361 NE 100 St (2)MIAMI SHORES VILLAGE \ BUILDING DEPARTMENT a k � �
305- 795 -2204
Building Inspection Request
rr
Date (01 1 S
Type Insp'n 71 le i n Prot
Permit No. BP 04 - 111
Name GmQn
Address 3&1_ NE. ick 5+
Company �Pi►�
Phone #
Inspection Date &+ t &
Approved
Correction
Re- Insp'n Fee
4,-e91 one Jai°
Approved
Correction
Re-Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date
110
gctq 0
Typelnsp'n Tlle, phSin9
Permit No. 4> Poil- in
Name Lea moo . �^
Address 3;: l N C 100 54-
Company G • ��
Phone #
Inspection Date 01 ��
MIAIiI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date � �,
Type Insp'n Y) G4 I 2 00T
6204 - m i
Permit No.
Name
Address 3& 1 N I00
Company ( -J Pe (``
Phone #
Inspection Date 2 /3
Correction
Re- Insp'n Fee
„taxat
e g r
s j `\, - r - ,
E/4 -e - •--5
No.
RESULT
No.
RESULT
No.
RESULT
No.
RESULT
No.
RESULT
1 -5
Passed
21 -25
Passed
41-45
71 -75
91 -95
6 -10
Passed
26-30
46 -55
76 -80
96-100
11 -15
Passed
31 -35
56-60
81 -85
101 -110
16 -20
Passed
36 -40
65 -70
86 -90
111 -200
FLORIDA
Testing Equipment: Digital Chatillon DFIS 200
THIS ROOF HAS PASSED:
Reviewed by:
Voice: 305.256.4550
Rafael Dro -S - da, P.E.
No.39228 & 843
22
23
2
18
20
bPoU �i�
Building Solutions For The Construction Industry
mg
eering &
Sulking, Inc. 13605 S.W. 149 Avenue Unit 1 Miami, FL 33196
Rafael Droz -Seda, P.E. 9130 Crescent Dr. Miramar, F133025
CONCENTRATED UPLIFT LOAD TESTING ON ROOF TILE
TO COMPLY WITH MIAMI -DADE COUNTY PROTOCOL TAS -106
PROPERTY ADDRESS: 361 NE 100 ST. PERMIT No: 04 -717
OWNER: PATRICIA FLEEMAN PCA No:
CONTRACTOR: WJ PEREZ ROOF CONTRACTORS ROOF PITCH: 3:12
ROOFING SQUARES: 18 INSPECTION DATE:
TILE TYPE: SANTA FE TEST DATE: 06/30/04
CONTACT PERSON :: JOB NUMBER:
19
Test Tabulation
FAILED ❑ THE STATIC UPLIFT IN ACCORDANCE WITH MIAMI-DADE COUNTY TAS 106.
"ROOF SKETCH"
17
21
15
12
5
Front
14
11
9
10
16
13
4 8
3 6
7
Lab Report No. 04-06018;
North
Certificate No.02- 0501.06
Req uired Testing Force: 35 Ibs
floridatec.net Fax: 305- 256 -1995
Miami Shores Village
10050 NE 2nd Avenue
Building Permit
Phone: 305- 795 -2204 Permit Number: BP2004 -717
Printed: 5/27/2004
Applicant: MARY FLEEMAN
Owner: FLEEMAN MARY
JOB ADDRESS: 361 NE 100 ST
' Parcel # 1132060135380
Signed: (INSPECTOR)
Page 1 of 1
Contractor W. J. PEREZ ROOFING CONT. CORP. Contractor's Address: 4759 PALM AVE, SUITE 144
Local Phone:
Legal Description: MIAMI SHORES SEC 1 AMD PB 10 - 70 LOT 20 & W1/2 LOT 21 BLK 39 LOT SIZE
Fees: Description Amount
FEE2004 -5422 Building Fee $275.00
FEE2004 -5423 CCF $4.80
FEE2004 -5424 Training and Education Fee $1.60
FEE2004 -5425 Technology Fee $6.88
FEE2004 -5426 Scanning Fee $15.00
Total Fees: $303.28
Total Fees: $303.2
Total Receipts: $0.80 C; G
Permit Status: APPROVED Permit Expiration: 11/21/2004 Construction Value: $7,700.00
Work: REMOVE EXISTING ROOF REPLACE DAMAGE WOOD /AS REQUIRED INSTALL OVERHANG PLACE STACKS, FLASHING MOP
JUN 0 7 PAID
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
e/
Miami Shores Village
Building D epartment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING i Permit No. eP.% .) `(, 7/ `7
PERMIT APPLICATION '44' 2. °' 11 Master Permit No.
FBC 2001 . 1"
Permit Type (circle): Building Electrical Plumbing Mechanical
Id t'�'.3os,l•aV.3 ---
Owner's Name (Fee Simple Titl ho ld erY Nl . �ATR�GIAe g , e mfg.) Phone # 14 30S. /6g, '?& '
Owner's Address 31,1 N E l 0 O ST
City MIA M1 State Ft— Zip 33L32
Tenant/Lessee Name Phone #
Job Address (where the work is being done) 31 N E" 10o sr
City Miami Shores Village County Miami -Dade Zip 33138
Is Building Historically Designated YES NO
Contractor's Company Name IN •.J • PeREZ Foo Ft 106 e.0/$T Q- ORFhone #
Contractor's Address 1 +159 P A L P € , 5
City RIpsL..E•lRt -1/4. State pt_ Zip 3,301
Qualifier
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit '1 760 Square Footage Of Work: I 1 b O
Type of Work: ['Addition ❑Alteration ENew tg Repair/Replace ['Demolition
Describe Work: RE Mel E I.XIST 1 N 6 R.00
RE ' LN E ztest.kkGE4 WOOD / AA R.Equ tKED
tO .sT V...t.. 80 eRt4 44 G , Pc e",; -1-N KS , FLAMAANG
tvt. o P 1 ot.t,. 1'.L AL ' - nLeS wl A.Dt4. C e l��n� / ?ly MDoe ply
.
