RF-10-890Project Address
262 NE 98 Street
Miami Shores, FL 33138 -2408
1132060134170
Block: Lot:
RODOLFO & BABARA GOMEZ E
Owner Information
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Address
Parcel Number
Valuation:
Total Sq Feet:
$ 2,300.00
100
RODOLFO & BABARA GOMEZ EMILIO R 262 NE 98 Street
MIAMI SHORES FL 33138 -2408
Contractor(s)
WHITE STAR ENTERPRISES INC
Phone Cell Phone
(305)251 -9019
Type of Work: Repair
Additional Info: REMOVE TILE IN A 10X10 AREA, LEAK
Classification: Residential
Fees Due
CCF
Education Surcharge
Permit Fee - Repairs
Scanning Fee
Technology Fee
Total:
Amount
$1.80
$0.60
$100.00
$6.00
$2.40
$110.80
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 regulating
construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Expiration: 11/16/2010
Phone
Amt Paid Amt Due
Pay Date Pay Type
Invoice # RF -5 -10 -37938
05/19/2010 Check #: 11579 $ 50.00 $ 60.80
05/26/2010 Check #: 11587 $ 60.80 $ 0.00
Applicant
May 26, 2010
Date
Cell
Available Inspections:
Inspection Type:
Roof Repair
Final Roof
May 26, 2010 1
a
BUILDING
PERMIT APPLICATION
FBC 2004
City Miami Shores Village
FOLIO / PARCEL #
Value of Work For this Permit $ OO9 0
Type of Work: ['Addition ['Alteration
Describe Work: /7/6 d
aitd/ / C_ /
Submittal Fee $ 50
Notary $ t>
Scanning $
Bond $
Training/Education Fee $
Miami Shores Village
Building Department
f0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Is Building Historically Designated YES NO
Contractor's Company Name
Contractor's Address / 6, 5 20
City ki 1 u /�/�
Qualifier Name (, Oe
State Certificate or R 'on No. Cue. 0/ ?- / 8
State
Architect/Engineer's Name (if applicable) Ai /A Phone #
DNew
JO /
60
Radon $ ( / DPBR $
Code Enforcement $ C
Structural Review. $
MAX 1 9 2010
Permit No. Kam- 5 -' ®> V%)
Master Permit No.
Permit Type (circle): Building Ro f
Owner's Name (Fee Simple Titleholder) L f / A/Q-Sa Phone # .305 - 29 x,56 4
Owner's Address Zt Z iv
cit /J/1i ®, 5X of cs State �� • Zip 3313
Tenant/Lessee Name
Phone # N/A
Job Address (where the work is being done) L 2 Al e ,8 �-
County Miami -Dade Zip 33 L38
J - , I C DT I g Phone# 96/? °
/ Q - 0 � /C)
P4 -
Zip 33 /S? •
Phone # 305 9 9 °
Certificate of Competency No.
Square / Linear Footage Of Work: / -
eplace ❑ Demolition
ad age /e
Permit Fee $ / J Cad CCF $ J - CO/CC—
Technology Fee $ __
v / Zoning $
Double Fee $
Total Fee Now Due $
See Reverse side ->
Bonding Company's Name (if applicable)
Bonding Company's Address _..
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDmONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection wil y ot be approve and a reinspection fee will be charged
, . }� ' MY COM g 0 J # 5 8427
June 11
, . ...__EXPIRES;
0 2014
1 r T hra Notary Pimllo Unda
Tool SARA MARi1NFZ
MY COMMISSION # DD 548427
ti PIRES:June 11 2010
N Ile U nderwriters
Signature ,` l 4 Mi ' .r_ Signature
Owner • Agent
The foregoing instrument was acknowledged before me this � 7 The forego
day ofi 20/4 b 9 fy Cy/ ,210 , day of
who ' rsonally known to me or who has produced who
_ As identi ! cation and who did take an oath.
