HomeMy WebLinkAbout111 Meadow BlvdCITY OF SANFORD
BAR 2 6 xU'1 BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No: C.)
Documented Construction Value: $ 4Af
Job Address: 3 Wextm Bud, �nfoM a, 92,lq i Historic District: Yes ❑.No.91
Parcel ID: Residential [2 Commercial ❑
Type of Work: New ❑ Addition ❑ Alteration ❑ Repair ❑ Demo ❑ Change of Use ❑ Move ❑
Description of Work: " —awf
Plan Review Contact Person: _ R11-1i-"() CA I'=LCl Title: r\.
Phone: Fag: -4 Oq : 3(0 (P.LOW Email: '8 f)f-0� h e r l VQ 4e Cr, CQfkJ
Property Owner Information
Name _ 4e,�-00_;�, Q Ck- D o Phone:
Street: 1 M f arkk )a Ld . Resident of property?: ®LA-) reQ_
City, State Zip:s�a 1� 0 9-CA f
Contractor Information
Name t 11 b Phone. •�JLP
Street: (�� rl o t o l t• J i Lk �CQ�.J Fag: _q 6 I ceicLe C
City, State Zip: lf� SSbber State License No.
Name:
Street:
City, St, Zip:
Bonding Company:
Address:
Architect/Engineer Information
Phone:
Fag:
E-mail:
Mortgage Lender:
Address:
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE
RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
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 standards of all laws regulating construction
in this jurisdiction. I understand that a separate permit must be secured for electrical work, plumbing, signs, wells, pools,
furnaces, boilers, heaters, tanks, and air conditioners, etc.
FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5" Edition (2014) Florida Building Code
Revised: June 30, 2015 4 11
a _ \ Permit Application
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be
found in the public records of this county, and there may be additional permits required from other governmental entities such as water
management districts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the requirements of Florida Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee at the time of permit submittal. A copy of the executed contract is required
in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with local ordinance. Should calculated charges figured off the executed contract exceed the actual construction value,
credit will be applied to your permit fees when the permit is issued.
OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating construction and zoning.
i�- 112- IQ r-7 P_Ir�
3/Zo/i
Sign re of wner/Agent Date ign a of Contractor/Agent Date
VU2. U _/ 7)
Print Owner/ ent's Print Contrac ge me
127 /t.� 31201 f e
re -State Date ignature of Notary -State of Florida Date
o1p8r P` 7F/Orida
;o1pRY P4BNotary Public Stateof Florida
;Pe Notary public State of Lesley G Garza
Lesley G Garza q� My Commission GG009517
y�- -ooc My Commission GG 0pFpo� Expires 07107/2020
oF� Expires07/07/2020
Owner/Agent i Contra cfi t-ii ' ersona ly own to Me or
Produced ID �_ Type of IDS C�pl `�� ^roduced ID Type of ID
BELOW IS FOR OFFICE USE ONLY
Permits Required: Building ❑ Electrical ❑ Mechanical ❑ Plumbing[] Gas ❑ Roof ❑
Construction Type:
Occupancy Use:
Total Sq Ft of Bldg: Min. Occupancy Load:
New Construction: Electric - # of Amps.
Fire Sprinkler Permit: Yes ❑ No ❑ # of Heads
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
UTILITIES:
FIRE:
Flood Zone:
# of Stories:
Plumbing - # of Fixtures
Fire Alarm Permit: Yes ❑ No ❑
WASTE WATER:
BUILDING:
Revised: June 30, 2015 Permit Application
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date: 3%Z,QI
I hereby name and appoint: +xy) 1 i�
I
an agent of.
to be my lawful attorney -in -fact to act for me to apply for, receipt for, sign for and do all things
necessary to this appointment for (check only one option):
❑ The specific permit and application for work located at:
r i 1 Wac,Q0� �1 kfd , San (MV d r-C 22-n -1
(Street Address)
Expiration Date for This Limited Power of Attorney:
License Holder Name:
State License Number:
James T. Welding
Signature of License Holder:
STATE OF FLORIDA
COUNTY OF SZwN MCI(2
t 5'ZQ C1 SO
The foregoing instrument was acknowledged before me this _ZC,�iay of ,
20019 , by Mtn wyes WP-1,!71 n c, who is ersonally known
to me or❑w.
identification
,, r
r
Notary P e of Florida
Lesley G Garza
009517
opt
OFf�
ExpCes07l07/2ommission 020
(Rev. 08.12)
Print or type name
Notary Public - State of — I
Commission No. &_,c;d2cY9 1%
My Commission Expires: '7/7120
N
THIS INSTRUMENT PREPARED BY:
Name: _Heritage Construction & Roofin
Address: 15" Seminola Blvd. Suite 136
Casselberrv. FL 32707
NOTICE OF COMMENCEMENT
State of Florida
County of Seminole
Permit Number.