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $� � 80 Permit Fee $ � CCF $ `"*/
Notary $ Training/Education Fee $ t 60 Technology Fee $ e,88
8
Scanning $ /5 Radon $ Zoning Bond $
Code Enforcement $
Total Fee Now Due $
(Continued on opposite side)
Structural Plan Review. $ •
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 CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is 1 : r. I th' . •sence of ► posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatur
The foregoing ins
day of
who i
NOTARY 'UBLIC:
Sign:
Print< �� H
Chu 12/15/03
tit . LP, Siwrnain Sll `EIO' Sign
Owner or Agent ontract .
ment was acknowledged before me this l7` ' The foregoing instrument was acknowledged before me this /7
20 CY, by , day of 1 , 2W, by
known to me or who has produced who is personall known to me or who has produced
as identification and who did take an oath.
As identification and who did take an oath.
My Commission Expires:
APPLICATION APPROVED BY:
'fi '�;:
,;..
ADA PEREZ
EXPIRES: January 2, 2008
Bonded Thru Notary Public Underwriters
NOTARY PUBLI
Sign:
Print:
My Commission
* * * * * * * * ** * * * * * * * * * * * * *a* * ** "Ruxx7nrxinm7[it * * * * * * * * * * * * * * * * * * **
(Certificate of Competency Holder)
State Certificate or Registration No. Cert, ate of Competency No.
************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
•' •N#DD264746
EXPIRES: January 2, 2008
•'44.„t\, Bonded Thru Notary Pudic Underwriters
**
Plans Examiner
Engineer
Zoning
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION
PERMIT NO.
STATE OF FLORIDA:
COUNTY OF MIAMI -DADE:
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real
property, and in accordance with Chapter 713, Florida Statutes, the following information
is provided in this Notice of Commencement.
1. Legal description of property and street/address: L-0T 20 � 1 12 b F LO cal
1 - out 3 - Kt 640 - ES S -1
P• .7o
2. Description of improvement:
3. Owner(s) name and address:
Interest in property:
Name and address of fee simple titleholder: 5Pt k.tr
4. Contractor's name and address:
TAX FOLIO NO.
5. Surety: (Payment bond required by owner from contrac TA
Name and address: ,IA�f[(�r'iyQf:RTIFY
original filed in L1+- : e
Amount of bond $
Lender's name and address:
By
7. Persons within the state of Florida designated by Owner upon whom otices or other documents may be served as
provided by Section 7 13.13(1)(a)7., Florida Statutes,
Name and address:
8. In addition to himself, Owners designates the following person(s) to receive a copy Section 713.13(1)(b), Florida Statutes. PY of the Lienor's Notice as provided
Name and address:
9. Expiration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a
dill: ent date is specified)
dl14o.
Signature of Owner T�
Print Owner's Name R. t'K('Rl[,l/k
Prepared by
Sworn to and subscribed before me this _ day of
2(ley
Address:
Notary Public
Print Notary': Nam
My commission ex
123.01 -52 PAGE . 4 8/02
Lee t .kt\
11( 111111111IIIII111111111111111IIIIIIIIIIIII
CFN 2004-R04-38057
OR Bk 22363 Ps 3175; (ips)
RECORDED 06/02/2004 13:58:17
HARVEY RUVIN, CLERK OF COURT
MIAMI -DADE COUNTY, FLORIDA
LAST PAGE
LAT
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O Low Slope
O Asphaltic
Shingles
Florida Building Code Edition 2002
1-ii9h Velocity t lurricane Zone UnIform Permit Application Forrn.
Seci:ion A (General lnforrnationl
Master Permit No. Process No.
Contractor's Name
Job Address /V-E- 1 bn '•\
ROOF CATEGORY
O Mechanically Fastened Tile
O Metal Panel/Shingles
- 0 Prescriptive BUR-RAS 150
ROOF TYPE
O New Roof cik Re-Roofing 0 Recovering 0 Repair 0 Maintenance
ROOF SYSTEM INFORMATION
Low Slope Roof Area (SF) Steep Sloped Roof Area (SF) Total (SF)
15(7o`
'
0 Wood Shingles/Shakes
Mortar/Adhesive Set Tile
Sector, B (Roof f,Dan),
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 pressureones and Iocation.
As+ (ISE Col€71, 771e,
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
roofing 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
explained.
(PI, 1. Aesthetics - Workmanship: The workmanship provisions of Chapter 15 (High Velocity Hurricane
Zone) are for the purpose of providing that the roofing system meets the wind resistance and water intrusion
performance standards. Aesthetics (appearance) issues arc not a consideration with respect to workmanship
provisions. Aesthetic issues such as,color or architectural appearance, that are not part of a zoning code, should
be addressed as part of the agreement between the owner and the contractor.
2. Renailing Wood Decks: When replacing roofing, the existing wood roof deck may have to be
renailed in accordance with the current provisions of Chapter 16 (High Velocity Hurricane Zones) of the Florida
Building Code. (The roof deck is usually concealed prior to removing the existing roof system).
i94 3. Common Roofs: Common roofs are those which have no visible delineation between neighboring
units (i.e. townhouses, condominiums, etc.). In buildings with common roofs, the roofing contractor and/or
owner should notify the occupants of adjacent units of roofing work to be perfonned.
p,9. 4. Exposed Ceilings: 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
penetrations of the underside of the decking may not be acceptable. The Florida Building Code provides the
option of maintaining this appearance.
p 4, 5. Ponding Water: The current roof system and/or deck of the building may not drain well and may
cause water to pond (accumulate) in low -lying areas of the roof. Ponding can be an indication of structural
distress and 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
original roofing system is removed. Ponding conditions should be corrected.,
, i? J. 6. Overflow scuppers (wall outlets): It is required that rainwater iiflow off so that the roof is not
overloaded from a build up of water. ,Perimeter /edge walls or other roof extensions may block this discharge if
overflow scuppers (wall outlets) are not provided. It may be necessary to install overflow scuppers in
accordance with the Florida Building Code, Plumbing.
R -9. 7. Ventilation: Most roof structures should have some ability to vent natural airflow through the
interior of the structural assembly (the building itself). The existing amount of attic ventilation shall not be
reduced. It may be beneficial to consider additional venting which can result in extending the service life of the
roof.
01.LP_,9'.iemni:4- / n
Owner's /Agent's Signature Date
C: \Doeumen� and SeUinFdchamma+U.acal Set inR+ \Trmp\'I'emporary Inlrrncl FilniCoo,.LIES\OKLUAFTnsECf10N 1514 1i.doc
Con actor's Signature
Roof System Manufacturer: !g
I I Li Carp
Notice of Acceptance Number: rt)v — I 7 - 1 1- •°(-2
Minimum Design Wind Pressures, If Applicable (From RAS 127 or Calculations):
Pmaxl: Pmax2: C /5 -1 / Pmax3: 57
Maximum Design Pressure n / .
(From the NOA Specific System): (Q(0
High Velocity Hurricane Zone Uniform Permit Application Form
Section D (Steep Sloped Roof System)
Deck Type:
Sloped System Description
pkivoDoel
ype Underlayment:
Insulation.
Ridge Ventilation?
Fire Barrier:
Mean Roof Height:
3ott ceA ..
Fastener Type & Spa
Adhesive Type:
ype Cap S
Roof
cing:
heet:
Covering:
It
�r ,
S, 12�1 (A
P
Q'o - ft R oll V-ook
Type & Size Drip
dge:
1 ) 1 'x 7 D'' wuktAl.
`fly 5 5 C,v4 ,
• . Where to Obtain Information
Description
Symbol
`Vhcrc to find
Design I' ssure
VI or I'2 or I'3
'LAS 127 Table I or by an engineering analysis prepared by 1'F :based on ASCII
7
Mean ool'11cight
II
Job Site
Root Slope
0
n Job Site
Acrod tunic multiplier
x
NOr\
Restoring, N1 tent due to (trashy
NI,
NOA .
tachmcnt Resistance
M
NOA
Reg red Moment Resistance
m,
Calculated
nn Attchment Restance
1 UpliIl
26.7
Rcistnncc
I,
Calculed
/Rcq"rcd
, \verage I ile Weght
W
24.5
lilt Dimensions
1• length w- wdth
29.8
ulations must he submitted to the Ilullding Ullicitl at the lime of permit application.
M Required Moment Resistance'
Mean Roof Height -1>
Roof Slope 7
15'
20'
25'
30'
40'
2:12
30.7
33.4
35.7
.7
40.7
3:12
28.7
31.3
33.4
35.2
38.1
4:12
26.6
28.9
30.9
32.6
35.2
5:12
24.5
26.7
28.5
30.0
32.5
6:12
' 22.5
24.5
26
27.6
29.8
7:12
20.8
22.6
4.1
25.4
27.5
High Velocity Hurricane Zone Uniform Permit Application Form
Section E (Tile Calculations)
For Moment based tile systems, choose either Method 1 or 2. Compared the values
for M with the values front M If the M values are greater than or equal to the Mr
values, for each area of the roof, then the tile attachment method is acceptable.
Method 1 "Moment Based Tile Calculations Per RAS 127"
(P,: f r X D 2s11 =1'�. i6 - Mg: 8 Z = M 1, NOA M ,(O(s2•
x X 0.2- 21� :.� - Mg: C, . 2 = M '2 4 NOA air, cote. .
(P, :� 2%
�S. x J� n .n _ ? , � Z t - na c •$L = 2Z4l. NOA Mr GAP .
9
Method 2 "Simplified Tile Calculation Per Table Below"
Required Moment of Resistance (M From Table Below
• NOA Mr
"Must be used in conjunction with a list of moment based ' c systems endorsed by the
13roward County Board of Rules and Appeals.
For Uplift based tile systems use Method 3. C. spared the v alues for F' with the
values for F If the F' values are greater th:. or equal to the F values, for each
area of the roof, then the tile attachment m ,. 10(I is acceptable.
Method 3 "Uplift Bas . Tile Calculations Per RAS 127"
(I', : x I: = x w: _, ) w: x cos 0: = F NOA F'
(P x I: = x w: = 4 = w: x cos 0: = F NOA F'
(P,: xI: = xw:= - W:__x cos 0 : _ =F • NOA F'
z� °DUC C'�7j�'li'���, O� A ,CE
Santa Fe Tile Corporation ' '
10302 N.W. South River Drive, Bay #16
Medley ,FL 33178
Your application for Notice of Acceptance (NOA) of:
Spanish "S" Clay Tile
under Chapter 8 of the Code of Miami-Dade County governing
Construction, and completely described herein, has been reco
County Building Code Compliance Office (BCCO) under the d
The expense of such testing will be incurred by the
ACCEPTANCE NO.: 00- 1212.06
EXPIRES: 02/01 /2006
APPROVED: 02/01/2001
1150.50001\ pt200011temphteslnouce aeccptance maw' pno.dot
In ternet mail address: postenaster@l0vildingeodeenlinc ,corn
FEB 13 '01 17:45
manufacturer.
