The URL can be used to link to this page

RF-13-2026Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-218832 Scheduled Inspection Date: September 02, 2014 Inspector: Rodriguez, Jorge Owner: , Job Address: 10650 NE 10 Place Miami Shores, FL 33138-2104 Project: <NONE> Contractor: MASIMO CONSTRUCTION INC comments REMOVE EXISTING ROOF SYSTEM AND INSTALL A BUILT- UP SYSTEM 03/07/2014 - As requested by the contractor the permit has been cancelled, a stop work order has been issued for the project. 08/14/2014 - CHANGE OF CONTRACTOR ISSUED TODAY. AS Passed Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Permit Number: RF -9-13-2026 Permit Type: Roof Inspection Type: Final Roof Work Classification: Flat Phone Number Parcel Number 1122320280870 Phone: (954)701-7425 INSPECTOR COMMENTS False Inspector Comments CREATED AS REINSPECTION FOR INSP-198714. WAS NOT SECURED AND NOT TALL ENOUGH August 29, 2014 For Inspections please call: (305)762-4949 Page 22 of 25 OFFICE COPY Permit Holder 6/ Permit # nn F.B.0 Violation'_ r'��✓��✓src. d'� Address �d ,�� !E) Date 3 — 7 — / By Building Official Mar 0414 04:20p 4 Extreme Roofing,lno March 04, 201.4 Miami Shores Village 10050 N.E. 2'' Avenue Miami shares, Fl. 33138 Ref: Permit # RF -13-2026 Attn: Building Department To whom it may concern, 305-225-1255 p.1 By mean of this letter l respectfully request that we be removed as contractor form the above mentioned permit for property address 10654 N.E. 10th place Miami Shores, Fl. 33139-2104. The Management Company that manages this property has not worked in good faith with us, issuing checks with no available funds. As this time we no longer are doing any type of business with them. Any questions or concerns, please feel free to contact me directly at 305-225-1535. Thank you, Naomi F Fuentes Qualifier CCC 1326021 19800 SW 180th Avenue #363 Miami, Florida 33187 Office # 305-225-1535 extremeroofinginc@yahoo.com Mar 04 14 04:20p Extreme Roofing, Ino Project Address 10650 NE 10 Place Miami Shores, FL 33138-2104 U S MORTGAGE FINANCE 11 LLC 305-225-1255 p.2 _ ��y.i4- - ' i�ii:j Rim'<• 1P APO _ ' -•, A' � r _..:.,-... � ' to .. Expiration' 03I312014 Parcel Number 1122320280870 Block: Lot: 200 S BISCAYNE Boulevard MIAMI FL 33131- 200 S BISCAYNE Boulevard MIAMI FL 33131 - Contractors) Phone Cell Phone EXTREME ROOFING (305)594-1915 (305)775-3877 Type of Work: Repair Additional Info: Classification: Residential Scanning: 3 e ice' Fees Due Miami Shores Village CCF 10050 N.E. 2nd Avenue NE DBPR Fee Miami Shores, FL 33138-0000 h ° Phone: (305)795-2204 Education Surcharge $0.80 Project Address 10650 NE 10 Place Miami Shores, FL 33138-2104 U S MORTGAGE FINANCE 11 LLC 305-225-1255 p.2 _ ��y.i4- - ' i�ii:j Rim'<• 1P APO _ ' -•, A' � r _..:.,-... � ' to .. Expiration' 03I312014 Parcel Number 1122320280870 Block: Lot: 200 S BISCAYNE Boulevard MIAMI FL 33131- 200 S BISCAYNE Boulevard MIAMI FL 33131 - Contractors) Phone Cell Phone EXTREME ROOFING (305)594-1915 (305)775-3877 Type of Work: Repair Additional Info: Classification: Residential Scanning: 3 e ice' Fees Due Amount CCF $1.80 DBPR Fee $3.75 DCA Fee $3.75 Education Surcharge $0.80 Permit Feg` New Roof $250.00 ScanniN-Fee $9.00 Technolc_W-Fee $2.40 Total: $271.30 Pay Date Pay Type Invoice * RF -9-13-49055 0910912013 Check* 2722 10/0212013 Check #: 2728 U S MORTGAGE FINANCE 11 LL vaallu-atlom $ 2,500.00 Total Sq Feet: 350 Amt Paid Amt Due S50.00 $ 221.30 $ 221.38 $ 0.00 Avallaole Inspecnons: Inspection Type: Review Roof ):Ficant Copy a Inspections, Call (305) 762-4949 or Log on at https:Hbldg.miamishoresvillage.comlcapl. Requests must be received by 3 pm for following' day inspections. NOTICE-,.. In addition to the requirements of this permit, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER additional restrictions applicable to this property that may be found In GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT the puti:rlgc records of this county. DISTRICTS; STATE AGENCIES, OR FEDERAL AGENCIES. , October 02, 2013 2 CjUIWI IW r%LFUII1 IU, it IL; .3i.i:-44; P I Guu P. 1 tea - 84402.13.1 Scope Ask pertains to the sin, itis tate responAFdyofmd%axdracIDrtDprovIde the owner with the required roofing perm, and to explain to the owrterthe content of the seclim The prw4isba of SeCODn R4402 govern the minimum requiremernts and standards of the industry for roofing system installations. Additionally, the ftftulng item mould be addressed as part of the agreemerd befteen the otter and the contractor. The owners mM m the destpu ted space imlicates #tact the ilem has been e*amed. �n �Je 1. AesdNft W : tie workmans 1p provislons of Simon 144402 ne for the purer of providing that the roof system meets the wW resistance seed water instruclion pallormance standards. Aestttefcs (apse) am not a contside:eatkhn with respect to mvbnwWtip provisions. Ae wdc issues such as eros or architectural appear irce, that are ad part of a zoning code, should be: addressed as part of the aWeanerit behmert Me owner wd the icortractor. 2. ,( V - _R=WnqwoW dodo: When relAacing rooter, the ex'sgahg wood roof do& may have to be renaled in accordom wth the current provisions of SecOm R4403. (The mat dem is usually pled prior to renwing the existing roof system). 3. —Al --Carnnm rook Common mat are those yr kb have no visits debeation bewmn neiglhlx nng units (r e., towrilirmses, oxiftnWons, etc.) In buildings with caumaon res, the rooft contractor andbr owner should nary the occuparb of adpoent units of roofug to be pa fornwd. 4. Bgmed Ceiling Exposed, open bean ceiftr s ane where the underside of tltm roofdecking can be viewed from below. The ear may wish b miaintalt the architectural appy; there, roofirry nail pertstration of thA urcferside of the docking may not be acceptable. This provides the option of maintaining the appearance. 5. N Poring r r: The current roof system ardke"of the bide maty not drdn well and may cam water t D pond (accumulate) in bw areas of the reoL Pounding can be an hiditallon of structural distress and may require the revim of a prakissiord struts engineer. Poun stag may shorten the fife ear and peritcrance of tate new roaft system. PoAding amndt" m may not be evident urd the, crUnal moft systern is wwved. PoundkV coniditions dwid be oorrec°ted. 6. �� / Overtkw saWpffs (wet ods): it is mp*W that rainwater tip off so Mat the roof is not overloaded trom a buklup of tate. Perimefed6dge wall or other rod extension may blvd this discharge if overflow scuppers (wag outiefs) we not proves. it may be necessary io ill overflow scuppers in accordance wb the mquiremefs of Sections R4402, R4443 and 844413. 7. MWIllfaftn., Most nasistnxtures should thane state ablifty to vent rel airflow through the Interior of ft structue membly (the buftng tel}_ The s&ft amount of alfa mddm shalt not be reduced. ft may be beneficial th consider additional verft which can result in adending the service mien of the e11"1 ' 3 town Agents Contractor nature tie Revised on 70M LD I ROOF ASSEMBLIES AND ROOFTOP STRUCTURES It UrNt SEP 0 0 2012 Florida Building Code Edition 2010 LBY:j� High Velocity Hurricane Zone Uniform Permit Application Form. : b I 6#1_ Section A.(General Information) : ■ _ ® r lt e a i . i_/_ _,I, - f- - Job Address l (a ROOF CATEGORY 4owslope Q. Asphaltic Shingles ❑ Mechanically Fastened Tile ❑ Metal Panel/Shingles ❑ Prescriptive BUR -RAS 150 ROOF TYPE ❑ Mortar/Adhesive Set Tile ❑ Wood Shingles/Shakes CI New Roof Reroofing 0 Recovering D Repair ❑ Maintenance ROOF SYSTEM INFORMATION Low Slope Roof Area (SF) Steep Slo ed Roof Area (SF) Total (SF) 3a_ S 7. Section B (Roof Plan) Sketch Roof Pian: 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. 15.34 2010 FLORIDA BUILDING CODE -- BUILDING ROOF ASSEMBLIES AND ROOFTOP STRUCTURES , • , SECTION 1525 HIGH -VELOCITY HURRICANE ZONES UNIFORM PERMIT APPLICATION Florida Building Code Edition 2010 High -Velocity Hurricane Zone Uniform Permit Application Form. INSTRUCTION PAGE COMPLETE THE NECESSARY SECTIONS OF THE UNIFORM ROOFING PERMIT APPLICATION FORM AND ATTACH THE . REQUIRED DOCUMENTS AS NOTED BELOW: Roof System Required Sections of the Attachments Required From Product Approval: Permit Application Form See List Below Low Slope Application A,B,C 1,2,3,4,5,6,7 Prescriptive BUR -RAS 150 A,B,C 4,5,6,7 Asphaltic Shingles A,B,D 1,2,4,5,6,7 Concrete or Clay Tile A,B,D,E 1,2,3,4,5,6,7 Metal Roofs A,B,D 1,2,3,4,5,6,7 Wood Shingles and Shakes . A,B,D 1,2,4,5,6,7 Other As Applicable 1,2,3,4,5,6,7 ATTACHMENTS REQUIRED: 1. Fire Directory Listing Page 2. From Product Approval: Front Page Specific System Description Specific System Limitations General Limitations Applicable Detail Drawings 3. Design Calculations per Chapter 16, or If Applicable, RAS 127 or RAS 128 4. Other Component of Product Approval 5. Municipal Permit Application 6. Owners Notification for Roofing Considerations (Reroofing Only) 7. Any Required Roof Testing/Calculation Documentation 2010 FLORIDA BUILDING CODE — BUILDING 15.33 ROOF ASSEMBLIES AND ROOFTOP STRUCTURES Florida Building Code Edition 2010 High -Velocity Hurricane Zone Uniform Permit Application Form. Section C (Low Slope Application) Surfacing: if in specific roof assembly comments and identify manufacturer (if a component is not used, identify as "NA") System Manufactimi • ! 7 1 illi E1'�4 Is Product Approval No.. -.1 c� Design Wind Pressures, From RAS 128 or Calculations: P1•'_ CA.k P2• -7/.'-) p3:_ 10k, Max. Design Pressure, from the spe,oc Product Approval system• ` 41> - J Dock: Type: } 4 W o n d- Gaugefrhickness:�� Slope: Anchor/Base Sheet & No. of Ply(s): Arty o/Base Sheet Fastener/Bon4ing Material: j Til') ,TAS i'j4 ✓Lsnr, 54i► ice. Insulation Base Layer: Base insulation Size and Thickness: d Base Insulation Fastener/Ss�dg, Material: Top insulation Layer: I Z -JA Top Insulation Size and Thickness: %� I -A Top Insulation FastendqBc}n Ing Material: L 1 _ j3 [A Base Sheet(s) & No. of PIy(s): Base Sheet Fastener/Bonding M %J Ply Sheet(s) & No. of Ply(s)Ag aL N 1 gs Pi Sheet Fastener/Bonding Material: t Top Ply: tU In 'to my Gast �-: t inOtatertat: ..L Ell Fastener Spacing for Anchor/Base Sheet Attachment: Field. " oc 0 Lap, # Rows Perimeter: ° oc 0 Lap, # Rows a " oc Corner. b" oc @ Lap, # Rows4-a oc Number of Fasteners Per Insullatti�on� Board: Fieldf Perimeter Comer �. Illustrate Components Noted and Details as Applicable: Woodbiocking, Gutter, Edge Termination, Stripping, Flashing, Continuous Cleat, Cant Strip, Base Flashing, Counter- Flashing, Coping, Etc. Indicate: Mean Roof Height, Parapet Height, Height of Base Flashing, Component Material, Material Thickness, Fastener_Typtf, Fa tener Spacing or Submit Manpfactur- ers Details that mply with RAS 111 and Chapter 16 T (� *3 ) _Parapet h Height PL34 LLVOLQS'�, Mean Roof Height 15.35 2010 FLORIDA BUILDING CODE •— BUILDING : TCFU.R1306 - Roofing Systems Page 2 of 53 The use of polystyrene Insulation board between minimum ala -in. thick perlite board and deck with rosin paper (perlite/rosin paper/pQlystyrene/perlite) Is a suitable alternate for polyisocyanurate board in the following Class A, B or C systems. "EnergyGuardT" RA" or "Tapered EnergyGuardT" RA" or "EnergyGuardym Composite RA" may be substituted for any Atlas Roofing Corp. polyisocyanurate Insulation in any of the following Classifications. Trumbull "Perma Mop° may be utilized with any of the following °Asphalt Felt Systems with Hot Roofing Asphalt°. °GAFGLAS@ #80 Premium Base Sheet" may be used In any of the following systems. "GAFGLAS® Flex Ply 6" and 'Tri -Ply® Ultra -Flexible Ply 6" are suitable alternates to "GAFGLASO Ply 6". "GAFTEMP Permalite Recover Board" may be used in lieu of any perlite insulation in any of the following NC Classifications. Unless otherwise indicated, any of the "Asphalt Felt Systems with Hot Roofing Asphalt" may be surfaced with "Fireshfeid MBO at 2Th to 3-gal/100-fe. "Ruberoid® Dual Smooth" may be used as an alternate to "Ruberoid® Mop Smooth" or "Ruberoid® 20" or "Ruberoid® 20 FIT" "Ruberoid® Mop Smooth 1.5" may be used as an alternate to "Ruberofd® Mop Smooth" Gass A, B and C Hot roofing asphalt, for use with organic and glass felts or modified bitumen membranes. "Ruberoid® Heat Weld" SBS roofing membrane may be used in lieu of "Ruberoid® Mop" SBS products in any applicable Classification. Class A 1. Deck: C-15/32 Incline: 3 Insulation (Optional): — One or more layers perlite or wood fiber or glass fiber or polyisocyanurate or urethane or periite/polyisocyanurate composite or periite/urethane composite or wood fiber/polyisocyanurate composite or phenolic, any thickness. Ply Sheet: — Three or more plies Type G1 or "GAFGLAS@ Ply 4" or "Tri -Ply® Ply 4" or "GAFGLASO Ply 6" hot mopped. Surfacing: — Gravel. 2. Deck: C-15/32 Incline: 2 Insulation (Optional): — One or more layers perlite or wood fiber or glass fiber or polylsocyanurate or urethane or perlite/polyisocyanurate composite or periite/urethane composite or wood fiber/polylsocyanurate composite or phenolic, any thickness. Ply Sheet: — Three or more plies Type Gl or "GAFGLASO Ply 4" or "Tri -Ply® Ply 4" or %AFGLAS® Ply 60. Cap Sheet: — One ply Type G3 "GAFGLASO Mineral Surfaced Cap Sheet° or "Tri -Ply® Mineral Surfaced Cap Sheet " or "GAFGLASO EnergyCapm BUR Mineral Surfaced Cap Sheet." 3. Deck: NC Indine: 2 Insulation (Optional): — One or more layers perlite, wood fiber, glass fiber, polyisocyanurate, urethane, periite/polylsocyanurate composite, perlite/urethane composite, woad fiber/poly[sManurate composite, phenolic, 2 -in. maximum. Ply Sheet: — Two or more plies Type GI "GAFGLASO Ply 4", 'Tri -Ply® Ply 4" or "GAFGLAS® Ply 6". Cap Sheet: — One ply Type G3 "GAFGLASO Mineral Surfaced Cap Sheet" or "Tri -Ply® Mineral Surfaced Cap Sheet" or "GAFGLASO EnergyCap," BUR Mineral Surfaced Cap Sheet." 4. Deck: C-15/32 Indine: 1 Slip Sheet (Optional): — Red rosin paper, nailed to deck. Insulation (optional): — Any thickness perlite or wood fiber or glass fiber or polyisocyanurate mechanically fastened or adhered with OMG Inc. "OlyBond Fastening System" or any UL Classified Insulation adhesive. Base Sheet: — One ply Type G2 "GAFGLASO #75 Base Sheet° or "Tri -Ply® #75 Base Sheet" (may be nailed). Ply Sheet: — One or more plies Type GI "GAFGLASO Ply 4" or'"fri-Ply® Ply 4" or GAFGLAS® Ply 6". Cap Sheet: — One ply Type G3 "GAFGLAS@ Mineral Surfaced Cap Sheet° or "Tri -Ply® Mineral Surfaced Cap Sheet" or "GAFGLASO EnergyCap'"" BUR Mineral Surfaced Cap Sheet." Surfacing (optional): — 'TOPCOAT® EnergyCoteT"" applied at a rate of 2-gal/100-fe. S. Deck: NC Indine: 3 Base Sheet: — One ply Type G2 "GAFGLAS® #75 Base Sheet° or "Tri -Ply® #75 Base Sheet". Ply Sheet: — One or more plies Type G1 "GAFGLASO Ply 4" or "Tri -Ply® Ply 4" or "GAFGLASO Ply 6". Cap Sheet: — One ply Type G3 "GAFGLASO Mineral Surfaced Cap Sheet" or "Tri -Ply® Mineral Surfaced Cap Sheet" or "GAFGLAS® EnergyCapTm BUR Mineral Surfaced Cap Sheet." 6. Deck: C-15/32 Indine: 2 Insulation: — One or more layers periite, glass fiber, polyfsocyanurate, urethane, perlite/polyisocyanurate composite, perlite/urethane composite, phenolic, 1 in. minimum (offset a minimum of 6 -In. from plywood deck joints). Base Sheet: — One or more plies Type GI or Type G2 or Type G3. http://database.ul.com/cgi-bin/XYV/template/LISEXT/1FRAME/Showpage.html% me -T... 6/27/2013 MIAMI DADE COUNTY, FLORIDA MEMO -RADE FIAGLER BUILDING BUILDING CODE COMPLIANCE OFFICE (BCCO) 140 WEST FLAGLER S'T'REET, SUITE I603 PRODUCT COP1 ML DIVISION MIAMI, FLORIDA 331WIS63 (303) 373-2901 FAX (303) 375-2908 NOTICE OF ACCEPTANCE (NOA) GAF Material Corporation 1361 Alp Road Wayne, NJ 07470 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 the BCCO and accepted by the Building Code and Product Review Committee to be used in Miami Dade County and other areas where allowed by the Authority Having Jurisdiction (AHJ). a 1 This NOA shall not be valid after the expiration date stated below. The Miami -Dade County'Pmduct Control Division (In Miami Dade County) and/or the AM (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 AIIJ•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 FloridatBuilding Code and the 1 ligh Velocity Hurricane Zone of the Florida Building Code. (DESCRIPTION: GAF Conventional Built Up Roof System for Wood Becks. ' LABELING: Cach 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. RF24EWAL of this NOA shall be considered after a renewal application has been filed and there has been no change in the applicable building code negatively affecting the performance of this product. TERMINATION of this NOA will occur after the expiration date or if there has been a revision or change in the materials, use, and/or manufacture of the product or process. Misuse of this NOA as an endorsement of any product, for sales, advertising or any other purposes shall automatically terminate this NOA. Failure to comply with any section of this NOA shall be cause for termination and removal of NOA. ADVEWISEMENT: The NOA number preceded by the words Miami -Dade County, Florida, and followed by the expiration date may be displayed in advertising literature. If any portion of the NOA is displayed, then it shall be done in its entirety. INSPECTION: A copy of this entire NOA shall be provided to the user by the manufacturer or its distributors and shall be available for inspection at the job site at the request of the Building Official. This NOA renews and revises NOA No. 03-0501.05 and consists ofpages I thro 19. 