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RF-10-787Scheduled Inspection Date: June 14, 2010 Inspector: Bruhn, Norman Owner: PHILIPPEAUX, BENCHY Job Address: 11028 NW 2 Avenue Miami Shores, FL 33168 -4304 Project: <NONE> Contractor: SRJ CONSTRUCTION CORPORATION Building Department Comments June 11, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 145930 Permit Number: RF -5 -10 -787 For Inspections please call: (305)762 -4949 Permit Type: Roof Inspection Type: Final Roof Work Classification: Tile Phone Number Parcel Number 1121360020260 Phone: (954)578 -8117 REPLACE EXISTING ROOF WITH NEW FLAT TILE ROOFING SYSTEM THIS PERMIT IS A NEW JOB IN REPLACE OF THE ROOF REPAIR PERMIT APPLIED IN 2009. FOR FURTHER INFO PLEASE CHECK RF 09 -1088 Passed d6.4/76 Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 142508. REPALCE ALL BROKEN TILE. SEAL COUNTER FLASHING FASTENERS AND EDGE. JR Page 25 of 29 Test Date: June 8 2010 Permit #: RF -5 -10 -787 Address: Philippeaux Residence 11028 NW 2n Avenue, Miami Shores, Fl. Contractor: SRJ Construction Roof Pitch: 3:12 Attachment method: Two Component Polyurethane Foam Adhesive — PolyPro AH 160 (06- 0201.02) Tile Type: Eagle Roof Tile (07- 1018.08) Device Used: "IMADA DPS 110" force gauge (Serial # 155879E) Total Sloped Roof Area: 18.00 squares Roof Area: 18.00 squares Total Number of Tests Number of tests Passed % Passed Field Area (1): 10.00 squares 18 18 100% Perimeter Area (2): 8.00 squares 18 18 100% No. of Comer Areas (3): 10 10 10 100% Ridge/Hip Areas: 121 pcs 14 14 100% June 8, 2010 To: Miami Shores Village Building Department 10050 NE 2 Avenue Miami Shores, FL 33138 €BB Engineering & Testing Co. 7450 Griffin Road, Suite 140, Davie, FL 33314 Phone: (954)581 -7115, Fax: (954)581 -2415 www.cebb.net Roof Tile Uplift Test Resort All Testing is in strict accordance with the Florida Building Code, 2007 Edition, High Velocity Hurricane Zone — Testing Application Standard AS 106. Based upon the field tests, I certify that 100% of the static up-lift tests "PASSED" the testing criteria of 35.0 lbf load, and meets the attachment resistance for adhesive Set Systems, as specified in the NOA. Should you have any questions regarding the above, or if require additional information, please do not hesitate to contact this office. Sincerely, CeBB Engineering & Testing Co. (NOA 08- 0924.12 revises NOA 07- 1002.07) 06/08/2010 Eduard C. Bads ■ Fla. Reg. No: "- Cc: SRJ Construction Enc. Location Sketch Calibration Certificate CBB Engineering & Testing Co. 7450 Griffin Road, Suite 140, Davie, FL 33314 Phone: (954)581 -7115, Fax: (954)581 -2415 www.cebb.net HANDLIFT RESULTS: Passed the protocol criteria of less than 3% loose. We performed the up -lift test. T — Tested tiles and Passed; F — Tested tiles and Failed; M — Missing Tiles; B — Broken Tiles; Total Area: - Field Area (1): - Perimeter Area (2): - No. of Comer area (3): - Ridge/hip areas: 18.00 squares 10.00 squares 8.00 squares 10 121 pcs TAS 106 TESTS LOCATION SKETCH Permit # RF -5 -10 -787 Philippeaux Residence 11028 NW 2 Avenue, Miami Shores, Fl. No. of tested Tiles: - Field Area: - Perimeter Area: - Comer areas: - Ridge/Hip areas: • 7R i ■ ■ ■■ •■Rgai 1uu. ■■ w■ Ma Iii 4111111 non i ii.■ ■.land= III ■ pi �i = ■ N■ � '�• a r.■w aw I .r..■ lii Mr . 