; 1
fel IAMI -DADE COUNTY, FLORIDA
METRO -DADE FLAGLER BUILDING
BUILDING CODE COMPLIANCE OFFICE
METRO -DADE FLAG LER BUILDING
1 10 NEST FLAGLER STREET. SU1TF. 1603
M(A,NII. FLORIDA 33130 -1563
(305) 375 -2901 I'AX (305) 375 -2905
CONTRACTOR 1.1CLNSINC SECTION
(305) 375.2527 VAX (3D5) 375 -2553
Co,' tu, ci oR ENFORCEMENT U1v'ISION
(305) 375 -2966 TAX (305) 375.2903
' CONTROL i)IVISION
(305) 375.2902 TAX (305) 372-6339
the use of Alternate Materials and Types of
rrtrnended for acceptance by the Miami -Dade
onditions specified herein.
This NOA shall not be valid after the expiration date stated be ow. BCCO reserves the right to secure this
product or material at any time from a'jobsite or mlanufactur�r's plant for quality control testing. If this
product or material fails to perform in the approved manner, �B CCO may revoke, modify, or suspend the
use of such product or material immediately, BCC° reser the right to revoke this approval, if it is
determined by BCCO that this 'product or material fails to i'Ineet the requirements of the South Florida
Building Code.
Raul Rodriguez
Chief Product Control Division
THIS IS THE COVERSHEET, SEE ADDITIONAL PAGES FOR SPECIFIC AND GENERAL
CONDITION
BUILDING CODE & PR DUCT RE !ENV COMMI7TLE
This application for Product Approval has been reviewed b the. BCCO and approved by the Building
Code and Product Review Committee to be used in Miami -.Obde County, Florida under the conditions set
forth above.
Francisco J. Quintana. R.A.
Director
Mi,arni -Dade County
Building Code Compliance Office
rtiimepage: http : /; »ww.bu Idingeodeonline.com
3058880050 PAGE.01
SA,NTAFE 'ULF COR'QRA 1QN
ROOFING Assr ry LY APPROVAL
Cnt --- =°- Rooting
Sub - Category: 07320 Roofing "files
Materials
Deck Ty_►c:
Clay Roof Tiles
Wood
k. SCOPE 1
This renews a roofing system using Santa Fe "Satltafel•S" clay roofing tile, manufactured by
Santafe Tile Corporation described in Section 2 of this kiotice of Acceptance, designed to
comply with.the South Florida Building Code, 1994 Edition for Miami -Dade County. For
locations where the design pressure requirements, as dStermined by applicable building code,
does not exceed the design pressure values obtain by c• lculations in compliance with RAS 127
using the values •Iisted•in herein. The attachment calcu shall be done as a moment based
system.
2 . PRODUCT DESCRIPTION
Manufactured by Test
Applicant Dimensions Specification
Santafe 'S' Clay
Roof Tile
Trim Pieces
FEB 13 '01 17 :45
i =18"
�v = 1 1.5
''A" thick
1= varies
= varies
varying
thickness
PA 112
PA 113
2.1 COMPONENTS OR PRODUCTS MANUFAC
'Test
Product Dimensions Specifications
Tile Screws 48 x 2 -' /-_" long PA 114
0.130" shank dia. AppendiN E
0.178 flute dia.
ACCEPTANCE No.: 00- 1212.06
Approval Date: February 3, 2001
Expiration Date: February 1, 2006
Product
Descrin - i tiun
O e piece high profile clay roof tile
e ipped with two nail holes. For nail -on,
m rtar set and adhesive set applications.
A ccssory trim, clay roof pieces for use at
hi s, rakes, ridges and valley terminations.
M nuFacturcd for each tile profile.
URED 13Y OTHERS
Product
Description
tainless Steel
3. LIMITATIONS
3.1 Fire classificatiorris not part of this acceptance,
3,2 For mortar or adhesive sct tile applications, a tic field uplift test shall be performed in
accordance with RAS 106.
3.3 Applicant shall retain the services of a Miaihi - Dade County Certified Laboratory to
perform quarterly test in accordance with I'Ai(1 12 a �._..' '
Submitted to the Building Code Compliance O+`_ ��., hall be
Zoaga, RRC
Roofing Product Control Examiner
Minnufncturer
generic
30588(0050 PRGE.02
Table 1:
Table 3: Attachment
Tile
Application
Resistance
For
Two Nails
Expresst.
Nail -On Syst
One Scrctiv
4
d as a Moment
w o Screws
38.28'
Mf (ft -Ibf)
One Screw
w/ Clip
57.31
_
Two Screws
w/ Cli�
57:60
Tile Profile
Santafe S
Direct Deck
21.8
29.16'
C
Battens
Battens
Direct
Deck
Battens
Direct
Deck
61.77
• 1. Approved screws as noted 'Product manufactured b ' others'
Santafe `S'
Table 1:
Table 4: Attachment Resistance Expres j
for Mortar or Adhesive S
d as a
t Systems
Moment - Mf (ft
Attachment •
Resistance
23.6
td
-- j
I
Tile
Profile
Tile
Application
Mortar Set
Santafe 'S'
or
Direct
beck
Adhesive Set
2 ":12"
61,9 –
Table 1:
Table
2: Restorinc_Moments
3 " :12"
_
due
• 4 ":12"
td
-- j
I
Gravity -
5 ":12"
M (ft -Ibf)
6" :12"
7 " :12"
greater
Battens
or
Direct
beck
Tile
Profile
2 ":12"
Battens
Direct
Deck
Battens
Direct
Deck
Battens
Direct
Deck
Battens
Direct
Deck
Battens
Direct
Deck
Santafe `S'
5.93
5.90
'5.85
5.82
5.73
5.69
.56
5.53
5.32
5.29
5.03
N/A
Table 1:
Aerodynamic Multi I ers– a.
2.. ( & I
Batten A• • lic Lion
ft
X (ft)
Direct Deck
Tile
Profile
Santafe 'S'
0.274
0.297
SANTAFE TILE CORPORATION
3.5 30/90 hot mopped underlayment applications nay be installed perpendicular to the roof
slope unless stated otherwise by the undcrl.ymcnt material manufacturers published
literature.
3.6 This acceptance is for wood deck applicationd Minimum deck requirements shall be in
compliance with applicable building code.
4. 1STALLATION
4.1.1 Santafe 'S' and its components shall be installer in strict compliance with Miami Dade
County Roofing Application Standard RAS 11 , RAS 1 19, and RAS 120,
4.1.2 Data For Attachment Calculations
ACCEPTANCE No.: 00- 1212.06
rank Zuloaga, RRC
Roofing Product Control Examiner
3
FEB 13 '01 17:46 3056$60050 PAGE.03
.SANTAFE TILE CORPORATION ! ACCEPTANCE No.: 00- 1212.06
5. LABELING
5.1 AJI tiles shall bear the imprint or identifiable nfarking of the manufacturer's name or logo,
or following statement: "Miami - Dade County l oduct Control Approved ".
6. BUILDf.NG PERMIT REQUIREMENTS
6.1 Application for, building permit shall be accomdanied 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 o1;'this system.
PROFILE DRAWINjC
SANTAFE "SANTAFE S" CLAY1ROOF TILE
FEB 13 '01 17:46
— nic ' ? t ' Ct1 1 1 : `1GI FR FRArlCfl
4
Franc Zuloaga, RRC
Roofing Product Control Examiner
— 7105 59 7 9484 TO 3058223390
3058880050 PAGE.04
P.05/05
"SMTOE TILE CORPORATION
NOTICE OF ACCEPTANCE STAriDA{ D CONDITJONS
1 Renewal of this Acceptance (approval) shall be considered aftenla renewal application has been filed and the
original submitted documentation, including test supporting date, engineering documents, arc no older than
eight (B) years. M1
ii
2 Any and all approved products shall be permanently labeled the manufacturers name, city, state, and
the following statement: "Miami - Dade County Product Control,+;Approvcd", or as specifically stated in the
specific conditions of this Acceptance.
3 Renewals of Acceptance will not be considered if:
a) There has been a change' in the South Florida Building Cocic affecting the evaluation of this product
and the product is not in compliance with the code chap cs
b) The product is no longer the same product (identical) as thif one originally approved;
c) If the Acceptance holder has not complied with all the requirements of this acceptance, including the
correct installation of the product;
d) The engineer who .originally prepared, signed and sealed the: required documentation initially
submitted, is no longer practicing the engineering professioift.
Any revision or change in the materials, use, and/or rnanufactury of the product or process shalt
automatically be cause for tcrltination of this 'Acceptance, unles;li prior written approval has been requested
(through the ding of a revision application with appropriate fee; and granted by this office.
5 Any of the following shall also - bc grounds fur rcntuvJ. c4 :b;r, l' lieotancc:
a) Unsatisfactory performance of this pr or process; II'1
b) Misuse of this Acceptance as an endorsement of any procf).ict, for salts, advertising or any other
purposcs.
6 The Notice of Acceptance dumber preceded by the words Miami padc County, Florida, and followed by the .
expiration date may be displayed in advertising literature. if any portion of the Notice of Acceptance is
displayed,, then it shall be done in its entirety. .
l
7 A copy of this Acceptance as well as approved drawings and oth �� d ocuments ; where it applies, shall lac.
.: ::: � _ iCiiide to
• • • ; , p � . dale user by the manufacturer or its distributors and still be available for inspection at the job
site at ail limes. The copies need not be resealed by the engineer'
8 Failure t0 comply with y se of t.hi - ACceptaticc shall be ca sc for termination and removal of
Acceptance.
9 This Acceptance contains pages 1 through 5
END OF THIS ACCEPTAN
FEB 13 '01 1 ? :46
5
CE
ACCEPTANCE No.: 00- 1212.06
,Frank Zuloaga, RRC
I!tootng Product Control Examiner
305B8B00S0 PAGE.05
:l::t: TOTAL PAGE. 05 ,K*
MIAM IDADE
NNW
PRODUCT CONTR(LHNOTICE OF ACCEPTANCE
i olyfoaw Products, Inc_
2400 Spring- Stucbncr Road
Spring ,TX 7 7383 -1132
Your application for Notice of Acceptance (NOA) o.t:
Two Component Polyurcthcnc Foam Adhesive
under Chapter 8 of the Code of Miami -Dade County governing the use of Alternate Materials and Types of
Construction, and completely described herein, has been recommended for acceptance by the Miami -Dade
County Building Code ComplianceOflice (BCCO) under the conditions specified herein.
TJiis NQA shall not•be valid after'the e;cpiration date stated below. BCCO reserves the right to product or material at any time from a jobsite or manufacturer's plant for quality ualit control testing. If this
product or material fails to perform in the approved m�-tnner, I s I this
use of such product or material immediately. BCCO reserves CICO right rnay revoke, modify,�or suspend the
determined by BCCO that this product or material fails to meet the requirements is ofsthe approval, if it is
South Florida
Building Code.
The expense of such testing will be .incurred by the manulacturcr.
ACCEPTANCE NO.: 01- 0521.02
EXPIRES: 05/10/2006
Raul Rodriguez.