�:'. Zvi '•j :'" i�i •':'.. E' •.1• i .i..•.!
1�. i•'i lJl_Ii__ 4.: _it 11 t i
i...! r :, ,fir: t '.t,'(_ ll11 ,_ 0UR i'Giii1�' ; Rfii LEh'
CLERK S t 2013032114.
1 1.IlC-i FEES Ir*-10 ii_i
Parcel ID Number: 11 -1 -i - 3y - S0'g - Q 0&606()
The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with
Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement.
OF PROPER : (Legal de cription of the property and -street address if available
loth
GENERAL DESCRIPTION OF IMPROVEMENT:
_ . (Le w)r
OWNER INFORMATION:
Name:_ / Fy O N► 0% 'S 171—D
Address: lil M FA 6 ckyJ Q 6 ✓a Lo P(3, t;�� i )
Fee Simple Title Holder (if other than owner) Name:
rersons wnnin the State of Florida Designated by Owner upon whom notice or other documents may be served
as provided by Section 713.13(1)(b), Florida Statutes.
Name:
Address:
In addition to himself, Owner Designates
Section 713.13(1)(b), Florida Statutes.
Of
To receive a copy of the Lienor's Notice as Provided in
Expiration Date of Notice of Commencement (The expiration date is 1 year from date of recording unless a
different date is specified) _
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF
COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13,
FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A
NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY
BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true
to the best my knowledge and belief.
V e e 0 i C� pi t;
er's Signature Owners Printed Name
Florida Statute 713.13(1)(g): • The owner must sign the notice of commencement and no one else may be permitted to sign in his or her stead.'
State of r 1 County of 4eV'�1V'G1e_
The foregoing instrument was acknowledged before me this day of 2019
by Vg<0 v1 %CG;i .S u4} 0 Who Is personally known to me ❑
Name of person making staterrige
OR who has produced Identification type of identification produced: (�
1pftY PL
sp
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Notary PubticState ofFlorida
(33 Garza
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HERITAGE
Construction & Roofing Mc.
1544 Seminola Blvd. Suite 136
Casselberry, FL 32707
PH: 407-366-6000
FX:407-366-6065
Info@Heritagecr.com
CGC1505045 CCC1326650
CONTRACT
G
Account Manager: G
Contact:
INSURANCE COMPANY INFORMATION
Company:-75
Policy #t:off___
Claim q:
MORTGAGE COMPANY INFORMATION
Company:
Loan Number:
Owner's):
-I--
Phone:
Address:
Cell:
/�
C_tIt' J
City:
State:
Zip Code:
Email
AJ F
Manufacture:
Style:
Color:
Roof CRV:
If 0%,ner's Insurance Company does not agree to pay for damages, this contract shall be voidable.
Direction to pay, for the roof replacement and interior damages but not limited to: I hereby assign any and all insurance rights, benefits and
proceeds under any applicable insurance policies, Assignment of Insurance Benefits and give direction to pay: Heritage Construction & Roofing, Inc.
("Heritage"), the scope of which shall not be limited to a Roof Replacement. 1 make this assignment and direction to pay authorization in consideration of
Heritage's agreement to perform services, supply materials and otherwise perform its obligations under this contract, including not requiring full payment
at the time of contract. I also hereby direct my insurer(s) and Mortgagee(s) to release any and all information requested by Heritage, its representative, or
its attorney for the direct purpose of obtaining actual benefits to be paid by my insurer(s) for services rendered, In this regard. I waive my privacy rights.