1 .. R ■ U NE R R i iil� •Ummonamw i•u L ■RR■ MN MINIMANUM MAR nuagamompazommo dis ■■ ■ ■ '�■■ toe- ■■■ Ham Il III■ ■rawi t t.R �I iFFr■ w ■ R■ AleisiiiiiiiirimIgilil ■R■ ■ ■ w■■ ■■ ■R r .R . Rw /R ■w■R ill 5.. z'ow wf. R■ ■ I 'WWII NT N. IPA. ■ ■■R/��/ r r �� I Rw■■ ■■■■■7 mum 000 , � I l. m p I I r a i■■■i■r■r..■ mR■ _MI ■R Air ■ ■■RR� ..■ , 4° _ o' ■■■■■U. ■ R11 tR■ � r•�va■ 1 ■ ■R■R . rl■ A■■•Ri■■■d■■R G7• MR MI MNIIIIM Min U AI EATIE111 EL 1 i ELSONIMMICE0111 _ 101111111•110111W1•411114•111 Cr: Ai u p P: l �ie:�m R ..w; a R . Iuu. ■■wR ■i■ ■R .IR iR�R ■ ■ ■Rni I fRi ■ wN � ■ F i iR ■ ■ ■■ fiW c■i■ ■ ■■lt ii 7 ■ ��■ p UM 6 R■■■■i ' � ■�■ ■ ■ p ■ ■R \■ 1■w■■ ■R '■'p�r'i w�iw r �j■eri�ir� I. °' : f :C '� i• . ; ■ s U R • RR 1 ■R/�►J/ ■ ■Ra �h immilR■■■■■ RRR ■■■Rw ■■R ■■R■►^■RR■■■■ ■■■■R11 HUMENIVOISIBtar COMM Mar 10 k ■ 111111. ■ R■R ■■ •r ■ ■ ■ nuR■ M.urT4 3n. Nialdhl filillffidt, gitin-95" INIMPAiridi R ■RRR � ■R■■R R R p . M j 4 RR ■r • ■� R � �■ L._ L 18 18 10 14 METALLURGICAL, INC. Testing & Consulting Services 2870 Stirling Road • Hollywood, FL 33020 -1199 • (954) 925 -0499 CEBB Engineering & Testing Co. February 17, 2010 Purchase Order No. Verbal IMADA Digital Force Gauge Range 0 -110 S/N 155879E QCM Job No. 10BM -191 CALIBRATION CERTIFICATE Standard Lb's Instrument Reads Lb's 10 10.0 20 20.0 30 30.0 40 40.0 50 50.0 60 60.1 70 70.1 80 80.2 90 90.4 100 100.4 110 110.5 Digital Force Gauge Acceptable. Calibrated with Instron Tensile Machine, Load Cell. S/N 936, QCM -414, 2 pieces. Range 0 -1000 Lb's.. Accuracy at ±1.0%. N.I.S.T. # Certs #30303, 30304. Date 8/11/2009 - 8/11/2010. Calibrated I.A.W. ANSI/NCSL Z540-1 The accuracy and calibration of this instrument are traceable to the National Institute of Standards & Technology and are guaranteed to meet published specifications. Environmental Condition:70 °F ±3 °F, approx. 50% RH. Calibration Date = 2/17/2010 Calibration Due = 2/17/2011 C iofano etallurgical, Inc. Fax (954) 925 -0988 • Miami (305) 949 -3166 • Email:cap c: icanect.net Project Address 11028 NW 2 Avenue Miami Shores, FL 33168 -4304 1121360020260 Block: Lot: BENCHY PHILIPPEAUX 1 Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 11028 NW 2 Avenue MIAMI SHORES FL 33168 -4304 Address Contractor(s) Phone Cell Phone SRJ CONSTRUCTION CORPORATION (954)578 - 8117 (954)703 - 8355 Type of Work: Re Roof Additional Info: TILE ROOF Classification: Residential Fees Due CCF Education Surcharge Permit Fee - New Roof Scanning Fee Technology Fee Total: Amount $2.40 $0.80 $275.00 $6.00 $3.20 $287.40 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. 1 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 regulating construction and zoning. Futhermore, 1 authorize the above -named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy May 14, 2010 Permit Issue Date: 5/12/2010 Permit NO. RF -5 -10 -787 Permit Type: Roof Work Classification: Tile Permit Status: APPROVED Expiration: 1W08/2010 Parcel Number Phone Pay Date Pay Type Amt Paid Amt Due Invoice # RF -5 -10 -37784 05/14/2010 Credit Card $ 287.40 $ 0.00 Applicant Cell Available Inspections: Inspection Type: Up Lift Report Tin Cap Final Roof Tile In Progress Roof Review Renailing Affidavit Cap Sheet May 14, 2010 Date 1 BUILDING PERMIT APPLICATION FBC 20 Miami Shores Village Building Department Permit Type: BUILDING ROOFING Owner's Name (Fee Simple Titleholder) 345Y10-111 ?H1(d Phone # 95 -25'16 Owner's Address 1.d.04B N W Z 14 nNU13 u City mi kiYli $ th51135 State ft, Zip 31.68 Tenant/Lessee Name NIA Phone # NIA Email rderric44 a (0-611.80014 . Ner Job Address (where the work is being done) SOZ€ • NW' V • of 1 A'Mz T City 'J Miami Shores Village County Miami -Dade Zip 331.68 FOLIO / PARCEL # Is Building Historically Designated YES NO 1( Flood Zone Contractor's Company Name Era Aruu) 01 Contractor's Address 1 5358 W. OIAMhmm1. RAC 13- P.ctd 1 Sulk 14.03 eT City IrtArklai Qualifier Name Scfrnitsli WM State Certificate or Registration No. CCU 432 r 1 &90 Certificate of Competency No. Contact Phone 951(-5x1$ 889 E -mail Sfato e'h}odmAlL. aro 14)-et Mona Value of Work For this Permit $ Square / Linear Footage Of Work: Type of Work: ['Addition ['Alteration ONew d Repair/Replace Describe Work: 3 F�jp► GOOF (Al NHS R IZ PO4f t4 StIS M . ' Architect/Engineer's Name (if applicable) Notary $ Scanning $ (Q ' Double Fee $ Structural Review. $ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No.IRT State ft. Training/Education Fee $ Radon $ DPBR $ Violation date: Master Permit No. Phone# 55 911r1 qS -. S IS) Zip 3335. Phone # 95t(- 908- 8955 Phone # A) A MAYl �, /Q8 O Demolition ******** * * * * * * * * * * * * * *,* *** * * * * * * * * * * ** F * * * * * *** * * * * * * *,* * * * * * * * * * * * *** Submittal Fee $ Permit Fee $ / CCF $ O( { 1 CO /CC $ Technology Fee $ Bond $ Total Fee Now Due $ zneelo- See Reverse side -+ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be poste at the job site for the first inspection which occurs seven (7) days after the building permit is iss ed. In the a ce of such p ' notice, the inspection will not ed an a r'inspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by g,„,,k1 ;�� , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED BY (Revised 07 /10 /07)(Revised 06 /10/2009) SERGE - RICHARD SAINT -ELOI MY COMMISSION #D0649901 EXPIRES: MAR 12, 2011 Bonded through 1st Stateinsur211C , 91",j Plans Examiner Engineer g 1 ct Zip ulr+ u1a KIR Signature Zip ontractor The foregoing instrument was . cknowledged before me this day of i■Aa. , 20 10 , by S. who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: My Commission Expires: MY COMMISSION #DD649901 EXPIRES: MAR 12, 2011 Bonded through 1st State IINUrance, Zoning Clerk checked Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid $ 27.00 $ 27.00 F DBA: Business Name: Owner Name: Business Location: Business Phone: Mailing Address: S R J CONSTRUCTION CORPORATION JOSEPH STANLEY REMY 8358 W OAKLAND PK BLVD 203E SUNRISE 33351 (954)578 -9117 Rooms Seats Number of M THIS BECOMES A TAX RECEIPT WHEN VALIDATED S R J CONSTRUCTION CORPORATION JOSEPH STANLEY REMY 8358 W OAKLAND PK BLVD #203E SUNRISE FL 33351 Employees 1 UNIT For Vending Business Only 2009 - 2010 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 - 954 -831 -4000 VALID OCTOBER 1, 2009 THROUGH SEPTEMBER 30, 2010 Receipt # 180 - 0007002 Business Type: GENERAL CONTRACTOR Business Opened: State/County /Cert/Reg: Exemption Code: Machines 03/07/97 CGCO58938 NON EXEMPT Professionals 0000000000 0000002700 0000001800007002 1001 9 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax Is levied for the privilege of doing business within Broward County �'' and is non - regulatory in nature. You must meet all County and/or municipality 0 ` ` ,-;� planning and zoning requirements. This Business Tax Receipt mus;yb.