Chief' Product Control Division
THIS IS THE COVERShIFET, Srr ADDITIONAL PAGES FOR SPECIFIC AND GENERAL
CONDITIONS
BUILDING CODE Sc PRODUCT REVIEW COMMITTEE
This application for Product Approval has been reviewed by the BCCO and approved by the Building
Code and Product Review Committee: to be used in Miami -Dade County., Florida under the conditions set
forth above.
APPROVED: 06/1412001
11; 0 -1500011pc200011tcmplace;lnoticc Icccpunca Co+cr paga.dac
Internet mail address: postmaster @buiidinl;codeonline.com
• 'NAT T C`T'1i1Rn \T i TiTVr.TT"T - - T
MIAMI -DADE COUNTY, FLORIDA
METRO -DADS FLAGLER BUILDING
['WILDING CODE COMPLIANCE OFFICE
METRO-DADE F•L,\GLER 13Ul1,DINO
1.10 w1 Sr FLAG LER STREET, SUITE 1603
Ml FLORIDA 33130 -1563
(305) 375 -29 FAX (3 05) 375 -2908
c:c1N•rRA(7014 1,1CFNS(N0 Sltr110N
D05)375-2527 FAX (3051 375 -255/1
CONTRAc"rott ENFORCE NI U1VISIOff!
(305) 37S -2966 FAX (305) 375.2909
I °ItODUCT' CONTROL. DIVISION
(30)375-2903 rA X (305) 372 -6)39
Francisco J. Quint:Inn, R.A.
Director
Mi;uni -Dade County.
1311ilding Code Colnpli :lace O11ice
Honlcp;lge: http : / /www.buildingcodconlinc.com
9inT nln Rnn S /VT nn • T T\TT n inn
cnn IT,
Pol.yfoam Products, [rte.
ROOFING ASSEMBLY APPROVAL
Ca tcrnr� : Roofing
Suh- Catccnry RooUTilc Adhesive
Materials: I'olytircthane
1. SCOPE
This approves Polypro® AI•I160 as manufactured by Polyfoam Products, Inc. as
described in Section 2 of this Notice of Acceptance. For the locations where the design
pressure requirements, as determined by applicable building code, does not exceed the
design pressure values obtained by calculations in compliance with Roofing Application
Standard RAS 127, for use with approved flat, low, and high profile roof tiles system using
Polypro® AH 160. Where the attachment' calculations are done as a moment based system
for single patty placement, and as an uplift ba_sed system for double patty systems
PRODUCT DESCRIPTION
NManufacturcd by
!�nnlicant Dimensions
Polypro® Ala I60 . N/A
Foattlpro® RTf 1000
- N /A
ProPack ®30 & 100 N/A
2 .1 Components or products manufactured by others:
Any Miami -Dade County Product Control Accepted Roof Assembly having a current NOA
which list uplill resistance values with the use of Polypro A1.1160 roof tile adhesive.
2.2 Typical Physical Properties:
Property
Density
Compressive
Strength
Tensile Strength
Water Absorption
Moisture Vapor
Transmission
Dimensional
Stability
Test
ASTM D 1622
ASTM D 1621
ASTM D 1623
ASTM D 2127
ASTM E 96
ASTM D 2126
'1A 7T'CT"111R(1V] TTVel.TT T
Tcs t
Specifications
PA 101
ACCEPTANCE No.: 01 021.02
Approval Date: _June 14, 200
Expiration Date: Mn 1 2000,
Results
1.6 lbs. /ft.'
18 PSI Parallel to rjse
12 PSI Perpendicular to rise
28 PSI Parallel to rise
0.08 Lbs. /Ft
3.1 Perot / Inch
4- 0.07"// Volume Change @ -40 F., 2
weeks
+6.0% Volume Chance O la
I tumidity, 2 weeks
Product
Description
Two component
• polyurethane
Dispensing Equipment
Dispensing Equipment
•
Frank 2uloaga, RRC
Product Control Examiner
Tcnr nIn cnn • ITTI ..,•.T .,..
Note: The physical properties listed above are presented as typical average values as determined by
accepted 4 STM test methods and are subject to normal manufacturing variation.
3. LIMITATIONS
3. Fire classification is not part of this acceptance. Refer to the Prepared Roof Tile
Assembly for ;lire rating.
3 .2 Polypro® A1.1160 shall solely be used with flat, low, & high tile profiles.
3.3 Minimum underlayments shall be in compliance with the Rooting Application
Standard RAS 120.
3 .4 Roof Tile manufactures acquiring acceptance for the use of Polypro® AI root'
tile adhesive with their tile assemblies shall test in accordance with PA 101.
3.5 Roof Tile manufactures acquiring acceptance for two paddy placement with the
use of Polypro® AI roof tile adhesive with their tile assemblies shall test in
accordance with PA 101 and with section 10.4 as modified herein.
(2/ —w
F'= JJ
MS
tvon
Polyfoam Products, Inc.
4. INSTALLATION
4.1 Polypro® AH1G0 may be used with any roof tile assembly having a current NOA that
lists uplift resistance values with the use of Polypro® AH 160.
4.2 Polypro® AI -1160 shall be applied in compliance with the Component Application
section and the corresponding Placement Details noted herein. The roof tile
assembly's adhesive attachment with the use of Polypro® AI-1160 shall provide
sufficient attachment resistance, expressed as an uplifl based system, to meet or exceed'
the uplifl resistance : determined in compliance with Miarni -Dade County Roofing
Application Standards RAS 127. The adhesive attachment data is noted in the roof
Tile assembly NOA
• 4.3 Polypro® A11160 roof tile adhesive and its components shall be installed in.
accordance with Roofing Application Standard RAS 120, and Polyfoam Products, Inc.
Polypro® A[-I160 Operating Instruction and Maintenance Booklet.
4.4 Installation must be by a Factory Trained 'Qualified Applicator' approved and licensed
by Polyfoam Products, Inc. Polyfoam Products Inc. shall• supply a list of approved
applicators to the authority having jurisdiction.