If payment is made directly to the Owner/Agent/Insured(s), it shall be endorsed over to Heritage immediately upon receipt. I agree thatany portion of
work, deductibles, betterment or additional work requested by the undersigned, not covered by insurance, must be paid by the undersigned on the day of
installation. DEDUCTIBLE: It is the Owner's responsibility to pay all Insurance Deductibles. Owner's out-of-pocket expense will not exceed the
deductible amount, as stated on insurer's loss sheet, UNLESS replacement/repair of deteriorated decking is required and/or Owner requests optional
upgrades. Heritage CANNOT pay, waive, rebate, or promise to pay, waive or rebate all or any part of the insurance deductible applicable to the insurance
claim for pa t of work. In the event of a discrepancy, the deductible amount stated on the insurer's Loss Sheet sh11 ver rule deductible listed below.
Deductible: MUST BE PAID IN FULL, PLUS ANY APPLICABLE SALES TAX ( Initials)
MORTGAG U HO TION: 1, Owner / Mortgagor, grant authorization for Mortgage Co. to speak with Heritage
Construction & Roofing, on matters including, but not limited to, the claim and payment status.
PAYMENT SCHEDULE: Owner agrees to pay Heritage based on the following pay schedule: (i) Deposit in the amount of S due
upon signing this contract; (ii) the Contract Price, less the Deposit and any applicable depreciation retained by Owner's insurer(s), plus Upgrade Costs,
due and payable to Heritage upon completion of work being performed; and, (iii) the remaining Contract Price (equal to any applicable depreciation
and/or change orders) due and payable to Heritage upon completion of work performed. In the event of a pending inspection, no more than 2% of
Contract Price maybe thheld until inspection has pas e . t�'Qna i tF'GRADE ITEM::_ _
QTY: PRICE: S U TOTAL: S_
Replacement Work and Price: Upon insurer's approval and subject to the terms and conditions herein. Heritage agrees to furnish all materials and provide
the labor necessary to perform the full roof replacement which shall take place following Owner's insurance company's approval, approximately within
30 days, conditions permitting. Owners Declaration of Intent: Owner acknowledges and agrees that, upon approval by insurance company for a full roof
replacement, Heritage shall perform the roof replacement upon receipt of funds from Owner's insurance company. CANCELLATION: If Owner elects to
terminate the services of Heritage, Owner may do so before midnight on the third business day after Contract is executed. Owner shall receive a full
refund of all deposits. Owner may also rescind Contract before midnight on the third business day after the contract is executed after notification from
insurer(s) that the claim for payment on roof contract has been denied, in whole or in part. All written notices of cancellation, regardless of reason, shall
be postmarked or delivered to Heritage's corporate office; 1544 Seminola Blvd., Suitc136, Casselberry, Florida 32707. CANCELLATION
EXCEPTIONS: The three (3) day right of cancellation DOES NOT APPLY to contracts for emergency home repairs as time is of the essence. I. Owner,
have read and understand all statements, terms and conditions of the "Roof Replacement Contract" and agree that all details are acceptable and
satisfacto .1 further understand that this contract constitutes the entire agreement between the parties and that any further changes or alterations to this
contract ust be made in writing and agreed upon by both parties. Each party represents nd warrants to the other that it has the full power and authority
to enter' the contract and that it is binding and enforceable in accordance with ity ter. r r III r
AuthorizTd er ge Representative (Dat4 , f O"er J I Date
1/EQ n N 1 t' n• C�
Print Name
TERMS Aft CONDITIONS:: Acceptance of Terms: 1, Owner, hereby agree to retain Heritage for a full roof replacement on the terms and conditions
stated herein. I further agree to provide Heritage with the Scope of Loss Report generated by my insurer and authorize and grant full access to the
property for the purpose of staging and completing all agreed upon work. Supplemental Claims: Heritage reserves the right to file a supplemental claim
with Owner's insurance in the event that the estimate is incorrect and/or additional damage is discovered after commencement. The supplemental claim
amoungs), in addition to any depreciated amounts held back by the insurer, are immediately due to Heritage upon receipt. Commencement of Work:
Work shall commence at Heritage's discretion. Heritage shall not be liable for delay in, or failure to perform due to: labor controversies, strikes, fire,
weather, Acts of God, war, governmental actions, inability to obtain materials from usual sources, delays caused by and/or as a direct result of. Owner's
insurer or other circumstances not listed which are beyond the control of Heritage. Noise Pollution and Vibrations: Prior to installation, it is the sole
responsibility of Owner to remove any and all items which are not secured to walls including, but not limited to, items on mantles, shelves or other areas
susceptible to vibrations, as these may fall. Heritage shall not be liable for noise pollution and/or vibrations due to the performance of work contracted
herein, or damages resulting to person(s) or property.