NOTARY PUBLIC:
My Commission E a . sires: 6 -//-20/ l � My Commission ires:6
APPLICATION APPROVED BY:
(Revised 07/10/07)
AeXee Yc.29
Contractor
as acknowledged before me this
20 / b �� cyc�
me or who s produced
d who did take an oath.
Plans Examiner
Engineer
Zoning
/y,
ROOF ASSEMBLIES AND ROOFTOP STRUCTURES
❑ New Roof
❑ Low Slope
❑ Asphaltic
Shingles
Low Slope Roof Area (SF)
Florida Building Code Edition 2004
High - Velocity Hurricane Zone Uniform Permit Applic8t(onl;Form.
Section A (General Information)
^ D r
Master Permit No. Process {
Contractor's Name {� l ® ��1 / e. -.51/7 EAJ
Job Address
ROOF CATEGORY
❑ Mechanically Fastened Tile
❑ Metal Panel/Shingles
❑ Prescriptive BUR -RAS 150
ROOF TYPE
❑ Reroofing ❑ Recovering
ROOF SYSTEM
INFORMATION
Steep Sloped Roof Area (SF)
SUBJECT u
STATE �r.�_ N l"
Mort Ihesive Set Tile
0 Wood Shingles/Shakes
❑ Maintenance
Total (SF)
Ragicgrtvn
Ili MAY it zoo
MH.LVJCL WITH ALL FEDERAL
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.
`ID REGULATIONS
••••
• •
••••••
•••• •
•
• ••• •
• • • ••••••
•• •
• •
• ••••••
•
• • •
••••••
•••••
• • •
•• • •••••
• • • ••••••
•• • •
• •
•
• •
••••••
•••••• • •
• ••••••
• •
••••
• •
••••
CI AQIr1A QI111 AIMfP (VU - -.. Dint F%IM#
• • I
•
®
••••••
•
•
• •
•
•
p
•
•
;m
t o
E.
j
ROOF ASSEMBLIES AND ROOFTOP STRUCTURES
❑ New Roof
❑ Low Slope
❑ Asphaltic
Shingles
Low Slope Roof Area (SF)
Florida Building Code Edition 2004
High - Velocity Hurricane Zone Uniform Permit Applic8t(onl;Form.
Section A (General Information)
^ D r
Master Permit No. Process {
Contractor's Name {� l ® ��1 / e. -.51/7 EAJ
Job Address
ROOF CATEGORY
❑ Mechanically Fastened Tile
❑ Metal Panel/Shingles
❑ Prescriptive BUR -RAS 150
ROOF TYPE
❑ Reroofing ❑ Recovering
ROOF SYSTEM
INFORMATION
Steep Sloped Roof Area (SF)
SUBJECT u
STATE �r.�_ N l"
Mort Ihesive Set Tile
0 Wood Shingles/Shakes
❑ Maintenance
Total (SF)
Ragicgrtvn
Ili MAY it zoo
MH.LVJCL WITH ALL FEDERAL
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.
`ID REGULATIONS
••••
• •
••••••
•••• •
•
• ••• •
• • • ••••••
•• •
• •
• ••••••
•
• • •
••••••
•••••
• • •
•• • •••••
• • • ••••••
•• • •
• •
•
• •
••••••
•••••• • •
• ••••••
• •
••••
• •
••••
CI AQIr1A QI111 AIMfP (VU - -.. Dint F%IM#
•
SECTION 1524
HIGH VELOCITY HURRICANE ZONES REQUIRED OWNERS NOTIFICATION FOR ROOFING
CONSIDERATIONS
1524.1 As it pertains to this section, it is the responsibility of the roofing contractor to provide the owner with
the required roofing permit, and to explain to the owner the content of this section.. The provisions of Chapter
15 of the Florida Building Code, Building govern the minimum requirements and standards of the industry for
ro oiing system installations. Additionally, the following items should be addressed as part of the agreement
between the owner and the contractor. The owner's initial in the adjacent box indicates that the item has been
�'• plaine��
,(� i � J •
_� • esthetics - Workmanship: The workmanship provisions of Chapter 15 (High Velocity u
� p p p p (H g ty H mcane
Z. e) . r for the purpose of providing that the roofing system meets the wind resistance and water intrusion
performance standards. Aesthetics (appearance) issues 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
addressed as part of the agreement between the owner and the contractor.
. Renailing Wood Decks: When replacing roofing, the existing wood roof deck may have to be
re n accordance with the current provisions of Chapter 16 (High Velocity Hurricane Zones) of the Florida
uildin� Code. (The roof deck is usually concealed prior to removing the existing roof system).
Common Roofs: Common roofs are those which have no visible delineation between neighboring
i, s (i. townhouses, condominiums, etc.). In buildings with common roofs, the roofing contractor and/or
er ould notify the occupants of adjacent units of roofing work to be performed.
� ,, • Exposed Ceilings: Exposed, open beam ceilings are where the underside of the roof decking can be
vie I ed rom below. The owner may wish to maintain the architectural appearance, therefore, roofing nail
p of the underside of the decking may not be acceptable. The Florida Building Code provides the
on of maintaining this appearance.
onding Water: The current roof system and/or deck of the building may not drain well and may
cai ; e er to pond (accumulate) in low -lying areas of the roof. Ponding can be an indication of structural
dish ess a d may require the review of a professional structural engineer. Ponding may shorten the life
expectancy and performance of the new roofing system. Ponding conditions may not be evident until the
'ginal roofing system is removed. Ponding conditions should be corrected.
oN, ' rloa
ov rflow
a cordan
,.1/
in! rio'
re uced.
roof.
Overflow scuppers (wall outlets): It is required that rainwater flow off so that the
d from a build up of water. Perimeter /edge walls or other roof extensions may ltlock•this
scuppers (wall outlets) are not provided. It may be necessary to install overflow
e with the Florida Building Code, Plumbing. ••••••
••••
Ventilation: Most roof structures should have some ability to vent natural 'aarfilo
f the structural assembly (the building itself). The existing amount of attic verrti!1gtitjr
t may be beneficial to consider additional venting which can result in extending trill .s'r
• • •
• •
• • •
.• •
Ur ALAI,
CA DOC1J?IE- 1kmp1LOCALS- 11Tsmp5ECT10N IS24.dx
5 / /3 20/6
Date
rodf is snot
disciajge if
sc s :in
•
• •
thrdugh the
shalll not be
e life ofthe
••••••
•
••••
• •
••••
••.•••
.•
•
•.••••
•
•
•••.•.
s •
0000
• •
00000
000000
•
•
•
•.•.••
• •
•.•.••
• •
MI
COUNTY
BUILDING CODE COMPLIANCE OFFICE (BCCO)
PRODUCT CONTROL DIVISION
NOTICE OF ACCEPTANCE (NOA)
Clay Forever
6801 NW 72 Avenue
Suite 301
Miami, FL 33166
MIAMI -DADE COUNTY, FLORIDA
METRO -DADE FLAGLER BUILDING
140 WEST FLAGLER STREET, SUITE 1603
MIAMI, FLORIDA 33130 -1563
(305) 375 -2901 FAX (305) 375 -2908
SCOPE:
This NOA is being issued under the applicable rules and regulations governing the use of construction materials.
The documentation submitted has been reviewed by Miami -Dade County Product Control Division and accepted
by the Board of Rules and Appeals (BORA) 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
Division (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. BORA reserves the right
to revoke this acceptance, if it is determined by Miami -Dade County Product Control Division 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: Volcan by Altusa, Spanish "S" Clay 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 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 chacge..in the
materials, use, and/or manufacture of the product or process. Misuse of this NOA as an endorseipent of any • •
product, for sales, advertising or any other purposes shall automatically terminate this NOA aaihire to cpmills;
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, Flai*ila,'and followed by
the expiration date may be displayed in advertising literature. If any portion of the NOA is dis • • thanf sha11
be done in its entirety. • • . • • • • •
INSPECTION: A copy of this entire NOA shall be provided to the user by the manufacturer tries distributors
and shall be available for inspection at the job site at the request of the Building Official. ; ":'
• •
• • •
• • • ••••
.. • • • •
••••
This NOA consists of pages 1 through 6.