4.5 Calibration of the Foampro® dispensing equipment is required before application of
any adhesive. The mix ratio between the "A" component and the "B" component shall
be maintained between 1.0 -1.15 (A) : 1.0 (B). The dispense timer shall be set to
deliver 0.0175 to 0.15 pounds per tile as determined at calibration. No other settings
shall be approved.
4.6 Polypro® AI -1160 shall be applied with Foampro RTF1000 or ProPack® 30 & 100
dispensing equipment only.
4.7 Polypro® A1,-1160 shall not be exposed permanently to sunit
3
"lpir'cr nlrnvl mun.tz -rn1
ACCEPTANCE No. : 01-0521.02'
Frank Zuloaga, RRC
Product Control Examiner
"'FAT nln i.nr •.VI In IT r,vT nn..n. +n
Table 1: AdI csive I'laccntcnt For Each Generic "file Profile
TilePruGle
Placement
Detail
Single Paddy Weijht
. 'Min. (t:rains)
Two,Pnddy Weight
per paddy Min.
(grnrus)
Flat. Low, 1-[igh Profiles
111
35
N/A
High Profile. (2 Piece Barrel)
ill
17 /side on cap and
34 /pan
N/A
Flat, Low, High Profiles
12
24
N/A
Flat,. Low, High Profiles'
113
8
cnn fdi
Polyfoant Pro'ducts, Inc.
• ACCEPTANCE No. : 01- 0521.02
4.8 Tiles must be adhered in freshly applied adhesive. Tile must be set within 2 to 3
minutes after Polypro® AH 160 has been dispensed.
4.9 Polypro® A1-1160 placement and minimum patty weight shall be in accordance with
the 'Placement Details' herein. Each generic tile profile requires the specific placement
noted herein.
5. LABELING
All Polypro® AH 1 GO containers shall comply with the Standard Conditions listed herein.
6. BUILDING PERMIT REQUIREMENTS
6.1 As required by the Building Official or applicable Building Code in order to
properly evaluate the installation of system.
4
tr'cr�nrtnvl ravn.rrerns
Frank Zuloaga, RRC
Product Control Examiner
9i.Ar Al's i.nn wVT /n or rsy♦
Polyloam Products; Inc.
Noll through platllc cement
Und.Alrmtnl
Ear. Gaunt
Fara Clout°
10 In:
Paddy IBanoalh T0.)
are :mnn only:
Karp weals: approe.
1 In. up hoot w..aphol.l
Nall through plaAtIc unman]
Undarl ymanl
P Addy IBanaolh Thal
Cart Came
101n.
Elul count only
Kopp oat live rpprps. l in. up
horn •crohaln
A'DLIESIVE PLACEMENT DETAIL 1.
SINGLE PATTY
Fnc11
Ens Claaura
"1.IT ' C r- ,nr - TAV 5 TItVA.TT•1rT 0
ACCEPTANCE No.: 01- 0521.02
Nall through plastic cement
Undcrlaymcnt
1
101n.
Ent Cowie
Eavo count anly:
Kaop adhall.a 3pproc.
4 In. up hoot Wasphol.l
Paddy IBonorlh TWI
F.1ch
Woepho4
E.rs cloeun
Odp.dge
Aemo.
lop ponlan
of th. 11,1
count :or cr Vic.
Abut la ucond coons of
tun Wea. Enturo 1111 end cl
0.0, and cover tllel 1rn
Ruch 11 oars Iln..
El,' clown
(mcnar ahow.n)
Wenphole Foacl1 B0
ptlorni2i4 for
sloop pitch appllailom Hal through plastic cam(
1) Placa anouph adhc/1v010 a cMcrc 1710 20
squats Indict In conUC1 with lha pan lila
0) Turn cows upIWi down. Pico adha.M In In`
Th 1 In. From Wilde odga of covor Ilia. ��
hen heull the 111.. /
Unoerlaymonl � / /
4‘
Frank ZLIIOabn ItRC
Product Control Exarnincr
Opilanal
P otnl•up Uorcar
on Imglludlnal
.d9.1 01114
S uULng
•
Polytonal Products, Inc.
Nall through plastic cement
EVIt CO 3 11lit •
bye Closure
Paddy (Beneath Tile)
Nail through olaatic cement
Ea c Come , I
Neel,
Nall through plastic cemeWnt
Undetlayrnent
7 In,
Earl. Cowrie
Piddy fnencgn The)
Un erlayrnont
7 In.
4 Pr to ‘ t
* 1111 4 116.
01'
Elva Closu
Fascia
Paddy (Beneath ille)
Fescla
Weephek
Eave cloaure
Drip edge
ADHESIVE PLACEMENT DETAIL 2
SINGLE PATTY
6
• • T C' r 'VI (TOW I 'MLA .T T T
ACCEPTANCE No. - 01-0521.02
Fratik Zuloaga, RRC
Product Control Examiner
• I. .
1
rnn Fdt
•
Polyfoant Products, Crtc. ACCEPTANCE No. : 01- 0521.02
Renewal of this Acceptance (approval) stall be considered after a renewal application has been filed
and the original submitted documents, include.' test - supporting data, engineering documents. are no
older than eight (K) ears
2. Auy and all approved products shall be permanently labeled twit the ntanul;ncwrcr's name, city,
state, and the following •statement: "Miami -Dade County Prod tie, Control Approval ", or as
specifically stated in the specific conditions of this Acceptance.
.3. Renewals of Acceptance will not bc considered if:
Then: has been a change in the South Florida Building Code affecting the evaluation of this
•
• product and the hrodiict is not in compliance with the code changes.
The produ'c( is no longer the same product (identical) as the one originally approved.