CITY OF'
Sk40RDBuilding &Fire Prevention Division
l RESIDENTIAL RE -ROOF POLICY & PROCEDURES
FIRE €?EPARTMENT
PERMITTING REQUIREMENTS - NO PLAN REVIEW REQUIRED
THIS DOCUMENT (SIGNED) ALONG WITH AN ACCURATE AND COMPLETED RESIDENTIAL RE -ROOF SCOPE OF WORK ARE
REQUIRED TO BE SUBMITTED AS PART OF YOUR PERMIT APPLICATION.
THE SCOPE OF WORK MUST INCLUDE ALL APPLICABLE FLORIDA PRODUCT APPROVAL NUMBERS FOR ALL ROOF
COMPONENTS THAT WILL BE INSTALLED ON THE PROJECT.
A PERMIT WILL NOT BE ISSUED WITHOUT THESE DOCUMENTS. COPIES WILL BE MADE TO POST ON THE JOB SITE.
"PROJECTS LOCATED IN THE SANFORD HISTORIC DISTRICT WILL REQUIRE PLAN REVIEW AND APPROVAL BY THE
SANFORD HISTORIC PRESERVATION BOARD
INSPECTION POLICY & PROCEDURES
A FINAL ROOF INSPECTION IS THE ONLY INSPECTION REQUIRED FOR RESIDENTIAL (SINGLE FAMILY, TOWNHOUSE,
MOBILE HOME, APARTMENT AND/OR CONDOMINIUM) RE -ROOF PERMITS.
THE FOLLOWING IS REQUIRED TO BE PROVIDE ON THE JOB SITE:
• PERMIT CARD, POSTED IN A CONSPICUOUS AND WEATHERPROOF LOCATION
• COMPLETED RESIDENTIAL RE -ROOF SCOPE OF WORK
• COMPLETED AND NOTARIZED INSPECTION AFFIDAVIT
• ALL FLORIDA PRODUCT APPROVAL AND CORRESPONDING INSTALLATION INSTRUCTIONS
(PRODUCT APPROVAL SHALL MATCH WHAT IS ON THE SCOPE OF WORK)
• DIGITAL PHOTOGRAPHS (MUST INCLUDE THE PERMIT NUMBER OR ADDRESS IN EACH PICTURE)
o EACH PLANE OF THE ROOF, SHOWING THE UNDERLAYMENT INSTALLED
o ROOF DECK NAILING PATTERN & SPACING (INCLUDING A MEASURING DEVICE OR RULER)
o ROOF DECK NAILS USED (INCLUDING A MEASURING DEVICE OR RULER SHOWING SIZE OF NAILS)
o UNDERLAYMENT PATTERN & SPACING (INCLUDING A MEASURING DEVICE OR RULER)
o DRIP EDGE & VALLEY ATTACHMENT (INCLUDING A MEASURING DEVICE OR RULER)
o SHINGLES INSTALLED, NAIL PATTERN AND LOCATION OF NAILS
• SKYLIGHTS (IF APPLICABLE)
o DIGITAL PHOTOGRAPHS SHOWING ALL INSTALLATION COMPONENTS, PER FL PRODUCT APPROVAL
O DIGITAL PHOTOGRAPHS SHOWING ALL REQUIRED FLASHING, PER FL PRODUCT APPROVAL
FAILURE TO FOLLOW THESE SPECIFIC GUIDELINES WILL RESULT IN AN AFFIDAVIT PROVIDED BY A FLORIDA DESIGN
PROFESSIONAL (ARCHITECT OR ENGINEER), CERTIFYING FBC CODE COMPLIANCE BY PERSONAL INSPECTION.