The submitted documentation was reviewed by Alex Tigera.
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date :. 11/18/09
Page 1 of 6
••••••
•
•
•
.....•
• •
...•..
•
•
.....
• •
.....
......
.
•
•
......
• •
......
• •
ROOFING ASSEMBLY APPROVAL
Category:
Sub Category:
Material:
1. SCOPE
This new roofing system using Volcan by Altusa Spanish "S" Clay Roof Tile as manufactured
by Gres Caribe, S.A. in Barranquilla, Colombia and distributed by Clay Forever LLC 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 Dimensions
Applicant nom
Volcan "S" Clay Roof
Tile
Trim Pieces Length: varies
Width: varies
varying thickness
2.1 SUBMITTED EVIDENCE:
Test Aeencv
Roofing
Roofing Tiles
Clay
Length: 20"
Width: 10 -3/4"
varying thickness
Test
Specifications
ASTM C 1167
TAS 112
Test Identifier
CLF- 004- 02 -01REV
PDI- 002 -02 -01
PDI- 01 -02 -01
99 -0041 NTRMA High
PRI Construction Materials
PRI Asphalt Technologies, Inc.
PRI Asphalt Technologies, Inc.
Roof Tile Association
3. LIMITATIONS
3.1 Fire classification is not part of this acceptance
Product
Description
High profile, one - piece, `S' shaped single roll
clay tile with a nominal 2 -1/2 inch headlap.
For direct deck nail -on, mortar set, or
adhesive set applications.
Accessory trim, clay roof pieces for use at
hips, rakes, ridges and valley terminations.
Manufactured for each tile profile.
Test Name/Report
ASTM C 1167
TAS 101
Date
07/13/09
10/08/02
TAS 101 10/08IcT : � •
Miami -Dade NO4 • • • 1999
• •••
•• • . • . •
eeeeee
000000
performed in
accordance with RAS 106. .... • . . • • . •
33 Applicant shall retain the services of a Miami -Dade County Certified Laboratolq to perform
3.2 For mortar or adhesive set tile applications, a static field uplift test mayb •
quarterly test in accordance with TAS 112, appendix `A'. Such testing shall '1>" • itibmitted to .
the Building Code Compliance Office for review. • ... •'
3.4 Minimum underlayment shall be in compliance with the applicable Roofs �llplication� • •
Standards listed section 4.1 herein. ' ... •
3.5 30/90 hot mopped underlayment applications may be installed perpendicular to the roof slope
unless stated otherwise by the underlayment material manufacturers published literature.
3.6 This acceptance is for wood deck applications. Minimum deck requirements shall be in
compliance with applicable building code.
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date: 11/18/09
Page 2 of 6
••••••
•
•.
•..•.•
0000
00000
• •
•••••
••••••
•
•
•
••••••
• •
•.••••
• •
4. INSTALLATION
4.1 Volcan by Altusa Spanish "S" Clay Roof Tile and its components shall be installed in strict
compliance with Roofing Application Standard RAS 120.
4.2 Data For Attachment Calculations
Table 1: Average Weight (W) and Dimensions (I x w )
Tile Profile
Volcan "S" Clay Roof Tile
Weight - W (Ibf)
7.5
Length - I (ft)
1.66
Width - w (ft)
0.895
Tile Table 2: Aerodynamic Multipliers - �. (ft3) 3
X (ft) X (ft 3 )
Profile
Batten Application Direct Deck Application
Roof Tile 0.235 0.255
Volcan "S" Clay
Batten
4.78
2 ": 12"
or less
Direct
Deck
5.12
Table 3: Restoring Moments due to Gravity - M (ft -Ibf)
4 ": 12"
3 ": 12"
Batten
4.71
Direct
Deck
5.05
Batten Direct
Deck
4.62 4.96
5 ": 12"
Batten
4.51
Direct
Deck
4.84
6 ": 12"
Batten
4.38
Direct
Deck
4.67
7": 12" or
greater
Batten
4.25
Direct
Deck
4.55
••••
•
•
.... .•••.• •
•
• • • • • • • •
•• • • • • •
.. • ......
