS: christine@citycoastinsurance.cam
INSURERS AFFORDING COVERAGE
NAIC it
INSURER A: American Builders Insurance Company
INSURED
Xpert Roofing odf South Florida, Corp.
9761 NW 57th Terrace
Doral, FI 33178
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR
TYPE OF INSURANCE
ADDL
SUB
POLICY NUMBER
MAD EFF
POLIMMIDD EXP
LIMITS
A
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ® OCCUR
ABIC13487-00
12/06/2022
12/06/2023
EACH OCCURRENCE
$ 300,000.00
PREMISES Ea occurrence
$ 5,000.00
MED EXP (Any one person)
$ 300,000.00
PERSONAL & ADV INJURY
$ 300,000.00
GENERAL AGGREGATE
$ 300,000.00
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO- LOC
PRODUCTS - COMPIOP AGG
$ 300,000.00
$
AUTOMOBILE LIABILITY
A
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT
Ea accident
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
UMBRELLA LIAB
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WC STATU- I OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
LICENSE # CCC1332334
CFRTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Miami Shores Village Bldg Dept.
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2nd Avenue
ACCORDANCE WITH THE POLICY PROVISIONS.
Miami Shores, FI.33138
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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JIMMY PATRONIS \\ `"" "' `*•, .
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW ' •
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 12/4/2021 EXPIRATION DATE: 12/4/2023
PERSON: GIOVANNY PEREYRA JR EMAIL: GIOJR@YBCPRINTING.COM
FEIN: 842788154
BUSINESS NAME AND ADDRESS:
XPERT ROOFING OF SOUTH FLORIDA CORP.
9761 NW 57 TERRACE,
MIAMI, FL 33178
SCOPE OF BUSINESS OR TRADE:
Rooting - AN Kinds and
Drivers
IMPORTANT: Pursuant to subsection 440.05(14). F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate
of election under this section may not recover benefits or compensation under this chapter. Pursuant to subsection 440.05(12). F.S..
Certificates of election to be exempt issued under subsection (3) shall apply only to the corporate officer named on the notice of election to be
exempt and apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to subsection 440.05
(13). F.S., notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing
of the notice or the issuance of the certificate. the person named on the notice or certificate no longer meets the requirements of this section
for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the
requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01433112 QUESTIONS? (850)413-1609
Scanned with CamScanner
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner— Workers' Compensation Insurance Exem
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
I. 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.
Signamre:V/'/,1,,k,/ 12�1Y/ _ 0 L/
Owner
State of Florida -
County of Miami -Dade
The foregoing was acknowledge before me this q day of. .�1 �� , 200L?�_.
By WaXt "n-)Ci V_6 who is personally known to me or has produced
as identification.
Notary:
RoOMNo
OF SOUTH FLORIDA
STATE OF FLORIDA
COUNTY OF DADE
June 10, 2023
Before me this day personally appeared GIOVANNY PEREYRA who, being duly sworn deposes and says:
That hy/or Ae will be the only person working on the project located at: Q-6 ry-,
Contractor Signature
The foregoing instrument was acknowledged before me by means of ❑ physical presence or 0 online
notarization, this 10 day of JUNE by GIOVANNY PEREYRA
Signature of
Print Name: