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RF-15-2371 ti Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-243680 Permit Number: RF-9-15-2371 Scheduled Inspection Date: July 01,2016 Permit Type: Roof Inspector: Mesa, Michel Inspection Type: Final Roof Owner: , Work Classification: Repair Roof Job Address:351 NE 98 Street Miami Shores,FL 33138- Phone Number Parcel Number 1132060135630 Project: <NONE> Contractor: GULFSTREAM ROOFING AND URETHANE INC Phone: (786)357-5327 Building Department Comments REMOVE AND RESET RIDGE TILES. Infractio Passed Comments INSPECTOR COMMENTS False Contractor must notified the building official the date and time during a week day that the work is to be performed. Inspector Comments Passed ` ® � o se Failed Correction ❑ Needed Re-Inspection a Fee No Additional Inspections can be scheduled until re-inspection fee is paid. June 30,2016 For Inspections please call:(305)762-4949 Page 4 of 31 TAS 106 TEST RESULTS REPORT GENERAL INFORMATION Testing Agency Name: A+ Engineering Testing Lab, LLC. Certification No. 16-0413.03 Address: 7066 SW 44 St Miami, F133155. Telephone: 305-668-5792 Fax: 786-513-3754 Email: aalusetWyahoo.com Representative Name: Eng. ABDIAS H. SAENZ. Title: P.E# 69687. SITE SPECIFIC. INFORMATION Roofing Contractor: GULFSTREAM ROOFING, INC. Permit#: RF-9-15-2371 Job Address: 351 NE 98 ST MIAMI SHORES,FL. 33138. Contact. Name: ALEX PH: 786-586-2790 Owners Name: GLADYS COWEN&ELIZABETH COWEN Type of Tile: EAGLE MALIBU Dae Installed: Roof Height: 12 feet Roof Pitch: 3/12 Job Access: LADDER Gate: NO Approximate Square Footage of Roof. 28.0 ft 2 Date Tested: 06/30/16 Required Testing Force: 35 LBS Testing Equipment: M2-100,S-3741465 TEST LOCATION PASS FAIL CORNER 12 - PERIMETER 28 - RIDGE 40 - FIELD 25 - TOTAL: 105 - Cj) U3 • -a: of Z IN ACCORDANCE WITH 0 C% RIA(T �A�106,THIS ROOF ASSEMBLY HAS PASSED THE STATIC UPS IFT QUALITY CONTROL TEST. THIS TAS 106 TEST HAS 19 ORDANCE TO THE REQUIREMENTS OF DADE COUNTY,WITH NO DEVIATIONS THIS REPORT 1S NOT GUARAL DISASTERS. eri,e,re111 A+En ink eerie Testing estin ROOF DIAGRAM. GULFSTREAM ROOFING,INC. 351 NE 98 ST MIAMI SHORES,FL. 33138. T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T 7066 SW 44 St Miami F133155 PH:305-668-5792 Fax:786-513-3754.aplusetl@yahoo.com Afi' tt + { 371 d� Roof � Miami Shores Village l�{fT11lf ►B' �, _:, �y 10050 N.E.2nd Avenue NE j`t6n �epir ... n. Miami Shores,FL 33138-0000 Phone: (305)795-2204 APPRf177� �l1S' 1VE} Expiration: 05/07/2016 Project Address Parcel Number Applicant 351 NE 98 Street 1132060135630 Miami Shores, FL 33138- Block: Lot: GLADYS COWEN TRAS&ELIZA Owner Information Address Phone Cell GLADYS COWEN TRAS&ELIZABETH 351 NE 98 Street -- - --- MIAMI SHORES FL 33138-2409 351 NE 98 Street MIAMI SHORES FL 33138-2409 Contractor(s) Phone Cell Phone Valuation: $ 1,200.00 GLANER CORP (786)586-2790 Total Sq Feet: 225 Type of Work:Repair Available Inspections: Additional Info:REMOVE AND RESET RIDGE TILES. Inspection Type: Classification:Residential Roof Repair Scanning:3 Final Roof Review Roof Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee Invoice# RF-9-15-57122 $2.00 11/09/2015 Cash $66.20 $50.00 DCA Fee $2.00 Education Surcharge $0.40 09/17/2015 Credit Card $50.00 $0.00 Permit Fee-Repairs $100.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $116.20 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in complian 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 pe ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for E RIC , LUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS FFI efti that all the of ' formation is accurate and that all work will be done in compliance with all applicable laws regulating constructio $nd oni Fut re hqn' e-I above-named contractor to do the work stated. November 09, 2015 Authorized Signa er / Applicant / / Agent Da e Building Departmen Copy November 09,2015 1 Miami Shores Village Building Department ` 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 `��- -�T-t FBC 20 l BUILDING Master Permit No PERMIT APPLICATION Sub Permit No ❑BUILDING ❑ ELECTRIC Q/ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL F_JPWMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP �sJ CONTRACTOR DRAWINGS JOB ADDRESS: �� ' / ` l-e e City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: �r/V 0(0 0 L25-630 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: 1 FFEE: OWNER:Name(Fee Simple Tiitleholder):1_l���1 O_QV,�t,3 Phone# � 51 ��SG /d J Address: 35- /V E 9g, S flF o f a City: (`a�t< Sh0 dP 5 State: Zip: 3 3/3 E Tenant/Lessee Name: Phone##: Email: C'o.Lt-e z (,y holicL r'. r 4✓°/ CONTRACTOR:Company Name: C—®'�� Phone#: '?49G T Address: � �1 Cv� City: -^State: � Zip: 3 � Qualifier Name: �' 6�C,� y' �L 6.4� l'�O iL. Phone#: "t �6-- 53—q�80 State Certification or Registration#: SC.`LA®P_'l A 61 Certificate of Competency# DESIGNER:Architect/Engineer: / A- Phone#: Address: City: State: Zip: r> Value of Work for this Permit:$zdo®, Square/Unear�Foo'tage of Work: i—/t/. � Type of Work: ❑ Addition ❑ Alteration 1:1 New LJ Repair/Replace ❑ Demolition Description of Work: til fi d e_ alt.O' e y e Specify color of color thru tile: Submittal Fee$ Permit Fee$ f� CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. ELI Signature Signa NER or AGENT tl CONTRA OR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of N(- .20 ,by day of C/✓i 2 20 GJ ,by IIAWCK R J Q�K> .who is personally known to ���o�o w,i/<db� .!who is personally known to me or who has produced M �\.1�1.J 09a -as me or who has produced I as identification and who did take an oath. identifi ' n and who did take an oath. NOTARY PUBLIC: NO P BLIC: Sign• Sign Print: Print: la 42n ...NII I LYMDLM4 Seal: Yom �e�F. Notary Public State of Florida Seal: * � MY S I�1�22745 Sindia Alvarez cc EXPIRES: May 13,2D18 ow V-1) MyCommission 18156750 �9fi `c WKNINITMu PubkUndembis APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ♦$N�1c.��S�' ORMiami V Village Building Department �OR1Dp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insura ce Exemption 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-ttrporate a or full-time employees,including the owner,must obtain workers' compensation coverage. Cofficers 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 corporation in the record$ of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida; Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: `►- � \ Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of 16f,20�. By��� {�� own who is personally known to me or has produced TA_ V. as identification. Notary: SEAL: o4eyo Notary Public State of Florida Sindia Alvarez My Nap o��g Ex Cres 09/03/2018 158750 4GLANER CORP .Engineers & Contractors LIC#E747 5790 IN 14 Lane,5Cfaleak FL'33012 TeL 305 822 1.974-YaX 305 397-1322 September 16, 2015 State of: Florida County of: Dade Before me this day personally appeared Teodoro Tundidor,who, being sworn, deposes and says: That he or she will be the only person working on the project located at: 351 NE 98 Street, Miami Shores, Florida 33138. Sworn to (or affirmed)and subscribed before me this 15 of September, 2015, by v Personally Know �� ��o 741,11 Or Produced Identification Type of ID Produced k\14 /! `z A-- Print,Type or Stamp Name of Notary LYDIA GONZALEZ MY COMMISSION#FF 122745 EXr{RES:May 13,2018 Notary Pubfx UndehVrbm I CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY E747 GLANER CORP. ' D.B.A.:NATIONS BROADBAND TUNDIDOR TEODORO J Is certified under the provisions of Chapter 10 of Miami-Dade County VAL1PTQA CQNTRACTING UNTIL05130/2015 CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY . .- E747 GLANER CORP. D.B.A.:NATIONS BROADBAND TUNDIDOR TEODORO J Is certified under the provisions of Chapter 10 of Miami-Dade2o�u1tS -uiaiay s�y6uiiw Rwouoaa�no6-apepiweiw nvun � 1 pi 3 day-S Rye-minr Crva'® -100d ONIWWIMS 9900 0NI:J00b t7t700 UiN(103)-­!t1?iaN3J 1.000 tS134`db1 0NI)jnv 10 7uawdolanap/noB'apep1we1w'.wnM. p—g aye;o FieJa S 3d aBued saleyp C® '�%i./ OOd ONIMMS 9900 01\11_�10021 "00 ONI�JEE IJN3 ddb'3N3J 1.000 (S)310"1 EWAirivnD I r QUALIFYING TRADE(S) 0001 GENERAL ENGINEERING 0044 ROOFING 0055 SWIMMING POO! MIAML l Charles Danger P.E. 1��,/�r_. . Secretary of the Board "�" -miamicade.gov/developmenl QUALIFYING TRADE(S) 0001 GENERAL(COUNTY) 0044 ROOFING 0055 SWIMMING POOL / MIAW D Juliana H.Sales P.E. Secretary of the Board c�.7�zl.t�f �yy miamidatle.gov/econcmy Miami-Dade County retains a property rights herein. I I i j I CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY E747 1GLANER CORP. D.B.A.:NATIONS BROADBAND TUNDIDOR TEODORO J Is certified under the provisions of Chapter 10 of Miami-Dade County VALID.FOR CONTRACTING UNTIL 0s13012015 CTQBConstrulifying Board v BUSINESS CERTIFICATE OF COMPETENCY j,.w E747 { GLANER CORP. D.B.A.:NATIONS BROADBAND TUNDIDOR TEODORO J Is certified under the provisions of Chapter 10 of Miami-Dade County VALID FOR CONTRACTING UNTIL 09/3012016 s I RICK SCOTT,GOVERNOR _ KEN LAWSON,SECRETARY STATE OF FLORIDA DEPA TMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD RG2971038t4 The GENERAL CONTRACTOR Named below HAS REGISTERE Under the provisions of Chapter 4 9 FS. Expiration date: AUG 31, 2017 RINDIVIDUAL M T MEETALL LICENSING EQUIREMENT PRIOR TO fNG IN ANY AREA) TUNDIDOR,TEODORO 0 GLANER CORP 5790L WEST14ThIFLA1 E ��: .: <kN "10%,11 w ISSUED' 10!272015 DISPLAY AS REQUIRED BY LAW SEQ 1r: L1510270004414 RICK SCOTT,GOVERNOR KEN tAWSON,SECRETARY i STATE OF FLORIDA DEPAOtTMgNT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD PMR"704M� The ROOFING CONTRACTOR Named below HAS REGISTERED " Under the provisions of Chapter4f iD FS. ` Expiration date: AUG 31,2017 (INDIVIDUAL MU T MEET A^. . CENSING REQUIREMENT PRIOR TIG IN ANY AREA) �, TUNDIDOR, TEODORO J GLANER CORP 5790 WEST 14TH LA '::P;.. w;,#i i HIALE4H • ,:. ' ,;. Esc t*A �r ■ ISSSMD: 1o/Pr2015 DISPLAY AS REQUIRED BY LAW SEQ# L1510270004413 I tt � ji i, .A �• S sr..+r.'. . ,m �r FI .i' N. 'Y '}y.' ,il' i.•<PF` i 4�•.Nj1 .,f3f- �< ��r'i;'-3E$ a>3�}}�j}••IP':5�'�^'� 1.J K..e!.µ i:`:. MC.Type OP■vows6 �R CORP T96 SPE PAYBfI Mt1VIM BY TAX pptpp CON 46.00 0W23WIS �(a) t E747 d?30-t5'002?77 TMaLoad ..TatiBw+M++�►�.yw.'yry�tawt«d �,nf► w ar�el onfes.IM.�leY a fteo"lseaa1 , rr�wepe�Phr•re1 ' Iteweel *M�leiwir.d Heber errt i�M wMr I' �wqr`rMrM e�ebrnq�ee�, lle BIt ND-efewrrrRrYPIeyM ae eM aL.NpN wuieiw qi iso�l,t]L I I is;t• l�w�ae�nigt i i I i i {!' il. fl: .1� I"`'.•. „'f. �iXf -: +�'Wf5 !,T ' ��: 'j i�.. #:• .:i' <� ,:'. ' '.1.}..�s , :- '�Ilht ,�R�MYrd�IYPM1�f'61MYINN ^F0 *14 IV"OF CORP GEN PAYYleR Igo � j,' BY TAX r i1UACTOM E747 45.00 OW4W16 0230-1` 177 lYM tT�BN�MM4 e�llrNteFli.leer NwW.wTlaaIfr �eMt�r�MBM1i�e1*j1eYNr't B�w�e,Anl�eere lbller i»te0�/IrwiBl�M�Mee�.ew ' YwBArl�wai�r�M+t+rMw+•�41ra�Mr.olrlw�MWF ' c.rea..w-bi �!'�•Mt1M1�Nee. Yp. GLANE4 OP ID:TC CERTIFICATE OF LIABILITY INSURANCE j 0911612015° THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS U N THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CO RAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TH ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. if UBROGATION 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 endonseme s. iPSure RODU6'�urence Brokers Teresa R.Carmona, A nt 8700 W.Flagler St,Suite 270 WC. .305-223-2533 W Ne;305-220-0765 Miami,FL 33174 � ;tearmo urebrokers.com r. Teresa R.CarTrwtla, Agent WSLIREIM AFFORDING COVERAGE NAIc 9 I IsuRERA:Intn'I Ins Co of Hannover Ltd INSURED Glaner Corp. B48UMR 0: Teo Tundidor 5790 W.14 Ln. INSURER C: Hialeah,FL 33012 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. LTR TYPE OF INSURANCE POLICY NUMBSIMMODNYM 00111011:11"Y" Lam A X COMMERCIAL GENERAL LIABILITY 'CH OCCURRENCE $ 1,000, CLAIMS-MADE X OCCUR 1G06AQ07577-00 01128/2015 01/28/2018 NVAS Ea NIF-Urrce S �r -MED EXP(Any—Parson) $ PERSONAL&ADV INJURY $ 11000, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000, PPOLICY❑PERC LOC PRODUCTS-COMPIOP AGG $ 1,000, OTHER: $ AUTOMOBILE LIABILITYBII dent)IN LIMIT $ (EaANY AUTO BODILY INJURY(Pm person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ � PROPERTY HIRED AUTOS pS ) $ UMBRELLA LUAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ANY PROPRIETORMARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? N/A EL.EACH ACCIDENT $ (Manila"in NH) IEL DISEASE-EA EMPLOYE $ y under OF OPERATIONS below EL,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addllonal Remarks SGeillule,may be aQacfred B more space Is required) General Contractor- License E747 CERTIFICATE HOLDER CANCELLATION VILLAMS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISION8. Fax:305.756-8972 10050 NE 2 Ave. AUTHORLI'W REPRESENTATIVE Miami Shores,FL 33138 ra"MAIte §w7tra"C-0 ©1 988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD JEFF ATWATFR ,yW•�Ra 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 below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 4/9/2014 EXPIRATION DATE: 4/8/2016 PERSON: TUNDIDOR TEODORO J FEIN: 651037427 BUSINESS NAME AND ADDRESS: GLANER CORP GLANER CORP 5790 WEST 14 LANE HIALEAH FL 33012 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by rgg a certificate of election under this sacnon may not recover benefits or compensation underline chapter.Pursuant to Chapter 440.05(12),F S.,Certificates of election to be exempt..apply only within the scope of the business or trade fisted on 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 shallbe subjectto revocation if at any time afterthe 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 secbdn for Issuance of a certificate.The department shall revoke a certificate at any time for tadure of the person named on the certificate to meet the requirements of this section. DFS•F2-DWC-252 CERTIFICATE OF ELECTI1bN TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1608 i To: Building Dpt Page 2 of 2 2016-03-21 17:08:30(GMT) From:XXX XXX . VRA . CE .'INS AW V.LIASILI TtM E3LAE $ �� � �� 1� T . AIM MF R{W Mt'HIS 3.kM!HE CERTWfdAItffdLbER. Cic t cA .Vis.: NOT, FWAATMLY..,a Nr�; EXTEND'OR a t $:tom I eiP A�Fl�'lE t2 '.1i OT-4 6 TITUTE A-C>M iCT GET EEt' .. :fSSS#ll�'tA1,�tf� $}.'Ai9�#��6�d . B E N tl?�4 CKP4004C. J N0.TW.0ERTjMAjE wi .� +�!NaC a+�i the: M1gRPi1 ,�eo.'sR'SDV{ YO'��!i DDIP.ikNAL fNSU Yta poli J{ J yy,,_,����,y�,�,.,,,q pJ°ii53GZl'+F�t9f'W.F I.RLIIN gIII iY M.. ,$FRVPO .• 99h at 375p,�9d�i��d..1[ 1 k$0!{ �. jd;0191F✓I$�9f '6?7'# &Yz�4S tk1 c 'iAY t 8P1 13$8511< A�'sUft1Mie tronthisCcw .:���'hot, 1[��A. r-iit'3lace�`sexcth�l9 . MU K N i6�Cz'�'•. Yt' raW. i..•�i^'f.6d�7tr .. Yet R.Cawrn�a,. etY erC�9R .._:five#•* Irasur�p td . A5A_tO'L .,- TabTandl ..�'t�B Ee08E}�' L 30.2- COVERAGES ..2 �a9; 9di5UAtEiNt� -CM 4CAM:WU YN1S is fO.CI RTIFY TliA!r 1 ti :'1 14401 S.C3F'F!+!`3ll# Q'MLCJW HAVE TNj It. RE3): . : 0—A T�tE.Pa;Q0Y€9R#6*'' tlVf3lGd�t7ECir O1�Rft7td i�$AjE lfdG`ABY` Cltlilt 5i:`sE�tktl�R t 3A1f7[T1C N-017.&NY.d 2li CT'OAt'OTHERw UIEkT wiftWiNts, {;EfdY1EfCA .i!$AY tr.'I Ee9't i:.Y�ft�9Y'At~R fAlh6,'T#iE(dYSLRAWGIE RRDE[9 8Y tE.PC1i lIES t CEtI DT�Ll1i lS St3STHE'Tt`4�9AS, EXCe l3S OtsfS.AI b.G�?1tf3kTl�t QE St$Ck:PtH L IES.L IT$StdC)6t FAi°i i�tlttn BEEN REDUCED OYPA0.01LAMS. fid' T 'DF11 tiF0A :. . ppyegy umn ' �~ EAC5tt13CGLiR1€!YJL� S iwi . uld #. . TOM=... . .o .G — PERWFAL S ADV S 1t�3,lifli'F GEWLAGGREGATEtM41TAPPLWS! T '` Poucy __. 01&SLCtC ' - Pftbl�', -CCk�SLbX�PAf#C3 8 it --- -, AW kt soWy3PdJu39'(fa6rpera n).: A id C 9r�PtED ..:SC 4KDUW0 _. t1UTTS AtliCs.S' HOdYIlI:N.djRy.(Pas,E 4j � AUTOS (r O l ems. AGORFGATE occ�ta a9ac►:itcs , y�r S"rATUPtE lrtt ' ANY i�12UY9'tlttW�t{!lTAKIA`C'tt�Rk5:4J'IfiYt ... •. .. .�^—'"^. -- ��1E£,�ER'E7f�lStp},:fYj' ... RiB' 6atatt E.L,, ssAsE-P0gg'rr'1.1w .fi4 kt1a }OF^'.QP"ltAtdlPCZJ�IIAB�lCQ�B(A6S`�� lp�4�YDa`aaac4aa91fzteote.� )$t•� t.(mnSeg R029TM814 E747 �'Ali1Y.'Qi~T�tE A9VE#YE R .IC $ :ti.A�iGl.i Et!BEFCRE �?✓ Ac�O Az ll9lfTHTi PZ ICYPi�i lC dS. 1�3�i+tE�ltve !k�-tatreC SRtcti'es.�`4 X3138 �u �,�•,� 01 20i4 A0ORI) ...i RPORATIOW,G figts�s ACS 26(2014M) The ACO RD name SW 1090 at*"OskWed Ma*s of AMM To: Building Dpt Page 1 of 2 2016-03-21 17:08:30(GMT) From:XXX XXX FAX COVER SHEET TO Building Dpt COMPANY Miami. Shares FAX NUMBER 13057568972 FROM XXX xxx DATE 2016-03-21 17:08:04 GMT RE COVER MESSAGE www.efax.com ' � a ROOF ASSEMBLIES AND ROOFTOP STRUCTURES ry ; Florida Building Code 5th Edition(2014) $ P k7 2015 1 Permit Application n High-Velocity Hurricane Zone Uniform Plicatiion For ,r pP ��,;g a ----- f C y Section A(General Information) 1 Master Permit No. Process No. 1 Contractor's Name 1 1 Job Address p e. 1 ROOF CATEGORY 1 ❑ Low Slope ❑ Mechanically Fastened Tile /Mortar/Adhesive Set Tiles 1 1 ❑ Asphaltic Shingles ❑ Metal Panel/Shingles ❑ Wood Shingles/Shakes ❑ Prescriptive BUR-RAS 150 1 1 ROOF TYPE 1 ❑ New roof 19 Repair ❑ Maintenance ❑ Reroofing ❑ Re 1 covenng ROOF SYSTEM INFORMATION 1 Low Slope Roof Area(SF)_5V Steep Sloped Roof AREA(SSF) AQQ Total(SF) L/00 1 go e r Alec,-- If 3 1 Section B(Roof Plan) 1 Sketch Roof Plan: Illustrate all levels and sections, roof drains,scuppers,overflow scuppers and overflow drains. Include dimen- sions of sections and levels,clearly identify dimensions of elevated pressure zones and location of parapets. sees 1 . . •e•s •..•. . . ' 1 00 .. e• . •• •e eeei • •s 0 so ti. Ise 0 0• S !.. .. . .•e• • •••••1 • 1 • 1 1 UJ 1 > 1 V 1 Z 1 _J 1 � 1 ca 1 FLORIDA BUILDING CODE—BUILDING,5th EDITION(2014) 15.37 Copyright to,or licensed by,ICC(ALL RIGHTS RESERVED);accessed by Eliezer Palacio on Jun 8,2015 10:32:12 AM pursuant to License Agreement.No further reproductions authorized. ROOF ASSEMBLIES AND ROOFTOP STRUCTURES Florida Building Code 5th Edition(2014) i High-Velocity Hurricane Zone Uniform Permit Application Form. 1 1 1 Section C(Low Slope Application) Top Ply Fastener/Bonding Material: 1 Fill in specific roof assembly components and identify 1 1 manufacturer 1 (If a component is not used,identify as"NA") Surfacing: 1 /� Fastener Spacing for Anchor/Base Sheet Attachment: 1 System Manufacturer._ )"� _�' /� ���� Field: le r 1 "oc @ Lap,#RoWs t"�@ oc 1 1 � 1 Product Approval No.: I�I — J Perimeter: b "oc @ Lap,#Rows I @�°oc1 fe 1 Design Wind Pressures,From RAS 128 or Calculations: Comer. Y -oc @ Lap,#Rows �J @ 6p oc 1 1 Number of Fasteners Per Insulation Board: 1 1 P1: 1 t P2: "� P3: L /)Y 1 1 Max.Design Pressure,from the specific product Field Perimeter Comer 1 approval system: Illustrate Components Noted and Details as Applicable: 1 1 Deck: Woodblocking, Gutter, Edge Termination,Stripping, Flashing, 1 1 Continuous Cleat,Cant Strip,Base Flashing,Counterflashing, 1 1 Type: Coping, Etc. 1 Indicate: Mean Roof Height, Parapet Height, Height of Base 1 Gauge/Thickness: Flashing, Component Material, Material Thickness, Fastener 1 1 Type, Fastener Spacing or Submit Manufacturers Details that 1 1 Slope: Comply with RAS 111 and Chapter 16. 1 1 Anchor/Base Sheet&No.of Ply(s): 1 1 1 Anchor/Base Sheet Fastener/Bonding Material: 9966 1 1 . • 6696 1 F91- e .6 19 Insulation Base Layer. .. ... '9.000 6 6 i9: 1 • 9999. 9J966 1 Base Insulation Size and Thickness: 6. 6 Parapet 9 1 •. ..' .'Neiaht 96199 Base Insulation Fastener/Bonding Material: .. ... 6 9. ..1.9 1 9 6 1 • . 669 a l9 1 Top Insulation Layer. •F'T 6 6 00100: . . %too: 1 Top Insulation Size and Thickness: 9 6 . 000 9 1 Top Insulation Fastener/Bonding Material: Roof 1 1 Height 1 1 Base Sheet(s)&No.of Ply(s): 1 1 1 1 Base Sheet Fastener/Bonding Material: 1 1 1 Ply Sheet(s)&No.of Ply(s): 1 1 Ply Sheet Fastener/Bonding Material: 1 1 Top Ply: 1 1 1 15.38 FLORIDA BUILDING CODE--i BUILDING,5th EDITION(2014) Copyright to,-licensed by,ICC(ALL RIGHTS RESERVED);accessed by me=Palacio on Jun 8.2015 1032:12 AM pursuant to license Agreement.No further reproductions authorized. ROOF ASSEMBLIES AND ROOFTOP STRUCTURES Florida Building Code 5th Edition(2014) High-Velocity Hurricane Zone Uniform Permit Application Form 1 1 Section D(Steep Sloped Roof System) 1 ,� Roof System Manufacturer. �,�h, 0 f �G o 1 Notice of Acceptance Number. o 2d /l 1 Minimum Design Wind Pressures,If Applicable(From RAS 127 or Calculations): 1 P1: - t r P1: ' C P1: i 1 Deck Type: 1 1 RlopeType Underlayment: J,fS 1 1 1:2 Insulation: 1 1 Fire Barrier: 1 1 1 Rid,9a�entllation?, Fastener Type&Spacing: ! ��� ���r,, J 1U`� g- d ✓ 55,M+ L /. �fc 1 Adhesive Type: / D�c� rca `t 1 Type Cap Sheet: A ..Joe Mean Roof Height: Roof Covering: �a� ��,�tiT� /� .�%Te `,�•1•� 0*00 Type&Size Drip ••� ' '31 �ifi�•�•�,Gs�- ..��. Edge: •• . . . . ...... 000 Vote: . . FLORIDA BUILDING CODE—BUILDING,51th EDITION(2014) 15.39 Copyright to,or licensed by,ICC(ALL RIGHTS RESERVED);—sed by Eliezer Palacio on Jun 8,2015 10:32:12 AM pursuant to License Agreement.No further reproductions authorized. ROOF ASSEMBLIES AND ROOFTOP STRUCTURES Florida Building Code 5th Edition(2014) 1 1 High-Velocity Hurricane Zone Uniform Permit Application Form. 1 1 Section E(Tile Calculations) For Moment based tile systems,choose either Method 1 or 2.Compare the values for Mr with the values from K.If the Mr values are greater than or equal to the Mr values,for each area of the roof,then the tile attachment method is acceptable. 1 1 Method 1 "Moment Based Tile Calcy lations Per RAS 127" 1 (P1: x = 10,3 -Mg:S�(�I=Mr, 4" tb Product Approval 1 (P2: .' x,% .7z,9=g 1. )-Mg: t5-.`ly=M21 Product Approval M, L (P3:JT : xx .23 = � �_Mg:==M„�aji Product Approval Mt-7-Ft) (,T- Method 2"Simplified Tile Calculations Per Table Below" Required Moment of Resistance(Mr)From Table Below Product Approval Mr 1 Mr required Moment Resistance* Mean Roof Height Roof Slope 15' 20' 25' 30' 40' 2:12 34.4 36.5 38.2 39.7 42.2 1 3:12 32.2 34.4 36.0 37.4 39.8 1 4:12 30.4 32.2 33.8 35.1 37.3 1 5:12 28.4 30.1 31.6 32.8 34.9 1 6:12 26.4 28.0 29.4 30.5 32.4 1 7:12 24.4 25.9 27.1 28.2 30.0 1 *Must be used in conjunction with a list of moment based tile systems endorsed by the Broword County Board of Rules and 1 Appeals. For Uplift based file systems use Method 3.Compared the values for F'with the values for Fr. If thq F'values are'guesteer than or,a o 9 e 1 equal to the Fr values,for each area of the roof,then the tile attachment method is acceptable. • • • • 0000 .... 1Method 3"Uplift Based Tile Calculations Per RAS 127" .00:*6 0 0000 :0•••�•• • • (P1: x L = x w:_ )-W: x cos 0 =Fr, Product Approval F' •••••• 1 - )- xcos0 =F 0000 (P2: x L - x w:- W: n Product Approval F' • • :000:0 1 (P3: x L = x w:=-)-W: x cos 8 =F,3 Product Approval F'�� ••• ••:••• •• 00 00 00.000 Where to Obtain Information 0000•• •• Description Symbol • • • ••* Whereto nd 0000•• • 1 Design Pressure RAS 127 Table 1 or •0099: 1 9 P1 or P2 or P3 pared by PE based on ASCE�700 64 neerir gar»Ittsis pre. 1 Mean Roof Height H Job Site Roof Slope 0 Job Site Aerodynamic Multiplier Product Approval Restoring Moment due to Gravity M9 Product Approval 1 Attachment Resistance Mt Product Approval 1 Required Moment Resistance M9 Calculated 1 Minimum Attachment Resistance F Product Approval Required Uplift Resistance Fr Calculated 1 Average Tile Weight W Product Approval Tile Dimensions L =length W=width 1 Product Approval All calculations must be submitted to the building official at the time of permit application. 1 15.40 FLORIDA BUILDING CODE-I BUILDING,5th EDITION(2014) Copyright to,or licensed by,ICC(ALL RIGHTS RESERVED);accessed by Eliezer Palacio on Jun 8,2015 1032:12 AM pursuant to License Agreement.No further reproductions authorized. m. yw $_ R I<OR<D� SECTION 1524 HIGH VELOCITY HURRICANE ZONES—REQUIRED OWNERS NOTIFICATION FOR ROOFING CONSIDERATIONS 1524.1 Scope.As it pertains to the section,it is the responsibility of roofing contractor to provide the owner with the required roofing permit,and to explain to the owner the content of the section.,The provisions of Section R4402 govern the minimum requirements and standards of the industry for roofing system installations.Additionally,the following items should be addressed as part of the agreement between the owner ant the contractor.The owner's initial in the designated space indicates that the item has been explained. 2• Renailing wood decks:When replacing roofing,the existing wood roof deck may have to be renailed in accordance with the current provisions of Section R4403. (The roof deck is usually concealed prior to removing the existing roof system). 4• Exposed Ceiling: Exposed,open beam ceilings are where the underside of the roof decking can be viewed from below. The owner may wish to maintain the architectural appearance;therefore, roofing nail penetration of the underside of the decking may not be acceptable.This provides the option of maintaining the appearance. s• Overflow scuppers(wall outlets): It is required that rainwater flows off so thatthe roof is not overloaded from a buildup of water. Perimeter/edge wall or other roof wdensien may 6108h As ••••;• discharge if overflow scuppers(wall outlets)are not provided. It may be nepessary;o instgll 9"dlow scuppers in accordance with the requirements of Sections R4402, R4403 arTd`r=13. 0000.. 0000.. 0000 •• 9909• i • 9009• Owner/Agent's Signature Date Contra r Signature•••• (fie •••••• 9900•• • w • •, • 0 909090 9.0000 • • 9 • • • • • 99999• Property Address Permit Number • Revised on 7/9/2009 LD;07/01/2015, i MIAMk % MIAMI-DADS COUNTY rNNWPRODUCT CONTROL SECTION 11805 S W 26 Street,Room 208 DEPARTMENT OF REGULATORY AND ECONOMIC RESOURCES(RER) Miami,Florida 33175-2474 BOARD AND CODE ADMINISTRATION DIVISION T{786)315-2590 F(786)315-2599 NOTICE OF ACCEPTANCE (NOM www miamidade eov/economy 3M Company 3M Center Building 0220-05-E-06 St.Paul,MN.55144-1000 SCOPE: This NOA is being issued under the applicable rules and regulations governing the use of construction materials. The documentation submitted has been reviewed and accepted by Miami-Dade County RER-Product Control Section to be used in Miami Dade County and other areas where allowed by the Authority Having Jurisdiction(AHJ). This NOA shall not be valid after the expiration date stated below. The Miami-Dade County Product Control Section (in Miami Dade County)and/or the AHJ(in areas other than Miami Dade County)reserve the right to have this product or material tested for quality assurance purposes. If this product or material fails to perform n the accepted manner,the manufacturer will incur the expense of such testing and the AHJ may immediately revoke, modify, or suspend the use of such product or material within their jurisdiction. RER reserves the right to revolve this acceptance, if it is determined by Miami-Dade County Product Control Section that this product or material fails to meet the requirements of the applicable building code. This product is approved as described herein, and has been designed to comply with the Florida Building Code including the High Velocity Hurricane Zone of the Florida Building Code. DESCRIPTION:3Wm 2-Component Foam Roof Tile Adhesive AH-1.60 9000 ABELING: Each unit shall bear a permanent label with the manufacturer's name or logo city, state atxi Jg.11p.wing •••• statement: Miami-Dade County Product Control Approved",unless otherwise noted herein. •• •• 0• 9 9 • 0000 RENEWAL of this NOA shall be considered after a renewal application has been tiled and *00000 (4been no•change .•• in the applicable building code negatively affecting the performance of this product. *0000 000 0 0 999999 0009 9 00:090 TERMINATION of this NOA will occur after the expiration date or if there has been a reviaiato or chstage in the 66696 materials,use,and/or manufacture of the product or process.Misuse of this NOA as an endorstrmert>•of any product,for ••••,• sales, advertising or any other purposes shall automatically terminate this NOA. Failure to coWInith any section of •• this NOA shall be cause for termination and removal of NOA. .. 00000: 9999 0 0 . .9 . 999.. ADVERTISEMENT: The NOA number preceded by the words Miami-Dade County, FlOriM ani follorple&9;the • expiration date may be displayed in advertising literature. If any portion of the NOA is displayed,then it sha11•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 revises NOA 13-0502.02 and consists of pages 1 through 11. The submitted documentation was reviewed by Alex Tigera. NOA No.: 14-0805.01 tpAMvNuN7r Expiration Date: 05/10/17 Approval Date:09104/14 Page I of 11 ROOFING COMPONENT APPROVAL: Category: Roofing Sub Category: Roof tile adhesive Materials: Polyurethane SCOPE: This approves 3MTm 2-Component Foam Roof Tile Adhesive AH-160 as manufactured byI3M Company as described in this Notice of Acceptance.For the locations where the design pressure requirements,as determined by applicable building code,do 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 tile systems using 2-Component Foam Roof Tile Adhesive AH-160. PRODUCTS MANUFACTURED BY APPLICANT: Product Dimensions Test Product;Description Specifications 3MTrt 2-Component N/A TAS 101 Two component polyurethane foam adhesive Foam Roof Tile Adhesive AH-160 Foam Dispenser N/A Dispensing Equipment RTF1000 ProPack®30& 100 N/A Dispensing Equipment PRODUCTS MANUFACTURED BY OTHERS: Any Miami-Dade County Product Control Accepted Roof Tile Assembly having a current NPA which list attaehrngnt resistance values with the use of 2-Component Foam Roof Tile Adhesive AH-160 roof tile adhpive p •••• 0000:0 .. . . .. • MANUFACTURING LOCATION: 0 • 0000.. 0000 000.. 0000.. .0000. 1. Tomball,TX. ..0 0 0000.. 0000 . ..... PHYSICAL PROPERTIES: •••••• "' ' ""'• .. .. .. 0000.. Property Test Results**:*: •• Density ASTM D 1622 1.6 lbs./ft' I • 0000.. Compressive Strength ASTM D 1621 18 PSI Parallel to rise .'. :..••: th 12 PSI Perpendicular to rise Tensile Strep .' :•: 0 0 g ASTM D 1623 28 PSI Parallel to rise 00 Water Absorption ASTM D 2127 0.08 Lbs./Fe Moisture Vapor Transmission ASTM E 96 3.1 Perm/Inch Dimensional Stability ASTM D 2126 +0.07%Volume Change(a} 0°F.,2 weeks +6.0%Volume Change @15 °F., 100%Humidity,2 weeks Closed Cell Content ASTM D 2856 86% Note: The physical properties listed above are presented as typical average values as dete fined by accepted ASTM test methods and are subject to normal manufacturing variation. NOA No.: 1.4-0805.01 M oto min Expiration Date: 05/10/17 Approval Date:04/04/14 Page 2 of 11 EVIDENCE SUBMITTED: Test Agency Test Identifier Test Name/Report Date Center for Applied Engineering #94-060 TAS 101 04/08/94 257818-1 PA TAS 101 12/16/96 25-7438-3 SSTD 11-93 10/25/95 25-7438-4 25-7438-7 SSTD 11-93 11/02/95 25-7492 SSTD 11-93 12/12/95 Miles Laboratories NB-589-631 ASTM D 1623 02/01/94 Polymers Division Ramtech Laboratories,Inc. 9637-92 ASTM E 108 04/30/93 Southwest Research Institute 01-6743-011 ASTM E 108 11/16/94 01-6739-062b[l] ASTM E84 01/16/95 Trinity Engineering 7050.02.96-1 TAS 114 03/14/96 P36700.04.12 ASTM D 1623 04/18/12 P39740.02.12 TAS 101 02/21/12 TAS 123 Celotex Corp.Testing Services 528454-2-1 TAS 101 10/23/98 528454-9-1 528454-10-1 520109-1 TAS 101 12/28/98 520109-2 ••••�• 520109-3 •••• •••••• 520109-6 •• •• • ...... .... ...... 520109-7 • 520191-1 TAS 101 .... 03/42/99. :••�•: 520109-2-1 .• ' •'•"• .... ..... LIMITATIONS: ••�••• �•� •••••• 1. Fire classification is not part of this acceptance. Refer to the Prepared Roof Tile Assembly foef flte rating. : ..••:• 2. 3M""2-Component Foam Roof Tile Adhesive AH-160 shall solely be used with flat,low:&aim the profiles. :....: 3. Minimum underlayment shall be in compliance with the Roofing Application Standard RAS 120. •..'•: • 4. Roof Tile manufactures acquiring acceptance for the use of 3W 2-Component Foam Roof Tile Adhesive AH- 160 roof tile adhesive with their tile assemblies shall test in accordance with TAS 101. 5. All products listed herein shall have a quality assurance audit in accordance with the Florida Building Code and Rule 61 G20-3 of the Florida Administrative Code. CMMUWKjHM=)ADE NOA No.: 14-0805.01 expiration Date: 05/10/17 Approval Date:09/04/14 Page 3 of 11 INSTALLATION: 1. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 may be used with any roof tile assembly having a current NOA that lists attachment resistance values with the use of 3MTm 2-Component Foam Roof Tile Adhesive AH- 160. 2. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 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 3MTm 2-Component Foam Roof Tile Adhesive AH-160 shalI provide sufficient attachment resistance to meet or exceed the resistance value determined in compliance with Miami-Dade County Roofing Application Standards RAS 127. The adhesive attachment data is noted in the!,roof tile assembly NOA. 3. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 and its components shall be installed in accordance with Roofing Application Standard RAS 120,and 3M Company's 3MTm 2-Component Foam Roof Tile Adhesive AH- 160 Operating instruction and Maintenance Booklet. 4. Installation must be by a Factory Trained'Qualified Applicator'approved and licensed by 3M Company.3M Company shall supply a list of approved applicators to the authority having jurisdiction; 5. Calibration of the Foam Dispenser RTF 1000 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)• 6. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 shall be applied with Foam Dispenser RTF 1000 or ProPack®30& 100 dispensing equipment only. 7. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 shall not be exposed permanently to sunlight. S. Tiles must be adhered in freshly applied adhesive.Tile must be set within I to 2 minutes after 3MTm 2- Component Foam Roof Tile Adhesive AH-160 has been dispensed. 9. 3MTm 2-Component Foam Roof Tile Adhesive AH-160 placement and minimum patty weight shall be in accordance with the'Placement Details'herein. Each generic tile profile requires the specific placemegeti tto herein. 0.00 0.00•• • • 000000 00.0 00000. 6 0.000. 0060 ..606• . . 66 00.0 00.00 000000 .0. • 0,0.0 • 0 • . 06 .. 06 9000.. 9 •.0.09 0 • • ,. . . . 9 . . 000090 00..0. • 0 • • 0 . . . .000.0 66 . . 9.6 6 .6 . ENOA No.: 14-0805.01 Muar nAnEc unrrY xpiration Date: 05/10/17 Approval Date:09/04/14 Page 4 of 11 Table 1: Adhesive Placement For Each Generic Tile Profile Tile Profile Placement Detail Minimum Paddy Contact Minimum Paddy Gram Area Weight Eave Course-Flat,Low,High All Eave Course 17-23 sq,inches 45-65 Profiles Flat,Low, High Profiles #1 17-23 sq. inches 45-65 Flat Profile #2 10-12 sq. inches 30 Low Profile 42 12-14 sq. inches 30 High Profile #2 17-19 sq. inches 30 Flat,Low,High Profiles 43 Two Paddys:8-9 sq. inches at 12 grams per paddy head of the 9-11 sq. inches at i overlap Two-Piece Barrel(Cap Tile) Two Piece 2 Beads(1 each longitudinal 17 grams per bead edge)20-25 sq. inches each bead Two Piece Barrel(Pan Tile) Two Piece 65-70 sq. inches 34 grams under pan LABELING: All approved products listed herein shall be labeled and shall bear the imprint or identifiable marking of the manufacturer's name or logo and following statement:"Miami-Dade County Product Control Approved"or the Miami- Dade County Product Control Seal as shown below. ECOUNTY • • •••••• •••••• • • • • •••••• •••• •••••• BUILDING PERMIT REQUIREMENTS: ...:.. . • As required by the Building Official or applicable building code in order to properly evaluate titeg*'n66jailation 1bth" ,••••• system. • • • • • • 0690.• . • • • • • • 0000•. 0000•• • • • • • • • . 000000 00 Illonoe couNrr NOA No.: 14-0805.01 1APPROVED1 Expiration Date: 05/10/17 Approval Date:09/04/14 Page 5 of I I ADHESIVE PLACEMENT DETAIL# 1 Wag n"°"OkPlastic Pada I •N►►rl.> Flat/Low Profile Tile fwfteragWeadl, , Y Blends tegete � ° 1. Starting at the eave course,apply a minimum 2" (50.8 mm)x 10"(254 mm)x 1"(25.4 mm)foam � paddy onto the underlaynlent positioned as shown, y. * -•...s� ,� ,:.� ��� },a a under the strengthening rib closest to the overlock of the tile being set. EaweC•eera `�,, �� ° ' 2. Continue in same manner, Insure approximately 17 (109.7 cm)—23(148.4 ctnZ)square inch adhesive ,a� 4 contact with the underside of the tile. e..«cl•.•..__.— Nall th "ghplasftce nem Medium Profile! Double Pan Tile When re"Ireo ,� ____—i•eay t ••chate�l 1. Starting at the eave course,apply a minimum 2" (50.8 mm)x 10"(254 mm')x 1"(25.4 mm)foam paddy onto the underlayment positioned as shown �:' k �:••, "' under the pan portion of the tile closest to the overlock of the tile being set. •,, 21awIM is -•�w. � ti r ••• Nettansv��aral ^�, "� 2. Continue in same manner. Insure approximately- 17 (109.7 cm )-23(148.4 Gl ,quare inch ve aahesl • contact with the underside n �{�e tile. •••• •• �•. f Y a ,� G � •••• • • • • • • • • • lY.allr�ugSepl.•"k >� p� High Profile 1 Single Pan Till•••••• • • trAtaror•ipn�•dl ti dillasn..eh7il.i • • • sea*• •••••• umd••irgn c�•>;h ,d '' 4 a` I. Starting at the eave coursehppLfgminiMum2" i••••i �•2� (50,8 mm)x 10"(254 mm))t f"(25.4 mull 110341 e T paddy onto the underlayment positioned a>;'Ilyo>4n under the pan portion of the tile closest to the 21n.wlda �4, r i overlock of the tile being set. Batt•as ,� tl4 a i , 2. Continue in same manner. Insure approximately 17 apti•nal r3 !y� 2 2{109.7 cm )-23(148.4 cm)square inch adhesive t contact with the underside of the tile. V da to 1e`<`^•, a 1,,, %`�^ -�"�.a�� jGtna theme 4 ►� s�''w Orlp edge s- MUMMADIE MAMMON"— NOA No.: 14-0805.01 1 xpiration Date: 05/10!17 Approval Date:09/04/14 Page 6 of 11 ADHESIVE PLACEMENT DETAIL#2 kail thm4ghpbsily.#among Mlgan•sthTd!•I (Rhm md� µ:�� Flat/Low Profile Tile S f~• "md•d'ye`°m Starting at the eave course,apply a minimum 2"(50.8 : ,. '= •.., mm)x 10"(254 mm)x I"(25.4 mm)foam paddy f onto the underlayment positioned as shown under the strengthening rib of the tile,closest to the overlock of the tile being set.Insure approximately 17(109.7 cm2) 23(148.4 cm)square inch adhesive contact with the ray.c.un. f r u. underside of the tile. 2. At the second course,apply a minimum 2"(50.8mm) 'tura ,' r R`'iasua x 7"(177.8 min)x 1"(25.+mm)foam paddy onto the 2 f� underlayment positioned as shown under the strengthening rib closest to the overlock of the the being set. 3. Continue in same manner.Insure approximately 10" (64.5 cm)- 12(77.4 cm2)square inch adhesive contact with the underside of the tile. "Nil YhMkMh0esticManeal Medium Profile/Double Pan Tile 4When requimdf ---Paddy jlllwea,htne, 1. Starting at the eave course,apply a minimu"050.8 { mm)x 10"(254 mm)x 1"(*.4•rmn)foam paddy ••••;• `d Y`"~ onto the underlayment sit'o>aed as sho the • pan portion of the the close to ti'I*4bverloc1L*dMhe •""' '` `"-•_.� the being set. Insure approx (?Iq'17(109.71`m2)— :....: 23(148.4 cm)square inch adUA%contacta diathe • y _ .�y ! •••• • ••••e sre�•�+�a ,, �� , ��,�- underside of the tile. ...... ... ..... 2. At the second course,apply a mmhum 2 (50,,8mm) •• x 7"(177.8 mm)x l"(25.4 m)4folmpadorVothe F&WO06fam underlayment positioned as town under tat*AAA• E•N•iCaU1*0 Fast"'�:�' - ,._. portion of the tile closest to the.ptredock of theWLe :•**a 9 • • • • being set. .. 3. Continue in same manner. Insure approximately 12" (77.4 cm2)- 14(90.3 cm)square inch adhesive contact with the underside o the tile. (Instructions continued on next page) 1"IIAM4DADE COUNTY NOA No.: 14-0805.01 Expiration Date: 05/10/17 Approval Date:09/04/14 Page 7 of I I ADHESIVE PLACEMENT DETAIL#2(CONTINUED) WallihmughpUmkca High Profile/Sin a Pan Tile twhenrogviredy `�, R+m9djr18tiea�ahrile3 1. Starting at the eave course.ripply a minimum 2"(50.8 Y' t' mm)x 10"(254 mm)x 1"(25.4 mm)foam paddy onto the underlayment positioned as shown under the + t pan portion of the tile closest to the overlock of the the being set.Insure approxiknately 17(109.7 cm2)— 23(148.4 cine)square inch adhesive contact with the Bmtens Optimal �ib # <m \ underside of the tile. E ,�,�t �A '.�S.,a tet• �.;y. 2. At the second course,apply a minimum 2"(50.8mm) r BaveCaw" s �;� 5s `'Fascia x 7"(177.8 mm)x 1"(25.4 mm)foam paddy onto the underlayment positioned as shown under the pan ion :n. r ,�', `� " portion of the tile closest to the overlock of the tile 'Drip edge being set. 3. Continue in same manner. Insure approximately 17" (109.7 cm2)- 19(122.6 cm)square inch adhesive contact with the underside of the tile. ...... .... ...... ....... . . . .... . ..... ....... ... . ..... ee ae .. ..tete taaeee e . . . ..tete ...... a . :0060: ee . e ... . e .e ruAoaoE ct�uNn NOA No.: 14-0805.01 Expiration Date: 05/10117 Approval Date:09/04/14 Page 8 of 11 ADHESIVE PLACEMENT DETAIL#3 man throtsgleplasticceamit Paddlrtbenreent l When 1 1. On the eave course only,apply a minimum 2"(50.8 IN,Mown aptianal mm)x 10"(254 mm)x 1"(25.4 mm)foam paddy onto the underlayment positioned as shown,under s;m,�e�aar P the strengthening rib for flat the or under the pan yr antog•ttae 'f portion of the tile for low or high profile file closest 4x41n. $"nom to the Overlock of the tile,being set. Leave approximately 4"(101.6 mm)up from the save S eglepwdy ,,� �� -, edge free of foam to prevent the expanded adhesive Zx41n. .4: from blocking the weep holes. insure approximately 17-23 int 109.7-148.4 cm2)of adhesive contact with the underside of the tile fasda in. d° 2. Apply a 4"(101.6 mm)x 4"(101.6 mm)x I"(25.4 WWWWMMJ mm)foam paddy onto the underlayment just below FlatnAWPrallleTlle the second course line positioned foam paddy under the strengthening rib for flat tile,or under the °anew Rn* r'n'fttfle pan portion of the tile,closest to the underlock for p a�yaetw•ntaes) the second course tile to be installed. Insure approximately 8-9 inn(51.6-58.1 cm2)of adhesive aI PA tur"Weel contact with the underside of the tile. IAW 0000 �t ` »+ '`+. (Instructions continued on nex�Ilagg) •••••• •••••• + kpaddyon #��`" 0•••0•Unaem • 0000 0000•• ��� i 0000•• • i••••i "�� `� 0000 • • • • Sin. • • 0000•• 0000 • 0000• - ®gsusg i 0000•• ••• • 0000• Eave roues• Fasd4 •• •• •• •••••• • 0000•• • • Medium PreflleTtle • 0 i••0 i• *0000:0 0 0 0• • • • • • • • • •000•• =UMNTNOA No.: 14-08(15.01 oAwr:cEx ;ration Date: 05/10/17 Approval Date:09/04/14 Page 9 of It ADHESIVE PLACEMENT DETAIL#3(CONTINUED) Nab"nano Phok Sje0e Paddy=derWe ImbWre"Ired) 3. Also apply a 2"(50.8 mm)x 4"(101.6 mm)x 3/e" aaaarlteu�� (19 mm)paddy on top of the eave course tile �. dyi,,,, nlai surface as shown,on top pf the strengthening rib du Optional r for flat tile or on top of the pan portion of the tile, closest to the underlock of the first course of tile. =, Install second course of time. Insure approximately AYain. 9(58.1 Cm2)- 11 (71cm2)isquare inch adhesive •, contact with the underside of the tile at the overlap �Vaona:atni � Fay and 7(45.2 cm2)-9(58.1,cm)square inch adhesive contact with the;underside of the tile at the head of the tile.Continue in same manner. Ease Course_ Fasda 4�e+gat►c+le t01fl 2111. edwte �pge High ProflteTtt9 • • •••• •••••• • •••• • *eggs 00069• es• • 00000 •e •• •o gee••• e •6.666 Nr • • • • � • • •••gee I NOA No.: 14-0805.01 MwMMADE Cot Expiration Date: 05/10/17 Approval Date:09/04/14 Page 10 of I I ADHESIVE PLACEMENT DETAIL TWO PIECE BARREL Two Piece Barrel(Cap and Pan)Tile 1. Starting at the eave course,apply a minimum 2" Plate ghadhesive h)er*bStwhen•7o&q.ht phdic&eion:nc� hepantile. required) (50.8 mm)x 10"(254 mm)x l"(25.4 mm)foam 2)Turn covers upside dman.Place adhesive in paddy onto the underlayment positioned as to I Then"'ham stallth outsidege of cover tile. shown under two adjacent pan tiles.Support eave Than Install thetil*.Ensure 20 to 2s sq(a cont&ctarea• s,- ° tiles from rocking until adhesive has a chance to Undedayment -y'4y cure. 2. Continue in same manner bringing two pan courses up toward the ridge, Insure approximately 65(419.4 cm)—70(451.6 cm2) square inch adhesive contact with the underside F Kw� ' of the pan tile. rYy� +y E&M*dOfU7 � �'•'.rJ � Sheathing asp (motorshoem) 3. Turn covers upside down exposing the underside Weephoie Fasv&eoard of the tile.Apply a minimum 1"(25.4 mm)x 10" (254 mm)bead of adhesive directly on the inner armvot•pportionau..necoursecov..uie•"Ustoseco,d ret edge of each side of the cover tile. Leave pan Was.Ensure*&we end of pan mW cover tftsare flushatesaeMne. approximately 3/4"(19 mm)to 1"(25.4 mm) Two Piece Barrel-High Profile Tile from the outside edge of the tile,inward,free of foam to allow for expansion. • •• ...... 4. Turn cover the over after foam-is applie.l jBd �• place onto pan the cou ei j sire a mhg:ijV of ��••;• 20(129 cm)-25(16 LA Gge. %quare i nclk contact area on each side pil4e coveretile t9 the pan tile.Continue in sarfiia awlier.T4iM?MAy ee•e. any cured exposed foain► Eve.Pointing of ••.••• ad longitudinal edges of the cover tiles are • •••••• • considered optional. .••••• • • • • . . . ...... 5. When additional nailingas r%ftred,r(50.8 ;•e••; mm)x 4"(101.6 mm)nai?e'1rs of the tib 48: ' system using galvanized,stainless steel for copper wire and compatible nails may be used. END OF THIS ACCEPTANCE NOA No.: 14-0805.01 hd—F lid tt'.0 a]ecouivrrJAPPROYEx iration Date: 05I10/17 + Approval Date:09/04/14 Page 11 of 11 Miami Shores Village g Fp—,p—,c-R VFD c� Building Department JUN 2 010 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 r Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 .�FBCC 2014 / BUILDING Master Permit No. j-4—I PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS VICHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 13`57 A/Ide' Ieyop City: Miami Shores County: Miami Dade Zip: X331-3P Folio/Parcel#: Is the Building Historically Designated:Yes NO P"Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Phone#: 13" WV- Address: �--:V/ /IJP fe ST���7' City: 4ti; S1yees State: r1a e.-z)4 Zip: 33/3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Qjdone#:I' � '�3 Z Address: /'KV2S7- A.) L4 e"-' City. State: ( Zip: �5 Qualifier Name: Phone#:'�5— 991/ 0 State Certificatio Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: Statie: Zip: Value of Work for this Permit:$ 11.2d®-ew Square/Linear Footage of Work: —72r ..y9 Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: h�CPi�/A �iC� ®r%/� eC��°�gGc� ;cb6e T`BS�) Specify color of Wo ru Mile: �c Submittal Fee$ Permit Fee$ CCF$ CO/cc$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City 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. 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 commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is is u d. In the absence o such posted notice, the inspection will not be approved and a reinspection fee will be charged. SignatureM�CSignature OWNER or AGENT CONTR4 CTOR The foregoing instru nt was acknowledged before me this The foregoin instrum t was acknowledged before me this day by ay of 20<c ,by oIla 1pkt— -Is personally known t �/►�✓ Die ® wh is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take�n oath. NOTARY C: NOTARY PUBLIC: Sign: Sign: Print Print iMTVXN=10N#ff 122745 ,.. Seal: EXPIA68;May 1t 201e Seal: :' MIGUEL COTES I1o�ae Puepa trKwnro 's :+= My COMMISSION#E 864537 '•• '.. '' EXPIRES Nov mber27,2016 «71398 0153 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ♦5k!ORFs Gi Miami shores Village "" Building Department ' o" 4ORm ► 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N.25: — t S- 239 I Owner's Name (Fee Simple Tide Holder DgAos C® QY� Phone Owner's Address: City:�-U State . Zip Coo Job Address (Of where work is being done City: Miami Shores State: Florida Zip Code;n!5 Contractor's Company Name: � nQD Q--)C),p Phone Ik Address: ' t O M Zane in Oq City: Lao C i State:(-4Vt.-tcYnZip Code: Qualifier's Name: lundA &00— Lic. Number Architect! Engineer of Record Name: Phone 4.- Address: :Address: City: State: Zip Code: Describe Woric -)V 1 1 hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal involvement. Signature z ' Signat 04.dor Agent Contractor or Architect The foregoing instrument was aknowledged before me The foregoing instrument wast aknowledged before me this day of 201(Qby Q� this /4*' day of �w�e ,2V6 by Who is ersonally known o me or who has produced _�eruo` ersonall r o n to me or who has produced as indentification. as indent cation. No P 0 Notary Sign: Sign: Seal: y. Seal: 11 DIA GONZN.`Z 4 -4 ill1�SI0Z13. 