000000 •
•
•
•
...••• •
0000 00 • • • •
000000
• • •• ....••
• • . •
• • . • • .
•
• •
• .
•
• •
....•.
• •
• •
•• • • •• •
• •
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date: 11/18/09
Page 3 of 6
•
•
.••...
......
Tile
Profile
Volcan "S"
Clay Roof
Tile
Table 4:
Attachment Resistance Expressed
for Nail -On Systems
Fastener Type Direct Deck
(Min 15/32"
plywood)
Fa
2 -10d Ring Shank Nails
1 -10d Smooth or Screw
Shank Nail
2 -10d Smooth or Screw
Shank Nails
1 .#8 Screw
2 .#8 Screws
1 -10d Smooth or Screw
Shank Nail (Field Clip)
1 -10d Smooth or Screw
Shank Nail (Eave Clip)
2 -10d Smooth or Screw
Shank Nails (Field Clip)
2 -10d Smooth or Screw
Shank Nails (Eave Clip)
28.6
5.1
6.9
28.7
58.2
23.1
29.3
27.6
38.1
as a Moment - Mf (ftlbO
Direct Deck
(Min. 19/32"
plywood)
41.2
6.8
9.2
28.7
58.2
23.1
29.3
27.6
38.1
Battens
19.4
2.8
7.3
N/A
26.8
19.0
24.0
38.6
41.8
Table 5: Attachment Resistance Expressed as a Moment Mf (ft -ibf)
for Two Patty Adhesive Set Systems
Tile
Tile Application
Til
Profile
Volcan "S" Clay Roof
Tile
Adhesive
2 See manufactures component approval for installation requirements.
3 Flexible Products Company TileBond Average weight per patty 10.7 grams.
Polyfoam Product, Inc. Average weight per patty 8 grams.
Minimum Attachment
Resistance
29.3'
Table 5A:
Attachment Resistance Expressed as a Moment - M (ft -Ibf)
for Single Patty Adhesive Set Systems
Tile Application
.... •
Tile
Profile
Volcan "S" Clay Roof
Tile
Polyfoam PoIyProTM
Polyfoam PolyPro 1M
4 Large paddy placement of 63grams of PolyProT°".
5 Medium paddy placement of 24grams of PolyPro'".
Minimum Attachment
Residence :°:
•.,635
•
•
• •
s
•
-. •
.
••• •
•
•. •.
• . •
es •
Table 5B: Attachment Resistance Expressed as a Moment - AA -Pty:
for Mortar Set Systems '
Tile
Application
Tile
Profile
•
• .
.1...
•
Attacflmbn • •'
Resistance "'
Volcan "S" Clay Roof Tile
Mortar Set'
24.50
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date: 11/18/09
Page 4 of 6
•
0
•
•
•
.•....
• .
.0.111
• •
..••s
• •
010.1
.s1..1
•
•
•
••....
• •
••..•.
• •
5. LABELING
All tiles shall bear the imprint or identifiable marking of the manufacturer's name or logo, or
following statement: "Miami -Dade County Product Control Approved ".
VOLCAN MADE IN COLOMBIA
LABEL FOR VOLCAN SPANISH "S" TILE
LOCATED ON THE TOP OF THE TILE
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 the Building Official or applicable
building code in order to properly evaluate the installation of this
system.
• •
• • •
•• •
• •
1111••
{••• •• •
•
• •
111
• •
•• ••
111••
• •
• • •
•• •
••••
• •
••••
• •••
• • •
•• •
1111••
•• • • 1111
• • • •••••
•• • • •
• •
•
• •
••••••
•
••••
• •
••••
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date: 11/18/09
Page 5 of 6
••••••
•
•
•
••••••
• •
000000
• •
•••••
• •
••••••
• •
••••••
• •
20"
PROFILE DRAWINGS
VOLCAN `S' CLAY ROOF TILE
END OF THIS ACCEPTANCE
• •
• • •
•• •
••••••
•
••••••
•••••
• •••.••
•
•• ••
••.•••
•
• •
• • •
•• •
••• • •
' ••••
• •••,
• • •
•• •
•
NOA No.: 09- 0923.07
Expiration Date: 08/26/14
Approval Date: 11/18/09
Page 6 of 6
••••••
•
•
•
••••••
• •
000000
• •
• •
•••••• ••••.
• • •
•• • •••••
• • • ••••••
•• • • •
• • ta
•••)••
.•••••
• •
• ••••.•
•••• • •
• •
••••
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE IMMIDDIYYt
POLICY EXPIRATION
DATE IMM/Dp/YY1
LIMITS
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.
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
Matrix Employee Leasing
a dba of Alliance Business Solutions, Inc
9016 Philips Highway
Jacksonville,FL 32256
INSURER A: Pegasus Insurance Company, Inc NAIC # 38474
INSURER 8:
EACH OCCURRENCE
$ )000)0(
INSURER E:
FIRE DAMAGE (My one fire)
$ )000X(
CLAIMS MADE OCCUR
MED EXP (Any one person)
$ )00X00
PERSONAL & ADV INJURY
$ )00(00(
GENERAL AGGREGATE
$ 0000X0
GEN'L AGGREGATE LIMA ' APPLIES PER:
PRODUCTS - COMP /OP AGG
$ )00000(
— 1 POLICY JF T LOC
Emp Ben.
XXXXXX
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea acddant)
$ )0(000(
BODILY INJURY
(Per person)
$ )00000(
BODILY INJURY
(Per accident)
$ )000U0C
PROPERTY DAMAGE
(Per accident)
$ X0000C
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$ XXXXXX
OTHER THAN EA ACC
$ X00010(
AUTO ONLY: AGG
$ 0000
EXCESS LIABILITY
EACH OCCURRENCE
$ 0000X0
7 OCCUR CLAIMS MADE
AGGREGATE
$ X00000(
DEDUCTIBLE
RETENTION $
$ XXXXXX
$ XXXXXX
$ XX)O(0X
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
2010769
01/01/2010
01 /01/2011
v
1I
L TORYLIMITS ER
E.L EACH ACCIDENT
$ $1 ,000,000.00
E.L DISEASE - EA EMPLOYEE
$ $1,000,000.00
E.L DISEASE - POLICY LIMIT
$ $1,000,000.00
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
THIS CERTIFICATE CONFERS NO ADDITIONAL INSURED RIGHTS UPON THE CERTIFICATE HOLDER. Insured's licensing Information is not warranted or validated by
III! ',surer.
Only the co- employees of Alliance Business Solutions, Inc and White Star Enterprises Incorporated, 10685 SW 190th St Suite 3109, Miami, FL, 33157 , but not subcontractors of
White Star Enterprises Incorporated are insured for workers' compensation.
ACORD CERTIFICATE OF LIABILITY
INSURANCE
05/14/2010 E(MEED
AUTHORIZED REPRESENTATIVE n
Wayne Stark Yl S Atout
PRODUCER
Pegasus Insurance Company Inc
860 Airport Drive
Alexander City, AL, 35010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURED
Matrix Employee Leasing
a dba of Alliance Business Solutions, Inc
9016 Philips Highway
Jacksonville,FL 32256
INSURER A: Pegasus Insurance Company, Inc NAIC # 38474
INSURER 8:
INSURER C:
INSURER D:
INSURER E:
Miami Shores Village
305 - 756 -8972 (Fax)
10050 NE 2 Ave
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH
NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,
ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE n
Wayne Stark Yl S Atout
COVERAGES
•
ACORD 25-S (7197)
Certificate #
173740
® A
J
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'WITHSTANDING
ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
Disk
A
4.
GENERAL
AA v a.. Z. -
LIASI1.1TY
op MWERCIALCiENERAL LWBiL]TY
POLICY NUMBER
10- 4699 -00
-
POLICY EFFECTIVE
DATE GIMApGDff11''YYtt
FOUL'S' EXPIRATION
DATED 153DM1
UI1TS
5 -14 -10
5 -14 -1 1
EACH OccuRRENCE
S / 0 1 1 0
DAmAGETo RENTED
PREIuIIBESIEA ara:„1
$ 100 000
CIADAS MADE D occuR
"ED°� (Any oast+ )
_
5 5.[1411
S 1 1 1 1 II
PERSONAL & ADV INJURY
■
GENERAL. AGGREGATE
r 1 1 1 17111 I
GENL
AGGREGATE UMIT APPLIES PER:
POLICY P LOC
PRODUCTS - COMPIOPAEG
f 1
B
AUTOMOBILE
MBE. ITT
ANY AUTO
AU. OWNED AUTOS
sCHEDu:EDAIT>Os
HIRED AUTOS
NON- OWNED
10- 4700 -00
5 -14 -10
5 -14
-11
�N,sgsl+£udar
a 300.000
■
BODILY MIRY
IPerpa's,*
•
$
■
BOoi.YIUURY
(Paz aB e
5
�a R
If
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY -EA ACCIDENT
$
EAACC
$
OTHER THAN
AUTO ONLY: AGO
I
EXCESS/UMBRELLA LIAB&r Y
EACH OCCURRENCE 5
.00CUR IN CLAWS MADE
AGGREGATE
$
DEDUCTIBLE
RETENTION $
5
S
$
WORKERS COMPENSATION ANC
NY
EMPLOYERS' LABIUM
ANY PROPRETORPJIRTNERJEXEO, TIVE
OFFTCERJWEMBER E%CI.JDED7
if yse desalt* under
SPECIAL PROVISIONS below
Y9C;STATU CIfH
v: dIC:
EL EACH ACCIDENT
$
Ed.. DISEASE - EA . r • ya
EL, DISEASE- POLICY UMW
$
OTHER
DESCRIPTION OF OPERATIONS J LOCATIONS /VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
Roofing Contractor
May 14 10 07 :51 p horlaa Insurance
COVERAGES
ACORD 25 (2001108)
Miami shores Village
10050 NE 2 ,AVE
Miles Morels, F]. 33138
CANCELLATION
AUTHORIZED REPRESENTATIVE
Toriy Zoghbi
.3U7r+ J.70
p.IL
ACORD., CERTIFICATE OF LIABILITY
PRODUCER
Florida Insurance Agency Of Miami
I P 0 Box 441340
' Miami F]. 33144
INSURED
White Star Enterprises Inc
10665 SW 190 st #3109
Miami Fl 33157
INSURANCE DALE(691JDD f)
5 -14 -1 0
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
1NSURERA: Clentlfry Tn.G. CO
HNC #
338:JRERB: NJa nnai Tng c-
INSURER C:
INSLRER D:
INSURER 5:
_ L
SHOULD ANY OF TILE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE IRE EXPRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO NAIL 30 DAYS WRITTEN
NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, SW FAILURE TO 00 BD SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY Kids UPON THE INSURER, tIS AGENTS OR
REPRESENTATIVES
el AC cO` 710N 1988
DATE BATCH h➢UM9BEF
; miaow
SEE OTHER SIDE
DO NOT FORWARD
WHITE STAR ENTERPRISES INC
10665 SW 190 ST 3109
MIAMI FL 33157
►, �ll�s�ll„ �sf��I�I�I�„ 11� „4t11E,J,1,�1„1��,1��1��l�i,n11