�s∎ transferred when the business is sold, business name has changed o - y otli ix -; have moved the business location. This receipt does not indicate tha th8 4 r =• business Is legal or that it Is in compliance with State or local lawd ; -`; regulations. "= eg ` c%._ - - CFC1428 $5 •'0-2j25j1"0 090328449" ONTRACTOR e e ],ow 3S CERTIFIED Wider the provisions of Cha pt /ration date: AUG 31, 201 AC# 44,371:191 MATS OF FLORIDA - ; DEPAR '1EOT OF .`BUSINESS - PROF SS-IONAL. CERTIFIED PLUMBING CONTRACTOR JOSEPH, ST GEYY REMY 3RJ CONSTRUCTION, CORPORATI ON :- IS- CERTIFIED uridor the provisions of- .Cti 48S mo? ration sates MKT _ 1, . 2010 L10022500321 STATE OF FLORIDA . DEPARTMAINT OF BUSINESOi MID PROFESSIONAL REGULATION cONSTRUCTIOWITNIDUSTRY: LICENSING B saw Linoz4aom THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY ItkQUIlttMtNI, ItItM 011 CUNUI I ION OF ANY CONIItACI 01: OIHtlt UUC.UMtNI WIIH Itkkl'tCI 10 WHICH IMIS CtItl IFICAIk MAYBE ISSU L) 011 MAY PERT.NN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED I-EREN IS SUBJECT TO ^LL TI€ TERMS, EXCLUSIONS /NID CON DMOMS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED B'i PAID CLAIMS LTR 1 LTR �. m NERD TYPE Of NSURANCE POLICY NUMBER DATE((MM/DDIYWY)) D MMIDDD LIMITS A Miami Shores Village GENERAL LIMMJIN COMAERCALGENERALLIABILITY 04GL000782356 02/19/10 02/19/11 EACH OCCURRENCE $1,000,000 X - 1= t eflce) $100,000 1 CLAIMS MADE X OCCUR WED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1 , 000 , 000 GENERAL AGGREGATE , $2,000,000 GENII AGGREGATE LIMIT APPLIES PER POLICY 1 jEa 1 LOC PRODUCTS - COMP/OP AGG $ 2 , 0 00 , 00 0 4 4 AUTOMOBILE LIABILITY AN'i AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRFrPAlrTOS NON -OWNED AUTOS 04GL000782356 04/28/10 02/19/11 I OMBJN SINGLE LIMB $1,000,000 _ BODILY IN,AJRY (Per person) X BODILY IN,)URY (Per accident) $ X {Per accident) ~� $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EAACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR f CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS COMPENSATION AN D EMPLOYERS' uABILrTY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If wo scribe laldcr SPE ascribe PROVISIONS bow I WC S1AIU• I o1H- TORY LIMBS ER E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I EPECUAL PROVISIONS General Contractor- Subject to the terms, exclusions and conditions of the policy. Proof of insurance only. From:Dorothea Warburton FaxID: ACOR PRODUCER P.J.K. INSURANCE, INC. 2500 NORTH POWERLINE ROAD POMPANO BEACH FL 33069 Phone:954 -979 -5855 Fax:954 -979 -6788 INSURED SRJ Construction Corporation 8358 W.Oakland Pk. Blvd. 1,203E Sunrise FL 33351 INSURERS AFFORDING COVERAGE INSI IRFR A Mid - Continent Casualty Co. INSURER B. INSURER C: INSURER D' INSURER E. DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE s PID 05/06/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NAIL # 23418 COVERAGES CERTIFICATE HOLDER ACORD 25 (2009101) Page 2 of 2 CANCELLATION Date:5 10 09:51 AM Page2 of 2 CCJRD'C ORPORATION. AO rights resery The ACORD name and logo are registered mark f ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MIAMISV DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICC TO TI IC CCRTIrICATC I )OLDER NAI.W TO TI IC LtrT, DUT TAILURC TO DO GO Cl IALL Miami Shores Village IMPOSE NO OBLIGATION OR UABRITY OF ANY KIND UPON THE INSURER RS AGENTS OR Attn: Bldg Dept. 10050 NE 2 Avenue REPRESENrArnES' AurHOR�o REPRESt37rATIVE 4-4 4# t Miami Shores FL 33138 From:Dorothea Warburton FaxID: ACOR PRODUCER P.J.K. INSURANCE, INC. 2500 NORTH POWERLINE ROAD POMPANO BEACH FL 33069 Phone:954 -979 -5855 Fax:954 -979 -6788 INSURED SRJ Construction Corporation 8358 W.Oakland Pk. Blvd. 1,203E Sunrise FL 33351 INSURERS AFFORDING COVERAGE INSI IRFR A Mid - Continent Casualty Co. INSURER B. INSURER C: INSURER D' INSURER E. DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE s PID 05/06/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NAIL # 23418 COVERAGES CERTIFICATE HOLDER ACORD 25 (2009101) Page 2 of 2 CANCELLATION Date:5 10 09:51 AM Page2 of 2 CCJRD'C ORPORATION. AO rights resery The ACORD name and logo are registered mark f ACORD DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 ALEX SINK STATE OF FLORIDA - CHIEF FINANCIAL OFFICER 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: PERSON: FEIN: BUSINESS NAME AND ADDRESS: SRJ CONSTRUCTION CORPORATION 8358 W OAKLAND PARK BLVD #203E SUNRISE FL 33351 SCOPES OF BUSINESS OR TRADE: 1- RENOVATIONS /RESTORATION DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 02/09/2010 EXPIRATION DATE: 02/09/2012 JOSEPH STANLEY R 650823889 CUT HERE 02 -09 -2010 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE * Carry bottom portion on the Job, keep upper portion for your records. IMPORTANT: Pursuant to Chapter 440 . 05114), 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 Chapter 440.06(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.06(13), F.S., Notices of election to be exempt and certificates of election to be exempt shell be subject to revocation 0, 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. QUESTIONS? (850) 413 -1609 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 02/09/2010 EXPIRATION DATE: 02/09/2012 PERSON: STANLEY R JOSEPH FEIN: 650823889 BUSINESS . NAME AND ADDRESS: SRJ CONSTRUCTION CORPORATION 8358 W OAKLAND PARK BLVD 0203E SUNRISE, M. 33351 SCOPE OF BUSINESS OR TRADE 1- RENOVATIONS /RESTORATION IMPORTANT O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. H Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed on R the notice of election to be exempt E Pursuant to Chapter 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. QUESTIONS? (850) 413 -1609 Master permit No. Contractor's Name Job Address ❑ Low Slope ❑ Asphaltic Shingles J/A Florida Building Code Edition 2007 HIGH Velocity Hurricane Zone Uniform Permit Application Form Section A (General Information) Process No. ROOF CATEGORY ❑ Mechanically Fastened Tile Mortar /Adhesive Set Tile ❑ Metal Panel/Shingles ❑ Wood Shingles /Shakes ❑ Prescriptive BUR -RAS 150 ROOF TYPE ❑ New RootRe- Roofing ❑ Recovering ❑ Repair ❑ Maintenance ROQF SYSTEM INFORMATION Low Slope Roof Area (SF) Steep Sloped Roof Area (SF) igt) Total (SF) V I ' MAY 0 7 2 Y \ 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. u 2 0 • • 0 3 L n w < CC I O l z Q u w U -J < 1 z U ,1 O -) o 0 u w LL1 CO < D Q ) .; • • • • • • • • • • •