CONTRACTOR (OR OWNER/BUILDER) SIGNATURE: DATE: ZG
CITY •
Ski4FORD
R e
FIRE DEPARTMENT
PERMIT # Af -1 'r 7
Building & Fire Prevention Division
RESIDENTIAL RE -ROOF SCOPE OF WORK
JOB ADDRESS: m Me c_x4. cam„ emvd • sc�I n e2r_a
STRUCTURE TYPE:ZP!CEMENT
E FAMILY RESIDENCE/TOWNHOUSE O MOBILE HOME O APARTMENT/CONDOMINIUM
RE -ROOF TYPE: (TEAR OFF EXISTING ROOF AND REPLACE WITH NEW COMPONENTS)
O RE-COVER (NEW ROOF INSTALLED OVER EXISTING ROOF)
DECK TYPE (PLEASE SPECIFY: v v 00 oft��G1'f h 1 G►
**PLEASE NOTE: ONL Y 100 SQUARE FEET OF THE EXISTING DECK IS PERMITTED BE REPLACED
ROOF VENTILATION: DOFF-R GE IDGE OSOFFIT OPOWERED VENT OTURBINES
SKYLIGHTS: O YES 0 IF YES, PLEASE PROVIDE FLORIDA PRODUCT APPROVAL #:
MAIN ROOF AREA
ROOF SLOPE: O LESS THAN 2:12 O 2:12 - 4:12 :12 OR GREATER
TYPE O OOF
FLORIDA PRODUCT APPROVAL
SHINGLE
MANUFACTURER
%'C-F
FL#
O METAL
FL#
O MODIFIED BITUMEN
FL#
O TORCH DOWN
FL#
O INSULATED
FL#
O TIX
FL#
OTHER: vvN64z,r }
+
FL# �) S-0 — R ,
ROOF EXTENSIONS (PORCHES, PATIOS, ETC.) **IFAPPLICABLE**
ROOF SLOPE: O LESS THAN 2:12 O 2:12 - 4:12 O 4:12 OR GREATER
TYPE OF ROOF
MANUFACTURER
FLORIDA PRODUCT APPROVAL
O SHINGLE
FL#
O METAL
FL#
O MODIFIED BITUMEN
FL#
O TORCH DOWN
FL#
O INSULATED
FL#
O TILE
FL#
O OTHER:
FL#
City of Sanford
Building and Fire Prevention
RESIDENTIAL RE -ROOF INSPECTION AFFIDAVIT
NAILING, SHEATHING, DRY -IN, FLASHING, AND ALL FINAL ROOF COVERINGS
PERMIT #: I _ (�(� ADDRESS: 1 j�^eCnG10W RW .
I (�W��i� \�/Z i4s\�!'C' , AS A(N) GENERAL, BUILDING, RESIDENTIAL, OR
ROOFING CONTRACTOR, ENGINEER, ARCHITEeT, OF F.S. CHAPTER 468 BUILDING INSPECTOR, I HEREBY AFFIRM, THAT ALL OF THE
FOREGOING INFORMATION IS TRUE AND ACCURATE AND THAT ALL ROOFING COMPONENTS LISTED ON THE SCOPE OF WORK AT THE
ABOVE REFERENCED ADDRESS HAVE BEEN INSTALLED IN ACCORDANCE WITH THEIR PRODUCT APPROVALS AND ALL APPLICABLE CODE
REQUIREMENTS — SPECIFICALLY FLORIDA BUILDING CODE, EXISTING BUILDING. IN ADDITION I CERTIFY THE INSTALLATION MEETS ALL
REQUIREMENTS FOR SECONDARY WATER BARRIER AND NAILING OF THE ROOF DECK, IN ACCORDANCE WITH THE HURRICANERETROFIT
MANUAL REQUIREMENTS (BASED ON F.S. CHAPTER 553.844).
LICENSE #: CCCkS 2. &6 S0
COMPANY / CONTRACTOR:
DATE: \O/ZS'A(k
OR OWNER/BUILDER)
A FINAL ROOF INSPECTION IS REQUIRED:_
THIS SIGNED AND NOTARIZED AFFIDAVIT MUST BE PROVIDED AT THE JOB SITE AT THE TIME OF THE FINAL ROOF INSPECTION,
ALONG WITH DIGITAL PHOTOGRAPHS OF EACH PLANE OF THE ROOF SHOWING IN DETAIL ALL COMPONENTS (DECKING,
UNDERLAYMENT, FLASHING, DRIP EDGE ATTACHMENT) WITH THE PERMIT NUMBER OR ADDRESS CLEARLY MARKED ON THE DECK
FOR EACH INSPECTION. THE PHOTOGRAPHS MUST INCLUDE A RULER OR MEASURING DEVICE TO CONFIRM ALL NAIL SPACING AND
OVERLAPS, INCLUDING DRIP EDGE AND VALLEY FLASHING. PLEASE REFER TO THE RE -ROOF POLICY AND INSPECTION PROCEDURE
PAPERWORK FOR FURTHER EXPLANATION OF ALL REQUIREMENTS.