'rho submitted documentation was reviewed by Jorge L. Acebo. NOA No.: 07-1219.09 Sapiration Date: 11/04/13 Approval Date: 03/20/08 Page 1 of 19 wide base sheet. NOA No.: 07-1219.09 Expiration Date: 11/04113 Approval Date: 034M Page 2 of 19 ROOFING SYSTEM ,APPROVAL Cateeorv: Roofing Sub-CaftgM BUR Dock Tyne: Wood Maximum Deslan -75 psf TRADE NAMES OF PRODUCTS MANUFACTIIRED OR LABELED BY APPLICANT: TABLE 1 Test Pralaet Produe Dimenadons S on Deweotioa Leak BusterTU MatrixTM 3, 5, 55 gallons ASTM D 41 Asphalt concrete primer used to promote 307 Premium Asphalt adhesion of asphalt in built-up roofing. Primer a GAF Mineral ShieldTAe 60 & 100 lb. bags ASTM D 1863 Granules for surfacing of exposed asphalt, Granules cold process cement or emulsion. GAF Mineral ShicldTm Granules shall be used for flashing applications only. Leak BusterTm MatrixTm 5 gallons ASTM 1227 Surface coating for smooth surfaced roofs.- oofs.305 305Fibered, Asphalt Emulsion Leak Busteirm MatrixTm 1, 5 gallons ASTM D 2824 Fibered aluminum coating. 303 Premium Fibered Aluminum Roof Coating LcakBustcrTM MatrixTNe 55 gallons Elastomeric roof coating. 322 Elastomeric Roof Coating LeakBusterTM MatrixTM 55 gallons Asphalt emulsion fibered. Select Asphalt Emulsion Fibered 306 Leak BusterTM MatrixTM 1, 5 gallons ASTM D-4586 Refined asphalt blended with a mineral 204 Wet/Dry Roof ASTM D-3409 stabilizer and fibers. Permits adhesion to Cement wet and dry surfaces. RUBEROID0 Modified 5 gallons ASTM D 4586 Fiber reinforced, polymer modified Flashing Bitumen Flashing cement Cement LeakBusterTM MatrixTm 5 gallons ASTM D 4586 Asphalt flashing Cement 201 Premium SBS Flashing Cement GAFGLAS® 975 39.37" (1 meter) ASTM D 4601 Asphalt impregnated and coated glass mat wide base sheet. NOA No.: 07-1219.09 Expiration Date: 11/04113 Approval Date: 034M Page 2 of 19 GAFGLAS' STRATAVEN'IO EliminatorTM Perforated GAFGLAS® Flashing GAFGLAS" STRATAVENT* EliminatorTm Nailable RUBEROe SBS Heat WeldTm Smooth RUBEROIDo SBS Heat-WeldTM Granule RUBEROIDo SBS Hcat-Weld'rm 170 FR RUBEROO SBS Heat WeldTM PLUS RUBEROIIP SBS Hcat-WeldTm PLUS FR RUBEROIe SBS Heat-WeldTm 25 3937" (1 motor)` ASTM D 4897 wide D 3672 Various 39.37" (1 meter) ASTM D 4897 wide D 3672 I meter (39.37") ASTM D-6164 wide 1 motor (39.37") ASTM D-6164 wide I meter (39.37") ASTM D-6164 wide 1 meter (3937") ASTM D-6164 wide I meter (39.37") ASTM D-6164 wide I meter (3937") ASTM D-6164 wide RUBEROID® Modified 39.37" (I moter) ASTM D4601, Base Sheet wide Type I1, UL Type 02 BUR • � � f iii i AF?KOV-D Fiberglass base sheet impregnated and coated on both sides with asphalt. Surfaced on the bottom side with mineral granules embedded in asphaltic coating with factory perforations. Asphalt coated glass fiber mat flashing sheet available in three sizes. Fiberglass base sheet impregnatedand coated on both sides with asphalt. Surfaced on the bottom side with mineral granules embedded in asphaltic coating. Non -Woven Polyester mat coated.with polymer -modified asphalt and smooth surfaced. Non -Woven Polyester mat coated with polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with polymer -modified asphalt and smooth° surfaced. Premium glass fiber reinforced SBS modified base sheet ACOA No.: 07-1219.09 Expiration Date: 11/04/13 Approval Date: 03MM Page 3 of 19 Test Product Product Dimen�igxis SaciCecafiton Description GAFGLAS® #80 39.37" (1 motor) ASTM D4601 Asphalt impregnated and coated, fiberglass ULTiMATM Base Sheet wide base sheet GAFGLAS® 39.37" (1 meter) ASTM D 2178 Type VI asphalt impregnated glass felt with Flex PlyTm 6 wide asphalt coating. GAFGLAS* Ply 4 3937" (1 motor) ASTM D 2178 Type IV asphalt impregnated, glass felt with wide ' asphalt coating. GAFGLAe Mineral 39.37" (1 meter) ASTM D 3909 Asphalt coated, glass fiber mat cap sheet Surfaced Cap Sheet wide surfaced with mineral granules. GAFGLAS'5 39.37" (i moter) ASTM D 3909 Asphalt coated, glass filer mat cap sheet EnergyCapTK Mineral wide surfaces with mineral granules with factory Surfaced Cap Sheet applied layer of TOPCOAT® EnergyCoteTu. GAFGLAS' STRATAVEN'IO EliminatorTM Perforated GAFGLAS® Flashing GAFGLAS" STRATAVENT* EliminatorTm Nailable RUBEROe SBS Heat WeldTm Smooth RUBEROIDo SBS Heat-WeldTM Granule RUBEROIDo SBS Hcat-Weld'rm 170 FR RUBEROO SBS Heat WeldTM PLUS RUBEROIIP SBS Hcat-WeldTm PLUS FR RUBEROIe SBS Heat-WeldTm 25 3937" (1 motor)` ASTM D 4897 wide D 3672 Various 39.37" (1 meter) ASTM D 4897 wide D 3672 I meter (39.37") ASTM D-6164 wide 1 motor (39.37") ASTM D-6164 wide I meter (39.37") ASTM D-6164 wide 1 meter (3937") ASTM D-6164 wide I meter (39.37") ASTM D-6164 wide I meter (3937") ASTM D-6164 wide RUBEROID® Modified 39.37" (I moter) ASTM D4601, Base Sheet wide Type I1, UL Type 02 BUR • � � f iii i AF?KOV-D Fiberglass base sheet impregnated and coated on both sides with asphalt. Surfaced on the bottom side with mineral granules embedded in asphaltic coating with factory perforations. Asphalt coated glass fiber mat flashing sheet available in three sizes. Fiberglass base sheet impregnatedand coated on both sides with asphalt. Surfaced on the bottom side with mineral granules embedded in asphaltic coating. Non -Woven Polyester mat coated.with polymer -modified asphalt and smooth surfaced. Non -Woven Polyester mat coated with polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Non -Woven Polyester mat coated with polymer -modified asphalt and smooth° surfaced. Premium glass fiber reinforced SBS modified base sheet ACOA No.: 07-1219.09 Expiration Date: 11/04/13 Approval Date: 03MM Page 3 of 19 RUBEROV 20 RUBEROID® Mop Granule Test Product Dimm"Low, Stye MS , n rintiog 3937" (1 meter) ASTM D 6163 SBS modified asphalt base`sheet and wide; ASTM D 5147 interply sheet reinforce with a glass fiber 39.37" (1 meter) ASTM D 6222 wide ' ASTM D 5147 RUBEROID® Mop Plus 39.37" (l meter) ASTM D 6222 (Granule) wide ASTM D 5147 RUBEROIi.P MOP = 39.37" (1 meter) ASTM D 6164 Smooth wide ASTM D 5147 RUBEROIEP MOP 3937" (1 meter) ASTM D 6164 170FR wide ASTM D 5147 RUBEROIDP MOP FR 39.37" (1 meter) ASTM D 6164 wide ASTM D 5147 RUBEROIDP TORCH 39.37' (1 meter) ASTM D 5147 Smooth wide RUBEROlV* TORCH 39.37" (1 meter) ASTM D 5147 Granule wide RUBEROID®TORCI I 39.37" (I mcter) . ASTM D 6222 PLUS (Granule) wide ASTM D 5147 RUBEROID* TORCH 39.37' (1 meter) ASTM D 6222 FR wide ASTM D 5147 RUBEROIDP 170FR 39.37' (1 meter) ASTM D 6222 TORCH Wide ASTM D 5147 RUBEROIDP 30 39.37" (1 meter) ASTM D 6163 wide ASTM D 5147 RUBEROID® 30 FR 39.37' (1 meter) ASTM D 6163 wide ASTM D 5147 RUBEROIDP 3937" (1 meter) ASTM D 6298 ULTRACLAD® wide ASTM D 5147 RUBEROIDP Dual FR 3937" (1 meter) ASTM D 6164 Wide ASTM D 5147 Vent Stacks (metal and TAS 100(A) plastic) ASTM D 1929 ASTM D 635 mat. Non -woven polyester mat coated with polymer modified asphalt and surfaced with Mineral granules. Non -woven polyester mat coated with polymer modified asphalt and surfaced with mineral granules. Non -woven polyester mat coated with polymer -modified asphalt and smooth surfaced. Non -Woven polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Non -Woven polyester mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Ileavy duty, polyester reinforced, asphalt modified bitumen membrane, smooth surface. Asphalt impregnated, coated felt, surfaced with mineral granule. I ieavy duty, polyester reinforced, asphalt modified bitumen membrane, granule surface. Heavy duty, polyester reinforced, coated with fire retardant asphalt modified bitumen membrane, granule surface. Heavy duty, polyester reinforced, coated with fire retardant asphalt modified bitumen membrane, granule surface. Non -woven fiberglass mat coated with polymer modified asphalt and surfaced with mineral granules. Non -woven fiberglass mat coated with fire retardant polymer modified asphalt and surfaced with mineral granules. Woven fiberglass mat coated with Polymer modified asphalt and surfaced .with aluminum, copper or stainless steel foil. Non -woven polyester and fiberglass mat coated with file retardant, polymer modified asphalt and surfaced with mineral granules. One way valve vent used to relieve built-up pressure within the roof system. GAF Vent Stacks are available in metal or, plastic. NOA No: 07-1219.09 Expiration Date: II/M3 Approval Date: 03170108 Page 4 of 19 I Expiration Date: 11/04/13 Approval Date: !Kf/MS Page 5 of 19 Test Prodaet P SnWACKtioa 1 tgtiaa Leak BusterT'w MatrixTm 5 gallons ASTM D2824, Non-fibered aluminum pigmented, asphalt 302 Non Fibered Type I roof coating. Aluminum Roof Coating OAF Built -Up Roofing 100 lb. cartons, ASTM D312, Interply mopping and surfacing asphalt." Asphalt bulk .Types I,.I III _ and rV RUBEROID® MOD 60 lb. kegs SEBS modified asphalt. Asphalt, Asphalt L & Asphalt P Leak BusterTm MatrixTm 5 gallons Surface coating for smooth surfaced and 602 mineral surfaced roofs. Leak BusterTm MatrmTm . 5 gallons Surface coating. for smooth surfaced and 715 mineral surfaced roofs. LeakBusteim Matrix""' 2 gallons Surface coating for smooth surfaced and 531 WeathecCoteTm mineral surfaced roofs. SeamCote'" • 2, 5 gallons proprietary Elastomeric roofing membrane. FireOutTm 5, 55 gallons tow VOC, fire barrier coating. VersaShield" 350 sq ft. roll Non -Asphaltic Fiberglass -Based Underlayment. VersaShied®FB-IS 350 aq R roll Non -Asphaltic Fiberglass -Based Underlayment. VersaShiele FII ZS 350 sq A roll Non -Asphaltic Fiberglass -Based Underlayment. TOPCOAT* FircShiele 5, 55 gallons ASTM D412 Elastomeric roofing membrane MB ASTM D-21-96 ASTM D1475 ASTM E-1644 Leak BusterTm MatrixTm 5 gallons ASTM D3019 Cold Applied Modified SEBS Asphalt 201 SBS Flashing Adhesive — Flashing Grade. Cement Leak BusterTm Matrix"'" 5 gallons ASTM D3019 Cold Applied Modified SEBS Asphalt 102 SBS Adhesive Adhesive. Leak Buster's MatrixTu 5 gallons ASTM D4586 Cold Applied Modified SEBS Asphalt 202 SBS Flashing Adhesive — Flashing Grade. Cement Leak Bustefrm MatrixTm 5 gallons ASTM D4586 Standard Plastic Asphalt Roofing Cement 203 Plastic Roof Cemenf Leak BusterTm MatrixTM 5 gallons ASTM D3019 Cold Applied Asphalt Adhesive. 103 Cold Process Adhesive NOA No.: 07-1219.09 Expiration Date: 11/04/13 Approval Date: !Kf/MS Page 5 of 19 Test Product Product Rijgnsloos Specification Dese rlution Leak BusterTm MatrixTM S gallons ASTM D 2824 FflwW aluminum coating. 303 Fibered Aluminum Roof Coating Leak BusterTm MatrixTM 5 gallons ASTM D2824, Non-fibered aluminum pigmented, asphalt 304 Non Fbbered Type I roof coating. Aluminum Roof Coating APPROVED INSULATIONS: Table 2 Product Name Product Description. Manufacturer (With Current NOA) EnergyGuardTM RA, RN Polyisocyanurate foam insulation BMCA " Composite A & N Polyis ocyanumte foam insulation with GAF Materials Corp. high density fiberboard or Permalite porlitc insulation. EnergyGuardTM Fiberboard Fiberboard insulation. GAF Materials Corp. EncrgyGuardTM Permalite Perlite insulation board. GAF Materials Corp. EnergyGuardTM GAFCANTTM Cut perlitc board GAF Materials Corp. F.nergyGuardTm Permalite Recover Pcrlitc recover board GAF Materials Corp. Board EncrgyGuardTM Tapered Edge Strip Tapered perlite board GAF Materials Corp. EnergyGuardTM Perlite Perlite insulation board GAF Materials Corp. rnergyGuardTM High Density High density wood fiberboard insulation. GAF Materials Corp. Fiberboard EnergyGuardTM Composite Polyisocyanumtc/wood fiberboard BMCA EnergyGuardTM Composite RA Wood Fiber High Density Wood Fiberboard Perlitc Insulation Dens Deck*, Dens Deck® Prime, Dens Deck® Dura GuardTM Structodek SecurockTM composite Polyisocyanurate/wood fiberboard composite Wood fiber insulation board Wood fiber insulation board Perlite insulation board Water resistant gypsum board Wood fiber insulation board Fiber reinforced roof board BMCA generic generic generic G -P Gypsum Corp Knight Celotex USO Corporation MOA No.: 07-1219.09 Expiration Date: 11f/13 Approval Date: 03/20/08 Page 6 of 19 Deck Type 1: Wood, Non -insulated Deck Description: "/n" or greater plywood or wood plank decks System Type F; Base sheet mechanically fastened. All General and System Umft dons shall apply. Fite Barrier: FkeOutTM Fire Barrier Coating, Vers aftieleNon-Asphaltic Fiberglass -Based (optional) Underlayment or SecurockTM. Base sheet: GAFGLAS® #80 ULTIMATM Base Sheet, STRATAVENT40 EliminatorTM Nailable, RUBEROiD® Modified Base Sheet, RUBEROID® 20, RUBEROV Heat Weld•n" Smooth or RUBEROWO Heat WeldTm 25 base sheet mechanically fsistened to deck as described below, Fastening Opdons: GAFGLAS® Ply 4, GAFGLAS® Flex PlYm 6, GAFGLAS® #75 Base Sheet or any of above Base sheeis attached to deck with approved annular ring shank nails and tin caps at a fastener spacing of 9" o.c. at the lap staggered and in two rows 12" o.c. in the field. (Maximum Design Pressure -45 psf See General Limitation #7) GAFGLASO Ply 4, GAFGLAS® Flex PlYm 6, GAFGLAe #75 Base Sheet or any of above Base sheets attached to deck with Drill -Tec''" #12 standard, # 14 or.# 15 Screws and 3" Drill-TecTm steel plate or Brill-Ted'i"'I AccuTrac Plates, 12" o.c. in 3 rows. One row is in the 2" side lap. The other rows are equally spaced approximately 12" o.c. in the field of the sheet4 (Maximum Design Pressure -45 psf, See General Limitation #7) GAFGLASe Flex PIyT"' 6, GAFGLAO #75 BaseSheet or any off above Base sheets attached to deck with approved annular ring shank nails and tin caps at a fastener spacing of 9" o.c. at the 4" lap staggered and in two rows 9" o.c. in the field. (Maximum Design Pressure 325 psf, See General Limitation #7) GAFGLASe#80ULT1MATm, RUBEROID®20, RUBEROe Mop Smooth, base sheet attached to deck with approved 1'/." annular ring shank nails and inverted 3" steel plate at a fastener spacing of 9" o.c. at the 4" lap and in two rows staggered with a fastener spacing of 9" o.c. in the center of the membrane. (Maximum Design Pressure -60 psf, See General Limitation #7) GAFGLAS® 975 Base Sheet or any of above Base sheets attached to deck with Drill`Tedm #12 standard, #14 or # 15 Screws and 3" Drill -Tec m steel plate or Drill-Tedm AccuTrac Plates, 12" o.c. in 4 rows. One row is in the 2" side lap. The other rows are equally spaced approximately 9" o.c. in the field of the sheet. (Maximum Design Pressure -60 psf, See General Limitation #7) Any of above Base sheets attached to deck approved annular ring shank nails and:3" inverted Drill-TecTm insulation plates at a fastener spacing of 9" o.c. at the 4" lap staggered in two rows 9" in the field. (Maximum Design Pressure --60 psf, See General Limitation #7) NOA No.: 07-1219.09 Expiration Date: 11/04/13 Approval Date 0=0/08 .-Page 17 of 19 APPROVED FASTENERS. TABLE 3 Fastener Product Product 07.02.97 Manufacturer Number Name Description Dimension (With Current NOA) 1. Drill-Tec?u #12 Standard, Insulation fastener and Various GAF Materials Corp. 07.29.94 #14 and #IS extra Heavy Base Play fastener for 4470 - TAS 114 04.01.98 Duty Fastener , Heavy steel, wood & concrete 05.11.07 PRI Asphalt Technologies, Inc. GAF -012-02-02 Duty Roofin&Fastener decks. GAF -020-02-01 2. Drill-TecTm ASAP Pre -assembled Drill- Various GAF Materials Corp. 01.18.02 TecT" Fasteners and TAS 114 03.22.02 metal and plastic plates. 3. Drill-TecTM #12 or #14 Base sheet fastening Various GAF Materials Corp. Standard screws with assembly. AccuTrac Plate 4. Drill-ToeTw Galvalume Round Galvalume stress 3" and 3 W GAF Materials Corp. Plates plates. 5. Drill-TecTu Round polypropylene 3" and 3 W GAF Materials Corp. Polypropylene Plates . stress plates. 6. Drill-TecTu AccuTrac Square Galvalume's 3" Square GAF Materials Corp. Plate coated steel plate. I EVIDENCE SUBMITTED: LOIS Aaencv Test Identifier Description Date Factory Mutual Rcscamh Corp. J.I.2B8A4.AM 4470 07.02.97 J.1.3B9QI AM 4470 01.08.98 J.I.ODOA8.AM 4470 07.09.99 J.1.OD iAS.AM 4470 - TAS 114 07.29.94 J.I.OY9Q5.AM 4470 - TAS 114 04.01.98 3029832 4470 - TAS 114 05.11.07 PRI Asphalt Technologies, Inc. GAF -012-02-02 Physical Properties 11.06.01 GAF -020-02-01 ASTM D 4977 02.01.02 IkT of S. Fl. 02-005 TAS 114 01.18.02 02-014 TAS 114 03.22.02 NOA No.: 07-121909 ,Expiration Dater 11/04113 Approval Date: 83/20108 Page 7 of 19 GAFGLAS® #75 Base Sheet or any of above Base sheets attached to deck with Drill -Ted"" #12 standard, #14 or # 15 Screws and 3" Drill-Tedrm steel plate or Drill TeeTM AccuTrac Plates, 8" o c. in 4 rows. One row is in the r side lap. The other rows are equally spaced approximately 9" oe. in the field of the sliest. (M=Imm Design Pressure-7SPV; See General MmiWkn #7) Ply Shy: One or more plies of GAFGLAS * PLY 4, #80 ULTIMA, RUBEROID® MOP Smooth or RUBEROW 20 adhered in a full mopping of approved asphalt applied within the EVT range and at a rate of 20401bsJsq. Cap Sheet: (Optional) One ply -of GAFGLAS* h ineral Surfaced Cap Sheet or GAFGLAS® EnergyCapTm Mineral Surfaced Cap Sheet adhered in a toll mopping of approved` asphalt applied within the EVT range and at a rate of 20-40 lbsJsq. Surfacing: (Optional, required if RUBEROW MOP Smooth. or RUBEROW 20 is top membrane) Install one of the following. 1. Gravel or slag applied at 400 lbsJsq. and 300 lbsJsq. respectively in a flood coat of approved asphalt at 60 lbsJsq. or applied in a flood coat of Leak BusterTM MatrixTm 103 Cold Process Adhesive applied at a rate of 3 galJsq. 2. GAFGLAS* Mineral Surfaced Cap Sheet, GAFGLAS® Energy Cap Mineral Surfaced Capsheet adhered in a full mopping of approved asphalt applied within the EVT range and at a rate of 20-40 lbsJsq.. 3. Leak BustcrTM MatrixTm 303 Premium Fibered:Aluminum Roof Coating, at 1.1 galJsq. 4. Leask Busteirm MatrixTu 715, Leak BusterTm Matriem 322, TOPCOAT® MB+, TOPCOAT* Fireshield Elastomeric Roofing Membrane, applied at 1 to 1.5 galJsq. 5. Leak BusterT14 MatrixTa 602 MB Xtra Elastomeric Roofing . Membrane, EnergyCoteO roof coating applied at I to 1.5 galJsq. 6. TOPCOAT* Surface Seal, TOPCOAT* Fireshieldo SB Solvent based Elastomeric Roofing Membrane applied at Ito 1.5 galJsq 7. Advance Green Technologies Photovoltaic Laminate solar energy collector auxiliary roof equipment installed in compliance with manufacturer's specifications and applicable Building Codes. Maximum Design Pressure: See Fastening Above NOA Na: 07.1219.09 Expiration Date: 1IJ04t13 Approval Dates 03aOM Page 18 of 19 WOOD DEcx SYSTEM LIMITATIONS: I A slip sheet is required with Ply 4 and Flex PlyTm 6 when used as a mechanically fastened base or anchor t sheet... 2. Minimum 'K' Dens Deck m or Ma" Type X gypsum board is acceptable to be installed directly over the wood deck. GENERAL LIMITATIONS: r 1. Fire classification is not part of this acceptance, refer to a current Approved Roofing Materials Directory for fire ratings of this product. 2. Insulation may be installed in multiple layers. The first layer shall be attached in compliance with Product Control Approval guidelines. All other layers shall be adhered in a full mopping of approved asphalt applied within the EVT range and at a rate of 20-40 lbsJsq., or mechanically attached using the fastening pattern of the top layer 3. All standard panel sizes are acceptable for mechanical attachment. When applied in approved asphalt, panel size shall be 4' x 4' maximum. 4. An overlay and/or recovery board insulation panel is required on all applications over closed cell foam insulations when the base sheet is fully mopped. If no recovery board is used the base sheet shall be applied using spot mopping with approved asphalt, 12" diameter circles, 24" o.c.; or strip mopped 8" ribbons in three rows, one at each sidelap and one down the center of the sheet allowing a continuous area of ventilation. Encircling of the strips is not acceptable. A 6" break shall be placed every 12' in each ribbon to allow cross ventilation. Asphalt application of either system shall be at a minimum rate of '121bsJsq. - Note: I Spot attached systems shall be limited to a maximum design pressure of -45 psL 5. Fastener spacing 6r! insulation attachment is based on a Minimum Characteristic Force (F) value of 275 ibf., as tested in compliants~ with'festing Application Standard TAS 105. If le fastener value, as field- tested, are below 2751bf. insulation attachment shall not be acceptable. 6. Fastener spacing for mechanical attachment of anchor/base, sheet or membrane attachment is paccd on a minimum; fastener resistance value in conjunction with the maximum design value listed within a specific system. Should the fastener resistance be less than that required, as determined by the Building Official, a revised fastener spacing, prepared, signed and sealed by a Florida Registered Engineer, Architect, or Registered Roof Consultant may be submitted. Said revised fastener spacing shall utilize the withdrawal resistance value taken from Testing Application Standards TAS 105 and calculations in compliance with Roofing Application Standard RAS 117. 7. Perimeter and corner area shall comply with the enhanced uplift pressure requirements of these areas. Fastener densities shall be increased for both insulation and base sheet as calculated in compliance with Roofing Application Standard RAS 117. Calculations prepared, signed and sealed by a Florida registered Professional Engineer, Registered Architect, or Registered Roof Consultant (When this limitation is specifically referred within this NOA, General Limitation #9 will not be applicable.) 8. All attachment and sizing of perimeter nailers, metal profile, and/or flashing termination designs shall conform with Roofing Application Standard RAS 111 and applicable wind load requirements. 9. The maximum designed pressure limitation listed shall be applicable to all roof pressure zones (i.e. field, perimeters, and corners}. Neither rational analysis, nor extrapolation shall be permitted for enhanced fastening at enhanced pressure zones (i.e. perimeters, extended corners and corners). (When this limitation is specifically referred within this 140A, General Limitation #7 wig not be applicable.) 10.. All products listed herein shall have a quality assurance audit in accordance with the Florida Building Code and Rule 9B-72 of the Florida Administrative Code. END OF THIS ACCEPTANCE NOA No.: 07-1219.09 Expiration Date: 11/04/13 Approval Date: -03/20= Page �19 of 19 Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNERS'S AFFIDAVIT OF EXEMPTION ROOF TO WALL CONNECTION HURRICANE MITIGATION RETROFIT FOR EXISTING SITE - BUILT SINGLE FAMILY RESIDENTIAL STRUCTURES PERSUANT TO SECTION 553.844 F.S. To: Miami Shores Village Building Department Date: 10050 NE 2nd Ave Miami Shores, FI 33138 Re: Owner's Name:7i(S r� 0 /Z -+!! h4 A �C! e_ L L° Property Address: 10 O PL - 4c -,(- Roofing Permit Number. Dear Building Official: certify that I am not required to retrofit the roof to wall connections of my 7Th ing because: e just valuation for the structure for purpose of ad valorem taxation is less than $300,000.00. Please attach proof of ad valorem taxation. o The building was constructed in compliance with the provisions of the Florida Building Code (FBC) or with the provisions of 1994 edition of the South Florida Building Code (1994 SFBC) Signature State of Florida County of Dade 7beod=Chr6WkmPMw Print Name The undersigned, being the first duly swom, deposes and says that he/she is the owner for the above property mentioned. Swom to and subscribed before me this �` day ofyU( J MWAvam Notary Public, Sate of Florida at Larg MVCOItmm" 4 EE WO Si t mbar W tai v U and the T I • When the just valuation of the structure for purpose of ad valorem taxation is equal to or more than building was notconstructed with FBC nor a 1994 SFBC. Then you must provide a building application from a General Contractor for the Roof to Wall connection Hurricane Mitigation. Revised on 5/21/2009 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: BUILDING SEP 0 0 2013 FBC 20 Permit No. Master Permit No O ROOFING JOB ADDRESS: 10&4-t /l% `0 106Q'w--_. City: Miami Shores County: Miami Dade Zip:1 Folio/Parcel#: //— Is the Building Historically Designated: Yes NO '� Flood Zone: OWNER: Name (Fee Simple Titleholder): s %t/[ p'2;T�n P �- !i�►^,nd — Phone#. Address: 00-00 S AAlV-d S -.5f1 o City: ru t.Arv. ►' State: Q" 1. Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: P,4 -,,,e Phone#: eat 143T - Address -- City: " i r State: (. Zip: Qualifier Name: 0/A' &7,Y% 1 P Phonei-®. T State Certification or Registration #: W-- 1 1 Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ i J U U ' 170 Square/Linear Footage of Work: Type of Work: ❑Addition n ❑Alteration ❑New A2epair/Replace Description of Work: Submittal Fee Scanning Fee $ Color thru tile: Permit Fee $ CCF Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CO/CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ ❑Demolition Bonding Company's Name (if applicable) Bonding,Company's Address city State Mortgage Lender's Name (if applicable) Mortgage Lender's Address city State zip Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for 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 properly is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. GLJSignature 11�Signature Owner or Agent ILL blwWp Fk=m IL LLC Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of J , 20 a, by lt'IYr�X� . i `y1S �S day of � , 20 l%, by 0 who 's personall known me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) CERTIFICATE OF LIABILITY INSURANCE Date 9/20/2013 Producer: Lion Insurance Company TNs certificate Is Issued as a matter of Information only and confers no rights 2739 U.S. Highway 19 N. Holiday, FL 34691 upon the certificate Holder. This certificate does not amend, extend or alter the `overage afforded by the policies below. 1 Insurers Affording Coverage MAIC # (727) 938-5562 Insured: South East Personnel Leasing, Inc. & Subsidiaries insurer A: Uon Insurance Company 11075 Insurers: 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer C: Insurer D: Insurer E: Coverages The policies of Insurance Rated have bow aboveforftpoUcyperlodindicated.obn nganr tarrnor on anry dor ooanerd reaped this certificate may be issued or may pertain, fire Insurance afforded byte policies described herein is subject to all the terms, wr4 siors, and coMitors of such policies. Aggregate Omits shown may have been reduced by paid claims. RNSR LTR ADDL NSRD Type of Insurance Policy Number Policy Effective Date Policy Expiration Date Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each0ararence 6 Commercial General Liability Claims Made 11 Occur Damage to rented premises (EA > $ Med EV Personal adv Injury eneral aggregate limit applies per General Aggregats Policy ❑ Project ❑ LOC Products- Comp/Op A99 UTOMOBILE LIABILITY Combined Single Limit Ary Auto AO Ownad Autos Scheduled Autos (EA Acddent) Bodily (Per Person) Bodily adurY Hired WDS Non Dmvd Autos (PerAccident) Property Damage (P-AcddeM EXCESS/UMBRELLA LIABILITY EachOccurrence ❑ Claims Made Aggregate ROccur Deductible A Workers Compensation and WC 71949 01/01/2013 01/01/2014 X I WC Statue- OTH- Empioyers' Liability tory Limits ER E.L. Each Accident 51000,000 Any proprietor/partner/executive officer/member E.L. Disease - Ea Employee 51,000,000 excluded? NO If Yes, describe under special provisions below. E.L. Disease -Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations/LLocations/Vehickrs/Exclusions added by Endorsement/Special Provisions: Client ID: 84-80-003 Coverage only applies In active employee(s) of South East Employee Leasing Services, Inc. that are leased to the following "Client Company": Extreme Roofing, Inc. Coverage only applies ID injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s) , while working in: FL Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by caning (727) 938-5562. Project Name: ISSUE 09-20-13 (rLD) SeWn Dat at 12/13/2012 CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES BUILDING DEPARTMENT Shotid any of the above described policies be cancelled betae tis eWtaton data tsreof, the Issuing Insurer Will wdeawr to mail 30 days written notice to the csrttcate holder named to the left, but failure to do so shall Impose no obigaton or Rab@ly of any Mrd upon the insurer, Its agents or representatives. 10050 NE 2 AVE MIAMI SHORES, FL 33138 Property Information Map Property Information Map Page 1 of 1 Aerial Photography - 2012 0 mmw=mm 113 ft This map was created on 9/6/2013 3:51:42 PM for reference purposes only. Web Site © 2002 Miami -Dade County. All rights reserved. M summary uetaiis: olio No.: 11-2232-028-0870 ro 10650 NE 10 PL ailing U S MORTGAGE FINANCE II ddress: LLC 00 S BISCAYNE BLVD 810 MIAMI FL r3131- Prope Information: Assessment Information: ear. 2013 2012 nd Value: $136,620 $78,177 uildin Value: $162,954 $178,68 aftt Value: $299,574 256,86 Value: $299,574 256,86 Taxable Value Information: Year 1000 SGL FAMILY - rimary Zone: 101-2300 SQ Applied Applied Exemption/ Exemption/ Taxable Taxable Value: Value: 001 RESIDENTIAL - LUC: INGLE FAMILY edsBaths: 0/$299,574 loors: View Additional Sales ' in Units: 0/$256,862 d S Foote e: 074 of Size: 750 SQ FT ear Built: 953 IAMI SHORES STATES PB 47-58 LOT 6 BLK 5 LOT SIZE egal 5.000 X 130 OR 19586 ascription: 994 03 2001 1 COC 3459-2429 06 2005 1 R 27992-2703 0112 12 Assessment Information: ear. 2013 2012 nd Value: $136,620 $78,177 uildin Value: $162,954 $178,68 aftt Value: $299,574 256,86 Value: $299,574 256,86 Taxable Value Information: Year 2013 2012 Taxing Authority: Applied Applied Exemption/ Exemption/ Taxable Taxable Value: Value: Tonal:0/$299,574 Beds to or from financial fnstftutons 0/$256,862 our 0/$299,574 0/$256,862 View Additional Sales 0/$299,574 0/$256,862 drool Board: 0/$299,574 0/$256,862 Sale Information: ale Date: 1/2012 ale Amount 9200 ale 0/R: ;7992-2701 ales Beds to or from financial fnstftutons uglification escrl tion: View Additional Sales http://gisims2.miamidade.govlmyhomelprintmap.asp?mapurl=http://gisims2.miamidade.gov... 9/6/2013 CERTIFICATE OF LIABILITY INSURANCE 8/14/ 013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 1 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemsnt(s) PRODUCER (305)752-2260 Eastern United Insurance of Lago Mar, Inc. JAIME DARIO ORDONEZ E-037165 16782 N. Kendall Drive MIAMI, FL 33196 NCOANEACT Jaime Ordonez PHONE .,.(305)752-2260 Ext. No.(305)752-2226 E-MAIL ADDRESS:., do®eullm.com INSURER AFFORDING COVERAGE NAIC0 INSURER A: CentUrY SUrety Insurance Company INSURED EXTREME ROOFING INC. 3100 SW 103 AVE MIAMI, FL 33165 INSURER B: Progress i ve INSURER C: INSURER o: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ININ7 RR TYPE OF INSURANCE AD SUB POLICY NUMBER POLICY EFF M/D POLICY EXP M/D LIMBrS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR CCP595378-2 04/10/13 04/10/14 EACH OCCURRENCE $ 1 000 000 DAMAGE TO HEN I D PREMISES a occurrence $ 50.000 MED EXP (Any oneperson) 11000 PERSONAL &ADV INJURY $ 110001000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG $ 11000,000 $ i B AUTOMOBILE LIABILITY(20TTIdEDt ANY AUTO ALL OWNED X SSC14EDULED A�� HIRED AUTOS NON -OWNED AUTOS(Per 01950188-0 11/23/12 11/23/13 en SINGLE LIMIT 100,000 BODILY INJURY (Per person) $ BODILY INJURY (Per acddent) $ PROPERTY DAMAGE $ accident UMBRELLA LU1B EXCESS UABCLAIMS OCCUR MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTNE OFFlCERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N �A TWO STATU- OTH- CRY I EEL E.L EACH ACCIDENT $ EL DISEASE - EA EMPLOYE $ EL DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remark, Schedule, I more apace Is required) ROOFING i CERTIFICATE HOLDER Miami Shores Vilage Building Dept 10050 NE 2nd Ave Miami Shores FL 33138 (305)795-2204 Ext. ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQED REPRESENTATIVE 019 The ACORD name and logo are registered marks All rights reserved. P Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: BUSINESS NAME: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 BUSINESS ADDRESS: s 6Z L D , ITY -C I STATE ZIP CODE L BUSINESS PHONE:FAX NUMBER (3� ,)a4 T CELL PHONE QUALIFIER'S NAME:i�'On-t �d2Lf�S' QUALIFIER'S LIC NUMBER: Coo f 3 -c-)_ to 0c)-1 E-MAIL ADDRESS (IF APPLICABLE): Created an 3119109 BY MLDV I RV 3IM09 MLDV 02-02-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCUILOFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW * e CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE PERSON: FEIN: 03/17/2012 EXPIRATION DATE: 03/17/2014 FUENTES NAOMI F 651131964 BUSINESS NAME AND ADDRESS: EXTREME ROOFING INC 3100 SW 103RD AVE MIAMI FL 33166 SCOPES OF BUSINESS OR TRADE: 1- ROOFING 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 440.05112), F.S.. Certificates of election to be exempt., apply only within the scope of the business or trade listed an the notice of election to be exempt 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 say 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 certiffcate to meet the requirements of this section. QUESTIONS? (850) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW I* EFFECTIVE: 03/17/2012 EXPIRATION DATE: 03/17/2014 PERSON: NAOMI F FUENTES FEK- 651131984 BUSINESS NAME AND ADDRESS: EXTREME ROOFING INC 3100 SW 103RD AVE MIAMI, Fl, 33165 SCOPE OF BUSINESS OR TRADE 1- ROOFING IMPORTANT F Pursuant to Chapter 440.051141, F.S., an officer of a corporation who O 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{77), F.S., Certificates of election to be exempt_ apply only within the scope of the business or trade listed on Rhe notice of election to be exempt E Pursuant to Chapter 440.05031, 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. O.UESTiONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 AC# 6 2 716 9 2STATE Of FLORIDA .-,.DEPARTMENT:.OF,BUSINESS AND PROFESSIONALREGULATION STRUCTION INDUSTRY'LICENSING BOARD —CON. SEW L12081502009 LICENSE RICX-'SCOTT KEN LAWSON GOVERNOR DISPLAY AS REQUIRED BY LAW SECRETARY THIS IS NOT A BILL — DO NOT PAY 533896-7 sij'Sai= !S'i iWkfvlh! LOCATION EXTREME ROOFING INC 3100 SW 103 AVE 33165 LININ DADE COUNTY ............ FIRST-CLASS U.S.'POSTAGE PAID MIAMI, FL PERMIT NO, 231 RENEWAL RECEIPT NO. 557643-5 STATE# CCC1326021 EXTREME ROOFING INC 0--Tspa ori Bush luss WORKER/S ' 196 SPECIALTY BUILDING CONTRACTOR I v*ull' A14V 'u%vil OP TW' 00 NOT FORWARD FRO."I ANY Ullitui EXTREME ROOFING INC OR Ll,'E.NSE Y- TPM S amu', I�, NAOMI F FUENTES PRES 3100 SW 103 AVE MIAMI FL 33165 07126/2012 09010208001 000075.00 coeriv° CERTIFICATE OF LIABILITY INSURANCE ATE 8/14/ 013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER (305)752-2260 Eastern United Insurance of Lago Mar, Inc. JAIME DARIO ORDONEZ E-037165 16782 N. Kendall Drive MIAMI, FL 33196 NAGATE CT Jaime Ordonez PHONE 305)752-2260 Ext. me No:(305)752-2226 E'M� ADDRESS, 'do@euilm.Com INSURER AFFORDING COVERAGE NAIC# INSURER A: CentUrY Surety Insurance Comparry INSURED EXTREME ROOF 1 NG INC. 3100 SW 103 AVE MIAMI, FL 33165 INSURER B: Progressive INSURER C: INSURER D: INSURER E: INSURER F: COVERAGE& CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN.SSR TYPE OF INSURANCE ADD SUB pOUCY NUMBER POLICY EFF MID POLICY EXP M/D LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADEI OCCUR CCP595378-2 04/10/13 04/10/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES R NTED occurrence $ 50, 000 MED EXP (Any oneperson) $ 1,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X I POLICY PRO LOC PRODUCTS - COMP/OP AGO $ 1,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO AAUUTOOSS X AUTO NED HIRED AUTOS AUTOS(Per 01950188-0 11/23/12 11/23/13 CO MINEDSINGLE LIMIT 100,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ accident $ UMBRELLA LIAS OCCUR EXCESS LIAB CLAIMS -MADE I EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LUWRM Y / N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFlCER/MEMBER EXCLUDED? (Mandatory In NH) If yes describe under DESCRIPTION OF OPERATIONS below N / A OR STATUS OY LIMITS TH- E.L.EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, H more apace is required) ROOFING I CERTIFICATE HOLDER CANCELLATION Miami Shores Vilage Building Dept 10050 NE 2nd Ave Miami Shores FL 33138 (305)795-2204 Ext. ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE ®191 The ACORD name and logo are registered marks All rights reserved. ' Extreme Roofing,lnc 306-225-1255 P.1 VERMCATION WORK SHEET In ac+cmdance with FEMA nagWadon aW Miami Shores Wine Flood DaInap costs of all improveaarnts must be monitored. The costs o f Preveati� pr�a�e the of � � � � past 12 months and the include P�ossd �venwnts must be shown on the xAorlcs WM The cast of inpovmmis mass demoht on, raw and finidwd maicnab (iaehaic those per,Formed� aaastruc-tiam„�,. bor (lodittg t oIuateer and self- v►hich are to be �cluded as �redt as those excktded 3 attachc3dment� Md � and pral�t. A lit o4� items the costs of mast be attache* %► Co" Of the Contract PROPERTY O �js !�A , ,�-A 1 I LLC_ PERMIT # ADDRESS: FOLrO NU",M :11-Z2 2 d� - Q � � l�LctOn ZONE: BASE FLOOD ELEVATION: FREEBOARD: IVS1' OF FL.CCCL: COST OF PAST IMPROVE -0 {12 MONTHS}: COST OF PROPOSED 114FROVFMEM: (ATTACH COPY OF CONTRACT) TOTAL CUMULATIVE COST OF IMPROVEM N—n (past and 3; Note Public State of F altprai w): � my carrtmission fa08G2935 iBQo.nf, Expires 02/1912018 �/'rSr de,14 4 DATE:_ � W.ANgFi7ili \l►CD. PLAN SIGNATURE: DATE: REVIEWER S '$ . J irEll"wwllo 3115 SW 103'd Avenue Miami, FL 33165 * Ph: (305)225-1535 & Fax: (305)225-1255 To: RED DOT MANAGEMENT Phone. 305-752-3272 Date. JUNE 25, 2013 Street: 13230 S,W..132"AVE Job Nam: 10650 NE 10 PLACE City: MIAMI, FL. 33186 Job Location: MZAMI SHORES, FL. PROPOSAL - CONTRACT "MINERAL SURFACE CAP SHEET " 1. Tear off existing roof down to wood deck or smooth workable surface and remove the tiles surrounding the flat roof to expose the tie-in. 2. Replace all rotten wood on the roof up to 100 lin. Ft. at no extra cost to contract price. 3. For additional wood, please refer to the Lumber Price List enclosed. 4. Install one ply Fiberglass base 75 lbs. mechanically attached in compliance with roof system (PCA). 5. Install one ply Ruberiod 20 in a full mopping of ASTM D 312 Type IV hot asphalt. 6. Furnish and install all new metal roof accessories using not less than 24 gauge galvanized. 7. Furnish and install all pipes roof penetrations flashing with approved lead sleeve -type. 8. Install new eave drip 26 gauge galvanized metal over the anchor sheet at fascia perimeter. 9. Install one ply of Mineral Surface Cap Sheet roof felt solid mopped with hot asphalt. 10.Install tiles at the tie-in to match as much as possible. 11.Upon completion of roofing work we shall remove all debris from roof site leaving the work area and surroundings clean and in neat conditions. 12.AII necessary license, insurance, taxes, and permit fees are included in this proposal. 11. All work shall be performed in accordance with Roof System Product Control Approval and Florida Building Code Chapter 9. 12.Contractor guarantee that all materials furnished will be of standard quality, type And condition. The contractor guarantees its work against any workmanship defect for a period of 5 years from the day of installation. WE PROPUSE TO FURNISH LABOR COMPLETE IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS FOR THE SUM OF: TWO THOUSAND FIVE HUNDRED DOLLARS $2500.00 PAYMENT TO BE MADE AS FOLLOWS: 20% CONTRACT- SIGNED4500.00, GO% FIRST DAY OF TEAR OFF $1.500.00 20% AT ROOF FINAL $500.00. TERMS: EXTREME ROOFING, INC. NET CASH —NO DISCOUNT n J INVOICE ARE DUE WHEN RENDERED f GENERAL TERMS AND CONDITIONS ON REVERSE , BY: ZX ROBERT FUENTES 305-606-3673 THIS BID MAY BE WITHDRAWN IF NOT ACCEPTED WITHIN 30 DAYS When this bid is accepted please sign and return a copy which will be our order to proceed with work and when approved by our credit department constitirtes the entire agreement of the parties. Attention is directed to the General Term and Conditions set forth elsewhere in this contract, which are incorporated herein by reference and made a part hereof. All work to be done or guaranteed shall be set forth in specifications, no promises verbal or otherwise will be valid. The undersigned accepts the above job at the price quoted and agrees to pay for said work promptly upon completion of same as herein specified. If any sums are due collected by suit or demand of an attorney or collection agency then the undersigned agrees to pay all costs, including reasonable attorney's fees for collection. DATE: ACCEPTED BY: O .AGENT Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 September 9, 2013 Permit No: FW 13-2026 Building Critigue Review 1. -PROVIDE CERTIFICATE OF WORKERS COMPENSATION INSURANCE FOR EMPLOYEES AS REQUIRED UNDER SECTION 105.3.5 OF FBC 2010. 2. -PROVIDE OWNERS NOTIFICATION FORM, FBC 1524 Ismael Naranjo Building Official Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re -submittal drawings. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tei: {305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 q. If" 1_�1II�7 PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC CKROOFING; AuG 09 2014 F BC ! ) Master Permit No2F-1 3 Sub Permit No. ❑ REVISION ®,EXTENSION ❑RENEWAL [-]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS (, CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACi'OR DRAWINGS JOB ADDRESS: 6 0(a!50 NE W PC � rit . � NiiamL,qhnrac rnanty_ Miami bade Zin: �� r ( ) Folio/Parcel#: s the.Buiiding Historically Designated: Yes NO . OccupancyType: Load;. ConstructioftType:. � <,_FioodZone: BFE:. FFE: OWNER: Name (Fee Simple Titleholder): (®t C c r )/?cncc Phone#: i fU kQ pZ, I G Address: ,,� [ U-0 so /11 C City: � ��! /L. / Shka i State: 7z- Zip: Tenant/Lessee Name: '°irva.---w�<- Phone#: Email: jji��-<er c C� CONTRACTOR: Company Nalne: M C451 W (j O I S 9 !' L) C- Phone#:(,T(s 1 9 q Ll C/ wd Address:1 Woi �W f City: 41�&hie Stater o'A Cn Qualifier Name: State Certification or Registratii DESIGNER: Architect/Engineer: #:) Q Certificate of Competency #: Address: l City: State Zip: Value of Work for this Permit: $ 010 Square/Unear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: ife ro -o% Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/Cc $ Scanning Fee $ '27, CQ) Radon fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews $ _ iaevMM2/24/20141 Double Fee $ Bond $ TOTAL FEE NOW DUE $ 154 • (Q - 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. ]f YOU 'INTEND TO OBTAINFINANCING,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 mast promise In good faith that a copy of the notice of commencement and construction lien low 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 (T) days after the building permit is issued. in the absence of such posted notice, the Inspection will not be approved and a reinspection fee will be charged. Signature �IWAUER or AGENT The foregoing instrum,,ent was acknowledged before me this ZZ- day of J 0.1 ti .20 19. by K1% r .x' \ l enl4% , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Signatu CONTRACTOR The foregoing instrument was acknowledged before me this day of N 20 . by rAt o is personally known to me or who has produced" k- P as Identification and who did take an oath. NOTARY PUBLIC: Sign: Si IREL ALBELO cA �vcl lr& Print:Comm4s5ana it Fe Print. $+y �,.� Seal: �.�waa`•� Com son Expires es Seal: Decemberr 05, 201,•. 1;, ANGELA DOUGLAS . '__ Notary Public Stale of Florida My Comm Expires Otto r 5j n ***nay***********e********c* *** *s****•**** **************** *�k* x **** 1itI 1423 APPROVED BY A'� Pians Examiner Zoning Structural Review (RevisedO2/24/2014) Clerk f0 's '01*j 1-ftj III Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Te[: (305) 795.2204 Far. (305) 756.8972 ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: 1,/ A. COPY Or QUALIFIER S STATE L1%oC11%aC:0 13. COPY OF LOCAL BUSINESS TAX RECEIPT C. ----L :COPY OF LIABILITY INSURANCE' D. Cl/ COPY OF WORKERS COMPENSATION INSURANCE* IF CONTRACTOR HAS A MIAMI. DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. - COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. C. COPY OF LIABILITY INSURACE* D. COPY- OF WqRKERS COMPENSATION INSURANCE* *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW - BUSINESS NAME: MCALS I rV'\0 C0r6JTL)(J0r BUSINESS ADDRESS: 05 C V -)CA ftbff 110 ITYQXA STATES 10 r k OCA ZIP CODE 3-q>'J '10 A ciq 0 FAX NUMBER BUSINESS PHONE: LTSP L, a I+ L CELL PHONE 15 -)00Q UALIFIER!S NAME:' 4 QUALIFIER'S LIC *NUMBER: C Cq v- 0 �3 .... . . . ............... . ...... . .. ..... ................ ...... .. .... .... ....... 4� . STATE OF FLORIDA DEPARTMENT OF BUSINESS AND CONSTRUCTION INDUSTRY LICH 1940 NORTH MONROE STREET �� s TALLAHASSEE FL 32 POLLACK, BRADLEY STEVENSON MASIMO CONSTRUCTION INC 16105 83 PLACE NORTH LOXA> ATCHEE FL 33470 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that Impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! I8 CERTIFIED under the proviaians ;of Ch.489 Fs 9smA=&im data= -AW 31, 2914 1612092S02383 DETACH HERE a e„_H(SDOCUI�ENTFfSl:COLQREDE3ACKCaRC7Ut$D;rMfCROFRINTIISC:,tINE�T/1RK MORE, ,i # 6316143. OF • . ' 1A CONST] SEQ#L12082902383 08 29..2012, 13,28051468. litCC1329031 The- ROOFING CONR'IiACTQR . Named belowI-S C$1TIFIgD Under the provisions of `Chapter 489 ;FS. Expiration date: AUG 31, 2014., POLLACX. BRADLEY BTEVNNSON` MAASIMO CONS, VCTION INC 16105 83 PLACE NORTH LOXAHATCHSL FL 33470 RICK - SCOR KEN LAWSON GOVSECRETARY ___ DISPLAY AS REQUIRED BY LAW 115 S. Andrews Ave., Rm. A-1 00, Ft. Lauderdale, FL 33301-1895 — 954831-4000 VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014 DBA:MASIMO CONSTRUCTION INC Business Name. Owner Name: BRADLEY STEVENSON Business Location: 16105 83 PLACE NORTH PALM BEACH COUNTY Business Phone: 954-303-2018 Receipt #'ROOFING/SHEET METAL Business Type: (CERT ROOFING CONTR Business Opened:02/05/2008 State/Cou my/Cert/Reg: CCC 13 2 8 0 3 3 Exemption Code: Rooms Seats Employees Machines Professionals 5 For Pending Business Only Number of Machines: Vending Type: Tax Amount I Transler Fee I NSF Fee I Penalty I Prior Years I Collection Cost Total Paid 27.00 0.00 1 0.00 2.70 1 0.00 1 1 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT 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 planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business Is legal or that it is in compliance with State or local laws and regulations. Mailing Address: BRADLEY STEVENSON 16105 83 PLACE NORTH LOXAHATCHEE, FL 33470 2013 -2014 Receipt #03A-13-00000162 Paid 10/04/2013 29.70 r JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This Certifies that the individual listed Mow has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 2/2013 EXPIRATION DATE: 202015 PERSON: POLLACK BRADLEY S FEIN: 203016640 BUSINESS NAME AND ADDRESS: MASIMO CONSTRUCTION INC 16105 83 PL N LOXAHATCHEE FL 33470 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL ROOFING - ALL KINDS CONTRACTOR AND DRIVER Pursuant to Chapter 440.05(14), F.S., an aftet of a mon afro elects a niption Arun M chapter by filing a cwtiticate of election mtlarM section may not raww WWb or ntrtder0ds depter. Pursuant to Chapffi44CAR14 F.S.. certificates of elan to be wompt.. apply only within the supe of the bum orbade Iced on 0te notice debc#M to be erwnpt. Pursuant to Ompter440.05(13). F.S., Notices ofetection to be exp anti of etc to be exanpt siW be auto revocation tat anytime alterilnelft of the notice or the fentance of the oertiemt% the pecaorn rmmed on the notice or oertftiC81e no I rrmetsthe r GfMbn fk)rof a int. line depwbnad shall rewaft e e st anytineferfalure ofthe person ne , onthecartificatatorneelftfeWhementsortift se m DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 Miami ahores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner —Workers' Compensation Insurance mPO oi Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if. 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the c=orporation in the records of the Florida (Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may nersonally,liable for the worker compensation injuries of anyperson allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Qwner Print Name: Signature: _ State of Florida County of Miami -Dade ) Sworn to and subscribed before me this � -2- day of = i, 20_L-1 . By IREL ACBECBE 0 • , M iss on 0 EE 150938 iSEAL) !� r My Commission Expires Contraetar Print Name:_J�rA d 'TD 116A c Signature: State of Florida ) County of Miami -Dade ) Swornto d subscribed before me this &�' day of � , 20_,&l. Commission # EE 150938 ,4coR7 10 CERTIFICATE OF LIABILITY INSURANCE °"0`x' 02/10/20142014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not coater rights to the certificate holder In lieu of such endorsement(s). PRODUCER Per Project Insurance Agency 3065 ROSECRANS PL STE 208 SAN DIEGO CA 92110-4822 CONTACT NAME: PHONE (88$) 269-0992 FAX (888) g69-0247 No: CRESS: customerservice@glquote.com ' INSURER(S) AFFORDING COVERAGE NAIC S INSURER A: Preferred Contractors Insurance Company RRG 12497 INSURED MASIMO CONSTRUCTION, INC. 836 NW 76TH TERRACE PLANTATION FL 33324-1443 INSURER a: INSURER C: INSURER D : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL 10050 NE 2nd Ave POLICY NUMBER POLICY EFF MND POLICY EXP MND LIMITS A GENERAL LIABILITY X COMMERCIAL. GENERAL LIABILITY CLAIMS -MADE a OCCUR 7PCIC5026-PCAS04796 09/04/2013 09/04/2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES ( occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL$ ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: Ra LOC X POLICYL1JPFCT PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOSL CO(EsMBINEDaaddSINGLE LIMIT BODILY INJURY (Per person) $ BODILY INJURY (Per ecddent) $ PROd�DAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTNE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A wQRY j ATI oTH- E.L. EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AdManal Remarks Soule, If mora space Is required) City of Miami Shores is named as a certificate holder. Roofing and General Contracting. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • Complete Items 1, 2, and 3. Also complete A. Silinature item 4 If Restricted Delivery Is desired. X Agent " ri❑3 n • Print your name and address on the reverse Addresses so that we can return the card to you. • Attach this card to the back of the mallplece, B=:=. Date of Delivery or on the front If space permits. D. Is delivery address different from Item 1? 13 Yes 13 1 Article Addressed to: If YES, enter delivery address below No Axle -3/ 3. Service Type 13 Certified Made 0 Priority Mail Express; - E3 Registered 13 Return Receipt for merchandise 13 Insured Mail E3 Collect on Delivery 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number - (flansfer from service MO 7012 1640 [1002 1271 4576 PS Form 3811, July 2013 Domestic Return Receipt Permit N:4 — 2 aff'h Miami hores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 lill 011, lei 4 S ZU01 Owner's Name (Fee Simple Tits Owner's Address: 0& 50 A City: 10106 D/ Offs C Phone #: 71 to iA a c 2 i C State: 67e- Zip Job Address (of where work is tieing done): 9 6 ((,2 JG & (0 City: Miami Shores State:—Florida Zip Code: Contracts Address: City: L Qualifier' Architect) Engineer of Record Name: Address: City: Describe State: Phone M I hereby certify that the work has been abandoned and/or the contractorlarchitect is unable or unwilling to complete the contract. I hold the Building Official and the Mia i Shores harmless for all legal involvement. Signature m Signature owner Contrac W orArd t d The foregoing intro was aknowdedged before me The foregoing instrument was aknowdedged before me anis 2 Zday of �2dq by k: age So. LA Y this day of C c� 20 by b i �c.fc Who Is personally known to me or who has produced who Is personally known to me or who has produced ) as identification. f 1 jJ t._- as indent cation. Notary Pu Notary Public: ,�4 IREL ALBEL ' Sign:` '�� sion # EE 150838 gi ' My Commission Expires Seal. '� December O5, 201 S Seal: •e�., ANGELA DOUGLAS Notary Public -State of Florida %o' My Comm Expires October, 25, 2015 Commission # EE141423 Date: 07/18/2014 RE: EXTREME ROOFING 19800 SW 180 AVE # 363 MIAMI, FL 33187 QUALIFIER: NAOMI FUENTES To Whom It May Concern: Permit # RF13-2026 10650 NE 10 PL MIAMI SHORES, FL 33138 This letter is to inform you of the changes being made to the above referenced address. You are being removed as contractor of record. The owner has decided to carry out a change of contractor.