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RF-16-1644 fv Miami Shores Village long Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 ��pR'rpR Tel: (305)795.2204 Fax: (305) 756.8972 RE: Permit# _�r � / DATE: INSPECTION AFFIDAVIT 1 1) - L � AA te� licensed as a n) Contractor/Engineer/Architect, (Print name and circle License Type) FS 468 Building Inspector License4!�'to r J 7 V On or about 6 / l°:3U , 1 did personally inspect the roof deck nailing n (Date&time) work at,__y � (Complete Job Site Address) Based upon that examination I have dete ined the installation was done according to the Hurricane Mitigation Retrofit anual(Based on 5 844 F.S) zo Signature State of Florida County of Dade: The undersigned, being the first duly swom, deposes and says that he/she is the contractor for the above property mentioned. Swom to and subscribed before me this l'1 '— day ofsaw �'uv►e. Notary Public, Sate of Florida at Large �L� �, lW#FFW" 16' 2019 ct Tta1VW olerY *General,Building,Residential,or Roofing Contracture or any individual certified under 468 F.S.to make such an inspection.Include photographs of each plane of the roof with pemdt#and address#clearly shown marked on the deck for each inspection Dcuioc,i nn l71dAMMA1FM1l9f1t16 k � E 6 � 1sN t®` Miami Shores Village Bf??f)z 7' �f , Ca 10050 N.E.2nd Avenue NE it Miami Shores,FL 33138-0000 711� Phone: (305)795-2204 »_ �'taRmA Exp iration: 12111/2016 Project Address Parcel Number Applicant 549 NE 106 Street 1122310140130 Miami Shores, FL 33138- Block: Lot: MYRON BARGER Owner Information Address Phone Cell MYRON BARGER 549 NE 106 Street MIAMI SHORES FL 33138-2045 ' Contractor(s) Phone Cell Phone Valuation: $ 3,200.00 D L ALLEN ROOFING INC (305)621-5119 _...,.. Total Sq Feet: 328 Type of Work:Re Roof Available Inspections: Additional Info:RE-ROOF FLAT SECTION B.0 SYSTEM Inspection Type: Classification:Residential Scanning:3 Tin Cap Final Roof Review Roof Roof in Progress Renailing Affidavit Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 Invoice# RF-6-16-60179 CCF $2.40 DBPR Fee $3.75 06/14/2016 Check#:2413 $772.90 $0.00 DCA Fee $3.75 Bond#:3108 Education Surcharge $0.80 Permit Fee-New Roof $250.00 Scanning Fee $9.00 Technology Fee $3.20 Total: $772.90 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. June 14, 2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy June 14,2016 1 � "` , S Miami Shores Village B;r �S. 10050 N.E.2nd Avenue NE K nq .5" r f 'T ' Wi Miami Shores,FL 33138-0000 P€rrrlfl8t� � ' yy Phone: (305)795-2204 t 'Issue i 6/14/2' , Expiration: 12111/2016 Project Address Parcel Number Applicant 549 NE 106 Street 1122310140130 MYRON BARGER Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell MYRON BARGER 549 NE 106 Street MIAMI SHORES FL 33138-2045 Contractor(s) Phone Cell Phone Valuation: $ 3,200.00 D L ALLEN ROOFING INC (305)621-5119 Total Sq Feet: 328 Type of Work:Re Roof Available Inspections: Additional Info:RE-ROOF FLAT SECTION B.0 SYSTEM Inspection Type: Classification:Residential Tin Cap Scanning:3 Final Roof Review Roof Roof in Progress Renailing Affidavit Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 CCF $2.4o Invoice# RF-6-16-60179 DBPR Fee $3.75 06/14/2016 Check#:2413 $772.90 $0.00 DCA Fee $3.75 Bond#:3108 Education Surcharge $0.80 Permit Fee-New Roof $250.00 Scanning Fee $9.00 Technology Fee $3.20 Total: $772.90 Applicant Copy For Inspections, Call (305) 762-4949 or Log on at https://bidg.miamishoresvillage.com/cap/. Requests must be received by 3 pm for following day inspections. NOTICE: In addition to the requirements of this permit, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER additional restrictions applicable to this property that may be found in GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT the public records of this county. DISTRICTS,STATE AGENCIES,OR FEDERAL AGENCIES. June 14,2016 2 Miami Shores Village lD Building Department artment JUN 14 016 'A 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201` BUILDING - Master Permit No. 1 1694 PERMIT APPLICATION Sub Permit No. F-1 BUILDING ❑ ELECTRIC /ROOFING ❑ REVISION ❑ EXTENSION F-1 RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP q� r f�] �^ , CONTRACTOR DRAWINGS JOB ADDRESS: ®5� /V / �/ 1-° City: Miami Shores County: Miami Dade Zip: Folio/ParcelM t—aa.3o f 3c) Is the Building Historically Designated:Yes NO Occupancy Type:s2rX Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name��(Fee SimpleTitlpholder): I "`�/r®r\ qe� Phone#:�S LEY6- �7 ttg Address: �T 1 /u F I()(a City: State: t-` Zip: 3/Zi. Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: b i L , !Al \?..ems I 0 O�11 �`� � ` Phone#: �j 0� (V zI -.f/// Address: � �� SLA) aT_1i '51 , City: axi` -State: - Zip: 3.3 Z�j Qualifier Name: L QM Phone#: 3 h g ^ 670- S l[F State Certification or Registration#: CQt,0 1 3 /:q_ Certificate of Competency#: DESIGNER:Architect/Engineer: I Z Phone#: Address: P City: State: Zip: Value of Work for this Permit:$ 200 Square/LinearrFF000tage of Work:?�_ Type of Work: ❑ Addition ❑ Alteration ❑ New LJ rtepair/Replace ❑ Demolition Description of Work: --r-b f Specify color of color thru tile: t4. lir 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 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-certifred copy of the-recorded WicL-gfcomm-errcem rit-must-b'e pbste-d—art;"ea-sire 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. Signature Signature OWNER oAGE CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this -- 1A day of —.,20 / �o by day of !—� — —J 2d J� by -_ 4 rZIA rte' who is personally known to _ P�i pin who is personally known to me or who has produced 1)ty� L"a as mke or who has produced /mss -- identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign• MARDO Print: ? : Print: .o3'r�, * — •.;�--MARCO SINAI Seal: mE;;RES:AWt16,2019Seal * * MyWWIS'.