7'.:1 2+: * My tAMMIS3I0N#FF 122745 w� EXPIRES:May18 IRES:May 13,2018 B0"d�T MaryPUmom P. Tt-Notmy PubOc UndeweReis STATE OF FLORIDA DEPARTMENT ENT OF BUSINESS AND ES L REGULATION •� CONSTRUCTION INDUSTRY LICENSING BOARD {850}487--1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MORENO,JUAN GUILLERMO GULFSTREAM ROOFING AND URETHANE ING 2649 NASSAU DR MIRAMAR FL 33023 Congra#ulationsl With this license you become one of the needy one mili'lon Floridan licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers,from boxers to barbeque restaurants, TATE OF FLORIDA and they keep Fkxida's economy strong. EPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to. CCC1327148 serve you better..For information about our services,please log onto ISSUED: 08/2512014 www.myffloddalkense.com. There you can find more information about our divisions and the regulations that impact you, subscribe CERTIFIED ROOFING CONTRACTOR to department newsletters and learn more about the Department's MORENO,4UAN GUILLI Initiatives_ GULFSTREAM ROOFING AND URETHANE IN Our missian.at the Department is:License Efficiently,Regulate Fairly. �1�constantlyysstrive to serve you better so#fiat you can serve your nk you for doing business in Florida, IS CERTIFIED under the provisions of Ch.489 FS. and congn3tulations on your now license! Exphffimt 1a:AUG 31,zags 04oez5no1712 DETACH HERE RICK SCOTT,GOVERN-OR _ KEN LAMON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL.REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD tC�CC132714-8 The ROOFING CONTRACTOR Named below IS CERTIFIED M . Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 MORENO,JUAN GUILLERMO a GULFSTREAM ROOFING AND URETHANE INC 2649 NASSAU DRIVE MIRAMAR FL 32303 ® e ISSUED. 08/2512014 DISPLAY AS REQUIRED BY LAW SEQ# L140 1712 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#;185-242171 Business Name'INCGUFSTREAM ROOFING AND URETHANE Business T ROQFING/SHEET METAL CONTRACTOR yl�•(ROOFING') Owner Name:NoRENo,JUAN GOILLERMo Business Opened:06/27/2011 BtWjnwW LoCsdon:2649 NASSAU DRIVE Statemounty/CerflRBg=d1327148 MIRAMAR Exemption Code: Business Phone:954-966-6840 Roams seats Employees Machines I Professionals 2 For Vendb*Business Qniy Number of MachMes: Vending Type: Tax Amount Tra Ww Fee I NSF Fe Penalty Prior Years Conaftn Cost Total Paid 27.00 0.00 0.00 1 2.70 1 0.00 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 Courtly and is non-regulatory in nature.You must meet an County and/or Munikipality 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. Mainrrg Address: GULFSTREAM ROOFING AND URETHANE IN Receipt if30B-15-00000031 2649 NASSAU DRIVE Paid 10/01/2015 29.70 MIRAMAR, FL 33023 2015 - 2016 MRO' WA Rn r.nl INW I _ L ACAL. .ISI 1111ESS_TARECORPT .!£FF ATMTM CSF FOIANcIA.oFp&-ER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SES DIVISION OF WORKERS'COMPENSATION CER71F=iE OF ELECTION TO BE SMPJPT FROM FLORIDA TSN LAW C®NWRUCTION INDUSTRY F m0 N6 This Oerbifm that the indlvldaal listed below has 9WW to be exempt frW F mfda VftimComm law. EFFECTIVE DATE: 7115a015 EXPIRATION DATE: 7/14!2017 PERSON: MORENO JUAN G DEIN: 262186901 BUSINESS NAME AND ADDRESS: GULFSTREAM ROOFING AND URETHANE INC. 2849 NASSAU DR. MIRAMAR FL 33023 SCOPES OF BUSINESS OR TRADE: LICENSED ROOFING CONTRACTOR ftsmdta( 440.05(14j F.S..goaffl=of acmpW8VM%ftebftWW"MftmVftdW9W byf9acarmhWeafekmaoatts ob 11 may nd reeart er arMKM drepier ftsuM ttol 440.05(12).F.S.,hof etecllon to le?mmpft..apply o um me SMS of ft bushma orfrsde glad an ftm rwdce of sbcam 10 bee Wusua"t to Chupter 44(L05(13),F.S.,Nabas of efteson ib be owa ofeteuntobee>�dpdtm for r#at argr*wmterfltefMoffhenoftcrfhe afma tea p ar the aimmara6ummeang meewftn3 requhamerm ofthb sedian for hmuence ofa cmak:mm The daparonmd ehsflsevake a i)FS+2-mAr,2s2 CEFmFirATE OF EtECTm TO 8E sawT Remm 08-15 (g yg1S-i8� Jun 171610:502 ' 'Delta Insurance Und. Inc. 3052691108 P.1 ____88WIN St 6A CERTIFICATE OF LIABILITY INSURANCE °�06/17J2016 D° "' THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.if SUBROGATION IS WAIVED,subject to the tends 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 endorsome s. PRODUCER CONTACTNAMLUIS DE LA LLERA DELTA INSURANCE UNDERWRITERS,INC. PHONE No Err: 305-269-1107 AM x.305-269-1108 777 N.W.72nd AVENUE,SUITE 3133 DELTAINSUN MIAMI,FLORIDA33126 ADDRESS: D�AOLCOM INSURERIS)AFFORDING COVERAGE MAIC 0 WSUI RERA: ARCH SPECIALTY INSURANCE COMPANY 21199 INSURED GULFSTREAM ROOFINGAND URETHANE,INC. INSURER 8: 14525 NW 2nd AVENUE o►SURE R C: MIAMI,FLORIDA 33188 eASURER& INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 RES PECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED 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. TYPE OF INSURANCE pySR vwD POLICY NUMB Mk% LJMITS GENERAL LIABILITY CONMERCLAL GENERAL LIAMUTY EACH OCCURRENCE $ 1,000,000. MI ARRLAGE TO RES CLAIMS-MADE ®OCCUR ES CEO occurrence $ 100,000. MED EXP(Any one person) $ 10.000. AGI-002110"I01/1212016 01/12/2017 PERSONAL BADVINJURY 5 1,000,000. GEL++I'L AGGREGATE LIMITAPPUES PER GENERALAGGREGATE S 11000,000. POLICY l PRODUCTS-COMPIOPAGG S 1,000.000. Deductible per Claimant $ 2,500, AUTOMOBILE LIABIUTY A�NYAUTO (Eaaoddenl) s ALL OWNED SCHEDULED 130DILY INJURY(Per person) S AUTOS AUTOS HIREDAUTOS NON-OWNED L BODILY INJURY(Peraaddent) $ AUTOS P erste DAEAAGE S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LWB I QAIMS-MADE A $ DED F R _TE-- $ WORKERS COMN'EN1'rgmAND $ Er1RPLOYER3'LJABILITY YIN UIH OFF:CER/MEM� WNERfEXECUTIVE NIA TO YLIMI ER E.L.EACHACCIDENT S (Mandatory yy.e8SWPWbqun ELIXEEIkSE-MEYP LOYEE $ NDHSCRIPTIO N OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT 15 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attagl ACORD 101,AddlUonal R-Its Schedule,It mote space is required) ROOFING CONTRACTOR LICENSE NUMBER CCCI327148. CERTIFICATE HOLDER CANCELLATION SHOU VILLAGE OF MIAMI SHORES/BUILDING DEPT FAUTHORJ:ZED ATION DAATEANY OF THE ATTHHEREO NOr'CE WIVE DMcm LL 8 DELIVERED IN INIES BE BEFORE 10050 NE Znd AVENUE NCE WITH THE POLICY PROVISIONS. MU4M1 SHORES,FL 33136 PH 305 795 2204 FAX 305 7588972 REPRE313drAT EVE LUIS DE LA LLERA ACORD 25(2010105) The ACORD name and logo are registered marks o ACORp10AGORD CORPORATION.All rights reserved, ��guREs �i s� t c Miami hores Village ones ami Building Department S-042-For—l! 0 10050 N.E.2nd Avenue ARNP` Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner— Workers' Compensation Insurance Exemption 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 acts 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 corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of twoears or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: C L_ Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this�,DL--day of ,201(. , BYQ whdQis personally kno o me or has produced as identification. Notary: Mr wWgS3I0N a FF 1 SEAL: g FIRES;Ma , 018 ®ondod ran,�ub�o UmbwbB GULFSTREAM ROOFING AND URETHANE INC 2469 Nassau Drive Miramar, Florida Tel. 954 889 4890 LIC# CCC1327148 June 21, 2016 State of: Florida County of: Dade County Before me this day personally appeared Juan G Moreno who being duly sworn, deposes and say: That he will be the only person working on the project at 351 NE 98 Street, Miami Shores, Florid 1138. u G Moreno n� Sworn to (or affirme nd subscribed before me this day of ,2016 by Personally Knovn— Or Produced Identification Typ Identificatio duced COMMISSION#FF IW45 EXPIRES:May 13,2D18 Bowled Thru Notary Pu*Undervr to Print,Type or Stamp Name of Notary