;If 'the Acceptance, holder, has , not complied w ith all the requirements of this acceptance,
including the correct installation oldie product.
d. The engineer who originally. prepared, signed and scaled the required documentation initially
submitted, is no Iongci practicing the engineering profession.
4. Any revision or change in the materials, use, and /or manufacture of the product or process shall
automatically bc cause for termination of this Acceptance, unless prior written approval has been
requested (through die filing_ of a revision application with appropriate fee) and granted by this
office. •
a.
5. • Any of the following shall also be grounds for removal of this Acceptance:
a. Unsatisfactory performance of this product or process. •
b. Misuse of this Acceptance as an endorsement of any product, • for sales, advertising or any
other purposes.
6. The Notice of Acceptance ni inber preceded by the words Nliami -Dade County, Florida, and followed
by the expiration date may be displayed in advertising literature. If any portion of the Notice of
• Acceptance is displayed, then it shall be done in its entirety.
7. A copy or this Acceptance as well as approved drawings and other documents, tvherc it applies, shall
bc provided to the user by the manufacturer or its distributors and shall be available for inspection at
•
the job site at all time. The engineer need not reseal flit copies. •
o.
�. Failure to•contply,witlt any 'section of this Acceptance shall be cause for • termination• and removal of
Acceptance.' •
9. This Notice of Acceptance cojtsists of I through 8. .
END OF THIS ACCEPTANCI;
•NhIT C T'NllffAVJ WvnJ7'1A/
Frank Zuloaga, ItItC
1`tutlncl GunUul l'.Nountne•
New Building Remodeling
To be constructed of Kind of foundation
I hereby su
be sent to..
Disapproved
(Signed)
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statt:uienr us use plans and specifications herewith submitted for the build
inc or other structure herein described. This application Is made In compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida. and all provisions of the Laws of the State of Florida all ordinances of Miami Shores Village and all rules and
regulations of the iir�ilding Division of Miami Shores Village shall be complied with, whether herein specified or not. A *espy of approved
plans and specifications nsust be kept at building during progress of the work.
Date
Owner's Name and Address 1 itin^a& 361 ,s..� }}
Registered Architect and /or EnOncer ... .
Name and address of licensed contractor
Location and built
,l/.�/..
legal description of lot to be ilt on:
Nk Lot. .. Block
Street and Number wheru work is to be done
State work to be done and purpose of building (by floors).
Estimated Total cost of improvements $ LQU , )
Zone Cubage required
Distance .to next newest building
Nlaximunt live load to be borne by each floor
Icy 1 lob
No . ». » »»....»...._.. Street_... » _...... »
n,.. VIM MMn. n,.\,
M.A4 f-.
Subdivision°. 4 1 0 /1 £ LL-3 -CYO
and for no other purpose.
Addition Repairs biz_ ' q f Stories
Roof Covering , „CL-4c 1
Amount of Permit IL
.Plan Cubage
Size of Building Lot
e pl, ns and specs stations for said building. All notices with reference to the building and its construction may
The cinitersicnccl applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of Libor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Sup clement,
and has complied ss itli the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as arc required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
Rem.uks (Signed)
PLANNING BOARD DATE
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared ___.. —.. _ .. »... »...._
••-- — ......to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the.
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein• by him stated ar true..
Permit No.._[`! 1 Date 101%.7 Read, Sworn to and Su fore me.
Notary Public, State of Fkrida Rr._, ,.a
�
Duil • ng inspector My Commission Expire ; roe. l»i:� i.d ., �:/7 •
Aondcd Ihiu IioY Fein lu,uwnw, Inc.
Chairman Member
Mfcrnber ._ Member _..._
Member .. .. _....._......- •--- .— ...._...... Member
Council Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has kern obtained from
the 1'L,nnir,.. llu.ird.
A rc.inspeetion fee of 31.00 will be charged when such re- inspection is mad* necessary by Improper notice for inspection oe faulty
materials anti /or workananship.
MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby uinde for the approval of the detailed statement of the plans and specifications herewith submitted for the build-
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
42 squares
Owner's Name and Address
Registered Architect and /or Engineer
STATE OF FLORIDA,
COUNTY OF DADE. ss.
Patty Fleeman
,19.78_
No 361 Str E . 100th St.
..tt•TTITV..1 t••- ttttlttleTt
Namc and address of licensed contactor Larg... o 'u . & .Tilt< CO R ,, Inc, ,,.573 N,W Miami, Fla. 12150
Location and legal description of lot to be built on:
Lot Block Subdivision
Street and Number where work is to be done..3 N.E. 100th Street...__
State work to be done and purpose of building (by floors).JeX'oO,f garage: Tear off existing.,roofirlg tin cap
130# felt to sheathing , mop 2 -15# felts with hot asphalt and apply pea rock (flash walls)
and for no other purpose.
New Building Remodeling Addition Repairs Partial R/lio. of Stories 1 _
To be constructed of Kind of foundation Roof Covering 4-Ply Gravel
Estimated Total cost of improvements 5.595. Amount of Permit $. 12 .5 0
Zone cubage required ........... __Plan Cubage
Distance to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the (provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the s' of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subconjjtors, og k to be pejformed under this
permit, as are licensed by Miami Shores Village.
Remarks (Signed).
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
and who, being by me first duly sworn, upon oath deposes and says that he is the.
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Permit No..____ Date Read, Sworn to and Subscribed before me.
Disapproved Date
Notary Public, State of Florida
(Signed)
to me well known,
Building Inspector My Commission Expires
PLANNING BOARD DATE
Chairman Member
\fcrrlber Member
Member Member
Council Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from
the Planning
A re- inspection Ice of 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection oe faulty
materials and /or workmanship.