-10N IFFW 7y 8*WTin BudgetNorarysow EXPIPES -.uyust16,2019' �'+rf��pQ�Oc Bmafe ��roor:•�e:NobrySBlMtes ****�W*x�+x°�*°°e*°���e�*�*r� wu�** sz� x�°**°�t���**�°*�:*��x�rr***���*°+�°�°*�°�s�x*°*•x�x��es�s�a+�*°r***x��s�a��ra�a****° APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) DLAR001 OP ID: KM CERTIFICATE OF LIABILITY INSURANCE DAT05/26/20 6 05/26/2016 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 policy(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 CONTACT J.W.Edens&Company PN ONE FAX Commercial Ins of Brevard,Inc A/c No A/C No): 325 Fifth Avenue,Suite 108 an�DRess: Indialantic,FL 32903 Scott M.Steele,AAI INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AXIS Surplus Ins.Co. 26620 INSURED D.L.Allen Roofing Inc.& INSURERS: Allen&Daniels Construction Company Inc. INSURER C: 5826 SW 23rd Street INSURER D: West Park,FL 33023 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. tLT R TYPE OF INSURANCE POLICY NUMBER M��EFF MP�p EXP LIMITS LTRINA& GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY FLGLN01841AX 08/13/2015 08/13/2016 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE FxI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Fa accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS PER ACCIDENT) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION TCOY LIA IT' OER TH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOWPARTNERIEXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Certified Roofing Contractor Dale Allen License # CCCO13874 CERTIFICATE HOLDER CANCELLATION MIAMISV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE Miami Shores,FL 33138 36d" ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD SEMINOLE FORM $86 PROPOSAL — Page No. 4VV ..e ✓�� > At/G/�"��. �eP�s°�J� of_ d&J&c__Pages /yw '007 PROPOSAL SUBMITTED TO: PFjpN_E: _ 1 + DATE: NAME: —JOOBB NAA�MEEt STREET: 526 SU✓' STREET: �j�iC� A06 57_,<C-F7— CITY: CITY: JSIA104ts STATE: STATE: p�r ys sq� We hereby submit specifications and estimates for: 19CROa-Pe SALI �►; ee�� We hereby propose to furnish labor and materials—complete in accordance with the above specifications,for the sum of: 00 /rZjr- t" �p n "'°°""' dollars($ 1 with payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs, will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. This proposal subject to acceptance within ® days and is void thereafter at the option of the undersigned. Authorized Signature ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are hereby accepted. You are authori o the work as specified. Payment will be made as outlined above. ACCEPTED: Sign Date Ile Signature , DETACH HERE ,_RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE-OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION,,INDUSTRY LICENSING BOARD a P imago= QCC1330531 The ROOFING CONTRACTOR Named below IS CERTIFIED Under the,provisions of Chapter 489 FS. Expiratid date: AUG 31;2016 �r ,? tt ��••gg �cwc. �.. .il' .. lY•If • �lif RU.810;3ULIQ CESAR S AAAERICAN EAGL RQ k S I IC 1.941 A MEARS ??/�RV�/ i4�ARGATE FL63 # a Y:•• ' y S +ca++en• rterss��rtle nugpl AV AR RPM IIRFn RY LAW SEQ# L140929DOD0584 AMERI-2 OP ID: SC ACORO� CERTIFICATE OF LIABILITY INSURANCE FDA05/2712016Y) o5r27r2o1s 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 confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Premier Protection Insurance NAME: Gerald Katz 409 SE 7th St ac°NN Ft,:954-467-8738 ac No:954-944-1881 Fort Lauderdale,FL 33301 E-MAIL Gerald Katz ADDRESS:jorry@premierprotectioninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:United Specialty Ins.Co. 12537 INSURED American Eagle Roofing INSURER B: Services Inc 1941 A Mears Parkway INSURER C Pompano Beach, FL 33063 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS-MADE a OCCUR SII1041A10482-01 02/15/2016 02/15/2017 DAMAGE TO RENTE9__ PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY JECOT- [�] LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NED P.r. er accident HIRED AUTOS AUUTOSTOS UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION rH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yesdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more space Is required) Lic.#CCC1330631 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE D.L.Allen Roofing,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 5826 SW 23 St West Park, FL 33023 AUTHORIZED REPRESENTATIVE C 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Date CERTIFICATE OF LIABILITY INSURANCE 5/31/2016 Producer: Plymouth Insurance Agency This Certificate is issued as a matter of information only and confers no 2739 U.S. Highway 19 N. rights upon the Certificate Holder. This Certificate does not amend,extend Holiday, FL 34691 or after the coverage afforded by the policies below. (727) 938-5562 Insurers Affording Coverage NAIC# Insured: South East Personnel Leasing, Inc. &Subsidiaries Insurer A: Lion Insurance Company 11075 2739 U.S. Highway 19 N. Insurer B: Holiday, FL 34691 Insurer C: Insurer D: Insurer E: Coverages The policies of insurance listed below ave been issue to t e Insured named a ve for the policy period Indicated. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate may be Issued or may pertain,the insurance afforded by the policies described herein is subject to all the terms,exclusions,and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. INSR ADDL Policy Effective Policy Expiration LTR INSRD Type of Insurance Policy Number Date Date Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence $ Commercial General Liability Damage to rented premises(EA Claims Made 0 Occur occurrence) Med Exp Personal Adv Injury General aggregate limit applies per: General Aggregate Policy ❑Project ❑ LOC Products-Comp/Op Agg AUTOMOBILE LIABILITY Combined Single Limit (EA Accident) $ Any Auto Bodily Injury All Owned Autos (Per Person) Scheduled Autos Hired Autos Bodily Injury Non-Owned Autos (Per Accident) Property Damage (Per Accident) EXCESS/UMBRELLA LIABILITY Each Occurrence Occur ❑Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2016 01/01/2017 X WC Statu- OTH- Employers'Liability tory Limits ER Any proprietor/partner/executive officer/member E.L.Each Accident $1A00,000 excluded? NO E.L.Disease-Ea Employee $1,000,000 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/Locations/Vehicies/Exclusions added by Endorsement/Special Provisions: Client ID: 84-65-902 Coverage only applies to active employee(s)of South East Personnel Leasing,Inc.&Subsidiaries that are leased to the following"Client Company": American Eagle Roofing Services,Inc. Coverage only applies to 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 calling(727)938-5562. Project Name: JULIO CESAR RUBIO,LICENSE NUMBER CCC1330531 AS QUALIFIER.ISSUE 05-31-16(AF) Benin Date 1/22/2013 CERTIFICATE HOLDER CANCELLATION D.L.ALLEN ROOFING INC. Should any of the above described policies be cancelled before the expiration date thereof,the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left,but failure to do so shall Impose no obligation or liability of any kind upon the Insurer,Its agents or representatives. 5826 SW 23RD.STREET WEST PARK, FL 33023 Miami shores Village Eggs no Building Department �y .d 10050 N.E.2nd Avenue R�p 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: /9 10050 NE 2nd Ave Miami Shores, FI 33138 Re: Owner's Name: 7�� Property Address: �s /!5;� -5-7,-ttCY— zz�U,71 1=4, Roofing Permit Number: Dear Building Official: I y,�w' ��45a%gA- certify that I am not required to retrofit the roof to wall connections of my building because: 1'fhe 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 Print Name State of Florida County of Dade The undersigned, being the flrst.duly sworn,deposes and says that he/she is the owner for.the above property mentioned. Sworn to and subscribed before me this l°V\- day of Notary Public, Sate of Florida at Large * EXPIRES:it wA 16,2019 .✓ i°'i �°� g�dfituBud���yggtrlces • when the just valuation of the structurefor purpose of ad valoremation is equal to or more than$300,000.00,ire building was not constructed with FBC nor a 1994 SFBC.Then you must provide a building application from a Gene I Contractor for the Roof to wall connection Hurricane Mitigation. Revised on 5/21/2009 OFFICE OF THE PROPERTY APPRAISER Summary Report Generated On:5/20/2016 Property Information ' �. Folio: 11-2231-0140130 Property Address: 549 NE 106 ST `� A Marna Shores,FL 33138-2045 Owner MYRON L BARGER&W MARION S rM � w Mailing Address 549 NE 106 ST MIAMI SHORES,FL 33138-2045 Primary Zone 1000 SGL FAMILY-2101-2300 SQ Primary Land Use 0101 RESIDENTIAL-SINGLE FAMILY 1 UNIT Beds/Baths/Half 2/2/0 3_ Floors 1 " Living Units 1 Actual Area 1,845 Sq.Ft Living Area 1,537 Sq.Ft rt. Adjusted Area 1,691 Sq.Ft Lot Size 9,150 Sq.Ft Taxable Value Information Year Built 1946 2015 2014 2013 County Assessment Information Exemption Value 1 $50,000 $50,000 $50,000 Year Xf5 2014 2013 Taxable Value 1 $55,207 $54,373 $52,831 Land Value 53,3j9 $109,873 $122,445 School Board Building Value $117,694 $114,650 $114,650 Exemption Value $25,000 $25,000 $25,000 XF Value 0 $0 $0 Taxable Value $80,207 $79,373 $77,831 Market Value $271,073 $224,523 $237,095 City Assessed Value 1 $105,207 $104,373 $102,831 Exemption Value $50,000 $50,000 $50,000 Taxable Value $55,207 $54,373 $52,831 Benefits Information Regional Benefit Type 2015 2014 2013 Exemption Value $50,0001 $50,0001 $50,000 Save Our Mmes Assessment $165,866 $120,150 $134,264 Taxable Value $55,2071 $54,373 $52,831 Cap Reduction Homestead Exemption $25,000 $25,000 $25,000 Sales Information Second Homestead I Exemption 1 $25,0001 $25,000 $25,000 previous Sale Price OR Book-Page Qualification Description Note:Not all benefits are applicable to all Taxable Values(i.e.County,School 03/01/1973 1 $46,000 00000-00000 Sales w hich are qualifiedBoard,City,Regional). Short Legal Description 36 52 41 31 52 42 PB 10-47 AMD FL MIAMI SHORES SEC 5 LOT 19&W1/2 LOT 20 BLK 109 LOT SQE 75.000 X 122 CF 73856858 The Office of the Property Appraiser is continually editing and updating the tax roll.This website may not reflect the most current information on record.The Property Appraiser and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp Version: .� Mme. 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 below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 4/7/2016 EXPIRATION DATE: 41712018 PERSON: ALLEN DALE L FEIN: 591841705 BUSINESS NAME AND ADDRESS: D.L.ALLEN ROOFING INC 5826 SW 23 ST. WEST PARK FL 33023 SCOPES OF BUSINESS OR TRADE: LICENSED ROOFING CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this 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 listed 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 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 DFS-F2-DWC-252-CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 JUN 1.4 016 �1 By - 1 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. Renaliing 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. •Does• •••• • •..•. d�••e Overflow scuppers(wail outlets): It is required that rainwater flows off so that the roof is •••••• not verloaded from a buildup of water.Perimeter/edge wall or other roof extension may block this • :e: herge if overflow scuppers(wall outlets)are not provided. It may be necessary to install overflow •••• •••mappers in accordance with the requirements of Sections R4402 R4403 and R441 Owne�A nt's S' a ate C ctor Signature Date • e e • .0 . { Property Address Permit Number Revised on 719/2009 LD;07/01/2015; "roc 1rj�P" ,rz 57,70 +Y _� 9Y I DATA_ O C ICI_ ^✓.TI I ALL FFDFRAL _ ! . M11) -�rrt j ATj( r,S ROOF ASS UES AND ROOFTOP STRUCTURES F70rkfa Building Code 5th Edition (2014) High-Velocity Hurricane Zone Uniform Permit Application Form. Section A(General Information) Master Permit No. Process No. Contractor's Nam8[ le 1 e e F07PF7;6JG Jots Address / Zo 6 ROOFCATEGORY Law Slope ® Mechanically Fastened 1-do ® Mortar/Adhesive Set Tiles Asphaltic Shingles 0 Metal PaneyShingles D Wood Shfngies/Shakes ® Prescriptive BUR-RAS 150 ®F TYPE ® New roof ® Repair ® Maintenance Reroofing ® Recovering ROOF SYSTEM INFORMATION Low Slope Roof Area(SF)-.3-L? Steep Sloped Roof AREA(SSF)_jA/ Tota!(S�3 Section S(Roof Plan) Sketch Roof Plan:illustrate all Imis and sections,roof drains,scuppers,overflow scuppers and overflow strains.Include dimen. sions of sections and levels,clearly identify dimensions of elevated pressure zones and location of parapets, • 00. 0000 T; 00 . • • 00 00 00 0000. 000 00 00 00000 • ... 00 • .. 0000..• • 0000 � - -- .of 0 WV . • • 00 0 000000 00 0 . 0 00 LL- G 44 F4 IDA OWLMG CODE Ofd 4B 15.37 !OOF ASSEMBLIES AND ROOFTOP STRUCTURES Florida Bulldlttg Code 5th Edition(2014) High-Velocity Hurricane Zone Unitorin Permit Application Form. Section C(Low Slope Application) Top Pty Fastener/Bonding Material-+ L �� Fill In specific roof assembly components and identify manufacturer (If a component isnot used, identify as"NK) Surfac(ng:�"<<��"`/ S v t'Taac.�- Fastener Spacing for Anchor/Base Shoot Attachment: System Manufacturer._ Field._I°oc® Lap, #Rows a ® / °oc Product Approval No.: 3^ 0 -VS Perimeter //__�_oc @ Lap.s Rows_!FQ 6 •oc Design Wind Pressures,From RAS 128 or Cak:ulations: Comer. oc @ Lap,#Rows le a oc P1:-L4 •2► P2: - M.(d P3: - r•'q- S Number of Fasteners Per Insulation Board: ! � Max.Design Pressure,from the s c productt Field 0 Perimeter 4 Comer!/A approval system:_ •~.s'L. • Illustrate Components Noted and Details as Applicable: Deck: o�uusBStrip, Stripping,Flashing,Cant Base Flashing,G _ _ -iS Coping,Etc. Indicate: Mean Roof Height, Parapet Height, Height of Base Gauge/T hickness: X Flashing, Component Maaterial, Material Thickness, Fastener ��, Type,Fastener Spacing or Submit Manufacturers Details that Slope: Comply with RAS 111 and Chapter 18. Anchor/Base Sheet&No.of Ply(s): l�� �''T An 44 orB•sdStaE►et F ten lR of 0000.. , • p� � ••Insulation Base Layer.:.: :apt Yf'' 0000.. 0000 l Mr •••ease tnaetat�n Sla®ar�d T6{da+ees: Parapet 0000. . 0000 • Base Insulsoon Vasten 0000.. �gltUing Material: �,t • 0000.. (� / 0000 ,,• Top I nsulatioa�Leyer. .00.00 0000 • ``'' j Top fnsuratimedize and Thickness: Iv ` Mean Top Insulation Fastener/Bonding Material: 3 X'j .. 2(otp.�q,�• Height A O Erase Sheei(s)&Na,of ply(a): ;►I it- °l .' -o•C_ Base Sheet Fastener/Bonding Material: ' Ply Sheet(s)& No. of Ply(s): Sheet Fastener/8onding ectal: Tap Ply:T-,°1����aS S CpnpSk4_*_+ _ .. a 15.38 FLORIDA BUILDING CODE—BUILDING,5th EDITION(2014) _ ------------ MIAMI-,pq,pE .. 1 OARDTMFNT OF REGULATORYPRODUCT OL SECTION BOARD ANU CODE AND ECONO NOTICE ADMM'STRATION DIVISIONXC RESOTIRCES{RER) 11805 SW 26 Street3317,3-2474 Room 208N OF A CCEPTANCE OA Miami Florid.33173-2474 GAF T(786)315-2590 F(796)31525-99 1361 Alps Road wo'w.miarrridade. ov/econom- Wayne,NJ 07470 SCOPE: This NOA is being issued under the applicable rules and re materials. The documentation submitted has been reviewed and accepted Product Control Section to be used in $uIations governing the use of construction g Jurisdiction ami Dade Coun ra by Miami-Dade County RER_ Raving Miami County and other areas�,�,hete allowed b This NOA shall not be valid after the expiration date stated be y the Authority Control Section(In Miami Dade Coun reserve the right tY)and/or the low'The Miami_Dade County Product material fails to er fo Ve this product or AHJ{in areas other than Miami Dade County) material tested for quality assurance and the AHJ snap rm in the accepted manner,the purposes.If this product or Y immediately revoke manufacturer will incur the expenSe of such testing jurisdiction. 1ZER reserves the right 'modify, or suspend the use of such product or material within Product Control Section that this product Or mavoke terial fails to their eptance, if it is determined by Miami-Dade County building code, meet the requirements of the applicable This product is approved as described herein,and has been designed t including the High Velocitygn o comply Hurricane Zone of the Florida Building Code, �the Florida Building Code • DESCR1pTIQ 0000 N: G4F'Vpnventional Built-Up Roof F1. Systems 1 e •.• ; Y ms for Wood Decks. •; 1�;P��tic1► ll • �� bear aWNEWly permanent label with the g 3t�Ment:ut�it. manufacturer's name or logo, city,state and Control Approved",unless otherwise noted herein. . tE'6�VAL "IVji�y.Dade County product Cofxllis NQ all be considered after a renewal application has been filed and th • change ine applicabl'a b11i'lding code negatively affecting the ere has been no •••�•• performance of this product. •�ERMIl1iA`l101q of IN 4NQA will occur after the expiration date or if there has been a revision or change in •the materiats,% e,andlor.Mlufacture of the product or process.Misuse of this NOA as an endorsement of any •prSduct,fol §apes,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. ADVERTISEMENT: 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. 13-0424.09 and consists of pages 1 through 16. The submitted documentation was reviewed by Jorge L.Acebo. k � T NOA No:13-1011.15 Expiration Date: 11104118 i i /. ApprovalDate: 111fl6114 Page 1 oY 16 03-09-'15 15:07 FROM- T-136 P0006/0008 F-988 Membrane Type; BUR Deck Type 11: Wood,Non-insulated Deck Description: 19r)2"or greater plywood or wood plank decks System Type)E: Base sheet mechanically fastened. All General and System Limitations shall apply. Fire Barrier; 1;ire0ut'"lire Barrier Coating,VersaShielde Fire Resistant Roof Deck Protection or (optional) Securocke'Gypsum;Fiber Roof Board. Base sheet: GAFGLAS®#80 Ultima"'Base Sheet,Stratavente Eliminator'"Nailable Venting Base Sheet,Ruberoide 20,Ruberoide SBS Heat-Weld"Smooth or Ruberoide SBS Heat-Weld"` 25 base sheet mechanically fastened to deck as described below; Fastening Options: GAFGLA.Se'Ply 4,GABGLAS®l:lexPly"6,GAFGLAS®#75 Base Sheet or any of 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 lap staggered and in two rows 12"o.c. in the field. (Max mumz Design Pressure-45 psf.See General Li► codon#7) GAFGLAS"Ply 4,GAl GLASe F'lexPly'"6,GAFGLAS"#75•Base Sheet or any of above base sheets attached to deck with Drill-Tec'" 912 Fastener or Drill-Tec`"#14 and Drill- Tec'"3"Steel Plate,Drill-Tec AecuTrae Flat Plate or Drill-Tec'"AccuTrac®Recessed Plate 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 sheet. (Maximum Design Pressure-45,psf.•See General Limitation 07) GAFGLAS"Flex Ply"M 6,GAFGLAS'#75 Base Sheet or any of 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. (Mazimmm Design Pressure—52.5 psf.See General Limitation#7) GAFGLAS`s#80 Ultima'°°Base Sheet,RuberoicP 20,Ruberoide 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)#75 Base Sheet or any of above base sheets attached to deck with Drill-Tec" 412 Fastener or Drill-Tec'" #14 Fastener and Drill-Tec"3"Steel Plate,brill-Tec" AccuTmc'm Flat Plate or Drill-Tec 'AccaTraee Recessed Plate 12"o.e.in 4 rows. One row is it)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-Tec'"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) ATOS#No.:13-1022.15 rIW Expiration Date: 11/04/10 Approval Date: 11/06/14 Page 14 of 16 03-09-'15 15:09 FROM- T-136 P0008/0008 F-988 WOOID DECD SYSTEM LIMITATioNS; 1 A slip sheet is required with GAFGLASa Ply 4 and GAFGLAS®Flex Ply'"6 when used as a mechanically fastened base or anchor sheet. 2. Minimum Y4?'DensDecke"Roof Board or 14"Type X gypsum board is acceptable to be installed directly over the wood deck. GENERAlL A. mTATIO1riSt I. 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 2040 lbs./sq.,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,pastel size shall be 4'x 4'maxiinum. 4. An overlay and/or recovery board insulation panel is required on all applications over closed cell foam insulations when the base sheet is fially 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 12 lbs./sq. Note: Spot attached systems shall be Utnited to a maximum desigo pressure of 45 pd. 5. Fastener spacing for insulation attachment is based on a Minimum Characteristic Force(1~)value of 275 lbf,as tested in compliance with Testing Application Standard TAS 105. If the fastener value,as field-tested,are below 275 insulation attachment shall not be acceptable. 6. Fastener spacing for mechanical attachment of anchor/base sheet or[membrane attachment is based on a[minimum fastener resistance value in conjunction with the maximums;design value listed within a specific system. Should the %• fal�tl resistance be less than,that required,as determined by the Building Official,a revised fastener spacing, p00: re0 0 0* Signe andsealed by a Florida Registered Professional Engineer,Registered Architect,or Registered Reff Ciopsultait may be submitted. Said revised fastener spacing shall utilize the withdrawal resistance value '. takep from Tegi ,iplication Standards TAS 105 and calculations in compliance with Roofing Application Stated RAS 117. . ....7. PV4i*ter and!'or 4veas shall comply with the enhanced uplift pressure requirements of these areas. Fastener ' 90%9 densities shall bC»creased for both insulation and base sheet as calculated in compliance with Roofuig Application SW&M RAS'ld7.Mculations prepared,signed and sealed by a Florida registered Professionai Engineer, Registered.AxoliiInksor Registered Roof Consultant(When this limitation is specifically referred within tb%N1QA,GBnetOLimitation#9 will not be applicable.) •' S. All Ifil chmentao§Wn of meter nailers brietal profile,and/or flashing termination designs g l� � P hiug gals shall confor>7o,to ****'* W%Applicgtion 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 specilrWally referred within this NOA,General Limitation#7 will not be applicable.) 10. All products listed herein shall have a quality assurance audit in accordance with the Florida Building Code and Role 61G20-3 of the Florida Administrative Code. END OF THIS ACCEPTANCE NOA No.:13-1022.13 c Expirstiou Date: 11/64/16 Approval Date: 11/06/14 Page 16 of 16 ONLINE CERTIFICATIONS DIRECTORY TGFU.R1306 Roofing Systems Page Bottom Roofing Systems See General Information for Roofing Systems GAF R1306 1 CAMPUS DR PARSIPPAW, N] 07054 USA "RUBEROIDO 20 Smooth" or"RUBEROIDO Mop Smooth" or"RUBEROIDO Mop Smooth 1.5" may be utilized as an alternate to Type G2 "GAFGLASO #75 Base Sheet" or"Tri-Ply@ #75 Base Sheet" or"GAFGLASO #80 Ultima'"' Base Sheet" base sheets in any of the following Classifications. 1/2-in. thick (minimum) gypsum board or'/4-in. thick (minimum) Georgia-Pacific Gypsum LLC "DensDeck@ Roofboard" or "DensDeck@ Prime Roofboard" or"DensDeck@ Dura Guard'" Roofboard" or r/4-In. thick (minimum) United States Gypsum Co. "SECUROCKO Roof Board" (Type FRX-G) or"SECUROCKO Glass-Mat Roof Board" (Type SGMRX) may be used in any existing noncombustible deck Classification. When this is done, the resulting roofing system is acceptable for use over combustible (15/32-in. thick minimum) roof decks. However, the butt joints In the gypsum board and Georgia-Pacific Gypsum LLC "DensDeck@ Roofboard" or"DensDeckO Prime Roofboard" or"DensDeck@ DuraGuardT Roofboard" are to offset a minimum of 6-in. with the butt joints in the roof deck. If polystyrene is part of the roof system, it must be placed belowthe overlayment board. 1/4-1n. thick (minimum) "SECUROCKO Roof Board" (Type FRX-G) and "SECUROCKO Glass-Mat Roof Board" (Type SGMRX) are limited to a maximum 3:12 slope when used over a combustible deck in a system with any UL Classified insulation except polystyrene. Multiple plies of Type G1 "GAFGLAS@ Ply 4" or"Tri-Ply@ Ply 4" or"GAFGLASO Flex Ply 6" or"Tri-Ply@ Ultra-Flexible Ply 6" may be adhered to Georgia-Pacific Gypsum LLC "DensDeck@ Roofboard" or"DensDeckO Prime Roofboard" or"DensDeck@ DuraGuardTM Roofboard" in hot roofing asphalt. "EnergyGuardTM Ultra" is an acceptable alternate to "EnergyGuardT"11 in any applicable Classification. ."GAFC&L.ASO4%Wi5gent@ Nailable Venting Base Sheet" may be mechanically fastened or fully adhered with hot roofing asphalt over :AER&Prnbustible Jecks aqd at%recover over existing roof systems. a�•�a•&-i •;RCR�yGuar to Inrulatiog" may be utilized as a cover board over"EnergyGuardT""' in any of the following systems. •efRane, otherwise indicated,•t?Vroof insulation is mechanically fastened, fully adhered with hot roofing asphalt or UL Classified insulli:lt?i adheAfe.!P►olystyrene referenced in any of the following Classifications include Insulation. • 00000 00•• 00.00• "as otherwise ipdicateg,411insulations may be adhered with any UL Classified Insulation Adhesive per the manufacturer's 0 insta�ation tr="ions (4excluding LRF Adhesive O) in any applicable Non-Combustible Roof Deck Classifications. ••000• •••• • "En:;yGuard'' **so alternate to "EnergyGuardT"" in any applicable Classification. •4VnergyGu&g�Vltra Taje0r*e R'0is an acceptable alternate to "EnergyGuardT"'00 Ultra" in any applicable Classification. 0000.00 000• • • ASPHALT FELT SYSTEMS WITH HOT ROOFING ASPHALT •00• Type G2 asphalt glass mat base sheet ("GAFGLASO #75 Base Sheet" or"Tri-Ply@ #75 Base Sheet" or"GAFGLASO #80 UltimaT"' Base Sheet") is a suitable alternate for Type G1 asphalt glass fiber ply sheet("GAFGLAS@ Ply 4" or"Tri-Ply@ Ply 4" or"GAFGLASO Flex Ply 6" or"Tri-Ply@ Ultra-Flexible Ply 6") in the Class A, B or C roof systems indicated below. The roof deck may first be covered with one ply Type G2 asphalt saturated glass mat base sheet"GAFGLASO Stratavent@ Nailable Venting Base Sheet" or"GAFGLASO Stratavent@ Perforated Venting Base Sheet". Perforated base sheets to be loose laid or fully adhered with hot roofing asphalt and nailable base sheets are to be mechanically fastened granule side down. As an option Type G2 asphalt glass mat base sheet ("GAFGLASO #75 Base Sheet" or"Tri-PlyO #75 Base Sheet" or"GAFGLAS(D #80 Ultima'" Base Sheet" or"GAFGLAS@ Stratavent@ Nailable Venting Base Sheet") may be substituted for Type G1 asphalt glass fiber ply sheet ("GAFGLASO Ply 4" or"Tri-Ply@ Ply 4" or"GAFGLASO Flex Ply 6" or"Tri-Ply@ Ultra-Flexible Ply 6") as the nailed base ply in the following systems. Bottom ply or base sheet may be fully adhered with hot roofing asphalt or mechanically fastened. Unless otherwise indicated, all insulations may be fully adhered with hot roofing asphalt or mechanically fastened. "GAFGLASO Flashing" or"RUBEROIDO" may be used for flashing in any of the Class A, B or C systems listed below. When "perlite" is referenced, this includes any UL Classified periite insulation. Crushed stones or slag are suitable alternates for gravel in any of the Class A, B or C systems listed. Structural cement fiber building units are considered suitable to be included as a deck in the following Class A, B or C systems listed over C-15/32 or NC. The use of gypsum board under any of the following Class A, B or C systems does not adversely affect the rating. The use*of 1 = In. minimum thick gypsum board is an acceptabie alternate for minimum insulation over C-15/32 thick roof decks. ' " The use of polystyrene insulation board between minimum 3/4-In. thick perlite board and deck with rosin paper(perlite/rosin paper/polystyrene/perlite) is a suitable alternate for polylsocyanurate board in the following Class A, B or C systems. Trumbull "Perma Mop" may be utilized with any of the following "Asphalt Felt Systems with Hot Roofing Asphalt". "GAFGLASO #80 Ultima'"' 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 "GAFGLAS@ Ply 6". "GAFTEMP Permalite Recover Board" may be used in lieu of any perlite insulation in any of the following NC Ciassifications. Unless othervvise indicated, any of the "Asphalt Felt Systems with Hot Roofing Asphalt" may be surfaced with "United CoatingSTM FireShield MB Roof Coating" applied at a rete of 21A to 3-gel/100-ft2. Class A,B and C Hot roofing asphalt, for use with glass felts or modified bitumen membranes. "RUBEROID@ Heat Weld" SBS roofing membranes may be used in lieu of"RUBEROIDO Mop" SBS roofing membranes in any applicable Classification. Class A 1. Deck: C-15/32 Incline: 3 Barrier Board(Optional):— One or more layers Georgia-Pacific Gypsum LLC "DensDeck@ Roofboard" or"DensDeck@ Prime Roofboard" or"DensDeck@ Dura Guard T" Roofboard", minimum 1/4-in. thick, or United States Gypsum Co. "SECUROCKO Roof Board" (Type FRX-G) or"SECUROCK@ Glass-Mat Roof Board" (Type SGMRX), minimum 1/a-in. thick. Insulation:—One or more layers perlite or wood fiber or glass fiber or polyisocyanurate or urethane or perlite/polyisocyanu rate composite or perilte/urethane composite or wood fiber/polyisotyanurate composite or phenolic, any thickness. Ply Sheet: —Three or more plies Type G1 "GAFGLASO Ply 4" or"Tri-Ply@ Ply 4" or"GAFGLAS@ Flex Ply 6" or"Tri-Ply@ Ultra-Flexible Ply 6", fully adhered with hoot roofing asphalt. Surfacing:— Gravel. 2. Deck: C-15/32 Incline: 2 Barrier Board(Optional):— One or more layers Georgia-Pacific Gypsum LLC "DensDeck@ Roofboard" or"DensDecka Prime Roofboard" or"DensDeck@ Dura Guard'•"' Roofboard", minimum 'A-in. thick, or United States Gypsum Co. "SECUROCKS Roof Board" (Type FRX-G) or"SECUROCKS Glass-Mat Roof Board" (Type SGMRX), minimum 1/4-in. thick. Insulation:— One or more layers perlite or wood fiber or glass fiber or polyisocyanurate or urethane or•• • perlite/polyisocyanu rate composite or perlite/urethane composite or wood fiber/polyisocyanj;&atesrnmpazil;%oor phermlic, �l�y thickness. • • • •••• Ply Sheet:—Three or more plies Type G1 "GAFGLAS@ Ply 4" or"Tri-Ply@ Ply 4" or"GAFG0AS@ Ilex PIy*&`6a'eTri-PIY.T Ultra-Flexible Ply 6", fully adhered with hot roofing asphalt. • • • • Cap Sheet:—Type G3 "GAFGLASO Mineral Surfaced Cap Sheet" or"SheetTri-Ply@ BUR Gr,&iW:-&p Sheet'-or"bAFGLAAX EnergyCap'" Mineral-Surfaced Cap Sheet", fully adhered with hot roofing asphalt. •• •• •••• +••••• 3. Deck: NC Incline: 2 06.06• •••• ••�••• 0000 • ••••a • • 0000•• Barrier Board(Optional):—One or more layers Georgia-Pacific Gypsum LLC "DensDeck@ REEtI?oard" A"DensDeckoelbio Roofboard" or"DensDeck@ Dura Guard"" Roofboard", minimum I/a-in. thick, or United Statee.6 p9um Co. "�ECUROCTC@ Roof Board" (Type FRX-G) or"SECUROCKS Glass-Mat Roof Board" (Type SGMRX), minimu"yrr-bra. thick.•• • 0400*• Insulation(Optional):— One or more layers perlite or wood fiber or glass fiber or polyisocyaauraLe or ut�tji�ie or • perlite/polyisocyanu rate composite orperiite/urethane composite orwood fiber/polyisocyarrurabe eomposLtg•grphengj"J;• In. maximum. • • Ply Sheet:—Two or more plies Type G1 "GAFGLASO Ply 4" or"Tri-Ply@ Ply 4" or"GAFGLASS Flex Ply 6" ar"eN-Ply@ Ultra- Flexible Ply 6", fully adhered with hot roofing asphalt. Cap Sheet:—Type G3 "GAFGLASO Mineral Surfaced Cap Sheet" or"Tri-Ply@ BUR Granule Cap Sheet" or"GAFGLASS EnergyCapT Mineral-Surfaced Cap Sheet", fully adhered with hot roofing asphalt. 4. Deck: C-15/32 Incline: 1 SHP 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 "GAFGLAS@ #75 Base Sheet" or"Tri-Ply@ #75 Base Sheet" or"GAFGLAS@ #80 UltimaTm Base Sheet" or"GAFGLAS@ Stratavent@Nai aabbie Venting Base Sheet", mechanically fastened. Ply Sheet:— One or more plies Type G1 "GAFGLASO Ply 4" or"Tri-Ply@ Ply 4" or GAFGLASS Flex Ply 6" or"Tri-Ply@ Ultra- Flexible Ply 6", fully adhered with hot roofing asp a t. z) Cap Sheet:—Type G3 "GAFGLAS@ Mineral Surfaced Cap Sheet" or"Tri-Ply@ BUR Granule Cap Sheet" or"GAFGLASO EnergyCapT'" Mineral-Surfaced Cap Sheet", fully a ere with hot roofing asphalt. Coating (Optional):— "United CoatingsT"'TOPCOAT@ EnergyCoteT Roof Coating" or"TOPCOAT@ MB Plus Coating" or "United Coatings'm Roof Mate MB Plus Coating" applied at a rate of 2-gal./100-ft.2. S. Deck: NC Incline: 3 Base Sheet:— One ply Type G2 "GAFGLASO*75 Base Sheet" or"Tri-Ply@ #75 Base Sheet" or"GAFGLASO #80 Ultima TM Base Sheet" or"GAFGLASS Stratavent@ Nailable Venting Base Sheet" or"GAFGLASO Stratavent@ Perforated Venting Base Sheet" or"GAFGLASO Stratavent@ Na liable Venting Base Sheet" or"GAFGLASO Stratavent@ Perforated Venting Base Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FIL , I Phone:(305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-263012 Permit Number: RC-7-16-1851 Scheduled Inspection Date:July 13,2016 Permit Type: Residential Construction Inspector: Mesa,Michel Inspection Type: Final Owner: BARGER,MYRON Work Classification: Alteration Job Address:549 NE 106 Street Miami Shores,FL 33138- Phone Number Parcel Number 1122310140130 Project: <NONE> Contractor: ALLEN&DANIELS CONSTRUTION CO,INC Phone:(305)621-5119 Building Department Comments REPAIR(ON) REPLACE(4)2 X 6 SYP#2 SOUTH Infractio Passed Comments YELLOW PINE STRUCTURAL TYPE RAFTER TIPS EACH INSPECTOR COMMENTS False WHICH IS 3 FT 9N LENGHT Inspector Comments Passed to Ccs . Failed Correction Needed ( (0S ( Re-Inspection Fee No Additional Inspections can be scheduled until reinspection fee Is paid July 13,2016 For Inspections please call:(305)762-4949 Page 38 of 45 '49BB Engineering & Testing Co. 7450 Griffin Road, Suite 140, Fort Lauderdale, FL 33314 Phone:(954)581-7115, Fax:(954)581-2415 www.cebb.net July 11, 2016 To: Village of Miami Shores 10050 NE 2nd Avenue Miami Shores Village, FL 33138 Re: Roof Rafters Rehabilitation Permit: RC-1851 Barger Residence 549 NE 106th Street Miami Shores Village, FL 33138-2045 Dear Building Official: Pursuant to the request of Allen & Daniels Construction Company and authorization from the homeowners, I the undersigned have visited the subject property on July 8, 2016, and made a comprehensive visual examination of the status of repair of the four jack rafters at the rear of the existing flat roof at the aforementioned residence. During our inspection was noted that the North four (4) roof rafters have sustained limited (less than substantial) structural damage due to rott and wood destroying organisms (WDO). The evaluation established that the flat roof in its pre-damaged condition complied with the provisions of the Section 606.2.2.1 of the 2014 Existing Building Code, and as the work shall not make the building less conforming than it was before the repairwas undertaken, the damaged roof rafters are permitted to be restored to their pre-damaged condition. Rafters were repaired using like materials and methods and the repairs were performed in strict accordance with Chapter 6 - Repairs of the 2014 Existing Building Code. Should you have any questions regarding the above, or if require additional information, please contact this office. CeBB Engineering &Testing Co. (CA#9807) 07/11/2 —0`; Eduard C. Badiu, P.E. #59997 Multiple States Licensed, 1 Page 3 3p A. P "1916' �s S Miami Shores Village r'UWW01 10050 N.E.2nd Avenue NES Miami Shores,FL 33138-0000 j Phone: (305)795-2204 Expiration: 0'10°/2017 1.6' 3 �A Project Address Parcel Number Applicant 549 NE 106 Street 1122310140130 Miami Shores, FL 33138- Block: Lot: MYRON BARGER Owner Information Address Phone Celt MYRON BARGER 549 NE 106 Street MIAMI SHORES FL 33138-2045 Contractor(s) Phone Cell Phone Valuation: $ 250.00 ALLEN&DANIELS CONSTRUTION C( (305)621-5119 _._... . _ .a... . Total Sq Feet: 6 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Window Door Attachment Date Denied: Framing Type of Construction:REPAIR(ON)REPLACE(4)2 X 6 SY Occupancy: Insulation Stories: Exterior: Drywall Screw Front Setback: Rear Setback: Final PE Certification Left Setback: Right Setback: Window and Door Buck Bedrooms: Bathrooms: Fill Cells Columns Plans Submitted:Yes Certificate Status: Review Building Certificate Date: Additional Info: Review Planning Review Electrical Bond Return: Classification:Residential Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural CCF $0.60 Review Mechanical DBPR Fee $2.00 Invoice# RC-7-16-60435 DCA Fee $2.00 07/05/2016 Check#:2420 $64.60 $50.00 Education Surcharge $0.20 07/05/2016 Check#:2421 $50.00 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. July 05,2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy July 05,2016 1 Miami Shores Village � 1CII-��� ,� D ` Building Department JUL ® X16 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20tq' BUILDING Master Permit No. ?45- I& (( 4-4 PERMIT APPLICATION Sub Permit No. lzc ((a (.3571 BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP U / CONTRACTOR DRAWINGS JOB ADDRESS: �/ xo g_> City: Miami Shores County: Miami Dade Zip: lyda Folio/Parcel#: 11' ,931—"_4134& Is the Building Historically Designated:Yes NO_p"" Occupancy Type: Load: �Construction Type: Flood Zone: BFE: eFFE: OWNER: Name(Fee Simple Titleholder): Phone#: Address: ✓�'� �� s ®� -�� £ — City: ��i'�7� �'. 1' State: ,�� Zip: v��� Tenant/Lessee Name: Phone#: Email: e C CONTRACTOR:Company Name: 47,41-AFF/el W,dl Phone#: � Address: City: State: ���. zip:. Qualifier Name: ��� �. �� � Phone#: State Certification or Registration#: �G� � ���4 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ a Square/Linear Footage of ,orl: Type of Work: ❑ Addition yp ❑ Alteration F-1 New Repair/Replace ❑ Demolitioonn4�� Description of Work: 2geA, ®2l���� -��' z !!;Xo _>r�Zy " �_0!R�?:��.5` Specify color of color thru tile: Submittal Fee$ �v r Permit Fee$ 01)®� CCF$ ° CO/CC$ o Scanning Fee$ q Radon Fee$ 200 DBPR$ „ e®” Notary$ d Technology Fee$ ®a Training/Education Fee$ 0, .w Double Fee$ Structural Reviews$ Bond$ (� TOTAL FEE NOW DUE$ g- (0 (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. Signature Signature �1,� ��� OWNE or ENT ��ilCO!/TRACTil0o The foregoing instrument w acknowledged before me this The foregoing instrument was acknowledged before me this �/Sr day off �JMli�y 020 Aa by �� day of_J'L(.L 20 J by ►"`��Y� I K� - ,who is personally known to L A ( (e_4n ,who is personally known to me or who has produced17'i'ZV Lt 'L as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: 4 � � r v Sign: Sign: Print: o ::° Sq�N Print: 611`'.: * my IMINNON I FF MM * * MY COMMISSION!FF 900766 Sea I: * EXPIRES:August 16,2019 Seal: EXPIRES:August 16,2019 mrq�a���� Banded Thru Budget N Setrl� `N711 Banded Thm Budd ferry soft i APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) t RISK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC037438 d The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 W. .ALLEN, DALE L ALLEN & DANIELS CONST CO INC 5826 SW 23RD ST HOLLYWOOD FL 33023-4063 NMI ISSUED: 07/08/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407080000859 04 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 below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 6/24/2016 EXPIRATION DATE: 6/24/2018 PERSON: ALLEN DALE L FEIN: 592556601 BUSINESS NAME AND ADDRESS: ALLEN AND DANIELS CONSTRUCTION COMPANY INC 5826 SW 23 ST. WEST PARK FL 33023 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 filing a certificate of election under this section may not recover benefits or compensation under this 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 listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt ar"d 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)41'3-1609 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:ALLEN & DANIELS CONST CO INC Receipt#:GENERIABL CONTRACTOR (GENERAL Business Name: Business Type:CONTRACTOR) Owner Name:DALE L ALLEN Business Opened:12/01/1987 Business Location:5826 SW SW 23 ST State/County/Cert/Reg:CGC3 74 3 8 HOLLYWOOD Exemption Code: Business Phone: 983-1297 Rooms Seats Employees Machines Professionals 3 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 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: DALE L ALLEN Receipt #iCP-14-00027887 5826 SW 23 ST Paid 09/22/2015 27.00 HOLLYWOOD, FL 33023 2015 - 2016 DLAR001 OP ID: KM CERTIFICATE 4F LIABILITY INSURANCE 701,613012016 (MM1 , 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 policy(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 CONTACT NAMEJ.W.Edens&CompanyPHONE Commercial Ins of Brvard,Inc E°NE FAX No): 325 Fifth Avenue,Suite 108 ADDRESS: Indialanfic,FL 32903 Scott M.Steele,AAI INSURERS AFFORDING COVERAGE MAIC# INSURER A:Axis Surplus Ins.Co. 26620 INSURED D.L.Allen Roofing Inc.& INSURER a: Allen&Daniels Construction sksuRERc Company Inc. 5826 SW 23rd Street INSURER D: West Park,FL 33023 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. ILTR NSR ADM SUBF POLICY TYPE OF INSURANCE POLICY NUMBER EF M LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0()Ol A X COMMERCIAL GENERAL LIABILITY FLGLN01841AX 08/13/2015 08/13/2016 PREMISES arrence $ 50,00 CLAIMS-MADE Fx-1 OCCUR MED EXP(Any one person) $ _5i00 PERSONAL&ADV INJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPLOP AGG $ 2,000,00 X POLICY f7 PRO- LOC $ AUTOMOBILE LIABILITYC BINED SINGLE LIMIT a 'den _$ ANY AUTO BODILY INJURY(Par person) $ ALL OWNED SCHEDULEDAUTOAUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNERPROPERTY AMA $ }TIRED AUTOS AUTOS ACCIDENT) UMBRELLALIAB OCCUR EACH OCCURRENCE $ 4:1ED—Ff XCESS LWB CLAIMS MADE AGGREGATE $ RETENTION $ WORKERS COMPENSATION WC STATU• OTH- AND EMPLOYERS'LIABILITY Y L NEP ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERLMEMBER EXCLUDED? NLA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Ifes,describe under SCR P I N OPERATIONS E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it Imre space Is required) Allen S Daniels Construction Company Inc license # CGC0374138 CERTIFICAM HOLDER CANCELLATION MtAMiSV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPATE THEREOF, Miami Shores Village ACCORDANCEIWITH THE POLICY PROVISIONS.E WILL BE DELIVERED IN Building Departmenet 10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 3&V1 01988-2010 ACORD CORPORATION.,All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD QRZ 22 ..... Miami shores Village Building Department �LORNA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. ✓ COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: AJ Int oa,,.;J, C^S-I yc,4-L, C-2• J4,ie,- BUSINESS ADDRESS: 2 C cj 9 3 S ' CITY C ) Qt 9 jjAj-STATE ZIP '3 3 6 0 BUSINESS PHONE: S ��3 ,� L�j 7 FAX NUMBER CELL PHONE q® QUALIFIER'S NAME:—b1-JC— QUALIFIER'S AME: - 1-JC-QUALIFIER'S LIC NUMBER: CG C,C) 7T'-"" �5�►OR93Fs Miami shores Y Building Department res 10050 N.E.2nd Avenue lORMiami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 F Notice to Owner - Workers' Compensation Insurance Exemption :E�%yam 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 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 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: O State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of ��L y ,2016, . Byg V'bm who is personally known to me or has produced V as identification. e .r Notary: Pygi. �IIW SEAL: � ' MY CO 016sI0N 4 FF WS * # EXPIRES:August 16,2019 04„ya '` 9aNhdThraWNo"SN*% ALLEN AND DANIELS CONSTRUCTION COMPANY, INC. 5826 S.W. 23RD STREET WEST PARK, FLORIDA 33023 BF-OWARD 954-983-1297 DADE 305-621-5119 FAX 954-989-1895 CGC037438 JULY 1, 2016 STATE OF FLORIDA COUNTY OF MIAMI-DADE Before me this day personally appeared Dale L Allen who, being duly swom, deposes and says: That he will be the only person working on the project located at : 549 NE 106 St. Miami Shores Sworn to (or affirmed) and subscribed before me this 1St day of July 2016, by Personally know Or Produced identification Type of identification produced Name o I-ta '2019 Call An Expert For Fast and Friendly Advice* `�g1B0t' g 5I ALLEN AND DANIELS CONSTRUCTION COMPANY, INC. 5826 S.W. 23RD STREET JUL0 5 2016 WEST PARK, RORIDA 33023 BKOWARD 954-983-1297 DADE 305-621-5119 :C 5 CGC037438 IV Ar 1t tr r z 0 q� a OI W f •. ... . . . . .. - W • • • • • • • • • _ m • •• • • • • ••• o C `Z, Cali An Expert For Fast and Friendly Advice. I' !� L) mD .00 • u • • • • • • • f �� C W 7 006 a ••• • Y r ••• • • __ C: V, U Y Y t •00 0 • • • • • • • • • • • • • ••• • • • ••• 0 •