"FAILURE TO FOLLOW ALL REQUIREMENTS WILL RESULT IN A FAILED INSPECTION, A RE -INSPECTION FEE AS
WELL AS REQUIRING A DESIGN PROFESSIONAL (ARCHITECT OR ENGINEER) TO CERTIFY, BASED ON PERSONAL
INSPECTION, THE INSTALLATION OF ALL ROOFING COMPONENTS.
STATE OF FLORIDA COUNTY OF
Sworn to and Subscribed before me this Q_ day of 20 _ft_ by:
Io is C�onally Known to me or has ❑ Produced (type of
as identification.
016
Print/Type Stamp Name
of Notary Public
ot�4t vex ;Notary Public State of Florida
? 'Lesley G Garza
o My Commission GG 009517
~j�l3F f�04 Expires 0710 i'I2020
r
City of Sanford
Building and Fire Prevention
RESIDENTIAL RE -ROOF INSPECTION AFFIDAVIT
NAILING, SHEATHING, DRY -IN, FLASHING, AND ALL FINAL ROOF COVERINGS
PERMIT #: I , S` ADDRESS: OrAL
z
AS A(N) GENERAL, BUILDING, RESIDENTIAL, OR
ROOFING CONTRACTOR, ENGINEER, ARCHITECT, OF F.S. CHAPTER 468 BUILDING INSPECTOR, I HEREBY AFFIRM, THAT ALL OF THE
FOREGOING INFORMATION IS TRUE AND ACCURATE AND THAT ALL ROOFING COMPONENTS LISTED ON THE SCOPE OF WORK. AT THE
ABOVE REFERENCED ADDRESS HAVE BEEN INSTALLED IN ACCORDANCE WITH THEIR PRODUCT APPROVALS AND ALL APPLICABLE CODE
REQUIREMENTS — SPECIFICALLY FLORIDA BUILDING CODE, EXISTING BUILDING. IN ADDITION I CERTIFY THE INSTALLATION MEETS ALL
REQUIREMENTS FOR SECONDARY WATER BARRIER AND NAILING OF THE ROOF DECK, IN ACCORDANCE WITH THE HURRICANE RETROFIT
MANUAL REQUIREMENTS (BASED ON F.S. CHAPTER 553.844).
LICENSE #: CCC1331153
COMPANY / CONTRACTOR: JASPER CONT
CONTRACTOR SIGNItTURE: DATE: `4 �nL 1 lb
(MUST BE SIGNED BY LICEN§Fei1bLDER OR OWNER/BUILDE
A FINAL ROOF INSPECTION IS REQUIRED:
THIS SIGNED AND NOTARIZED AFFIDAVIT MUST BE PROVIDED AT THE JOB SITE AT THE TIME OF THE FINAL ROOF INSPECTION,
ALONG WITH DIGITAL PHOTOGRAPHS OF EACH PLANE OF THE ROOF SHOWING IN DETAIL ALL COMPONENTS (DECKING,
UNDERLAYMENT, FLASHING, DRIP EDGE ATTACHMENT) WITH THE PERMIT NUMBER OR ADDRESS CLEARLY MARKED ON THE DECK
FOR EACH INSPECTION. THE PHOTOGRAPHS MUST INCLUDE A RULER OR MEASURING DEVICE TO CONFIRM ALL NAIL SPACING AND
OVERLAPS, INCLUDING DRIP EDGE AND VALLEY FLASHING. PLEASE REFER TO THE RE -ROOF POLICY AND INSPECTION PROCEDURE
PAPERWORK FOR FURTHER EXPLANATION OF ALL REQUIREMENTS.
"FAILURE TO FOLLOW ALL REQUIREMENTS WILL RESULT IN A FAILED INSPECTION, A RE -INSPECTION FEE AS
WELL AS REQUIRING A DESIGN PROFESSIONAL (ARCHITECT OR ENGINEER) TO CERTIFY, BASED ON PERSONAL
INSPECTION, THE INSTALLATION OF ALL ROOFING COMPONENTS.
STATE OF FLORIDA COUNTY OF SEMINOLE
Sworn to and Subscribed before me this q day of AQ 'I'-, ' 20 16 by:
Who is ❑ Personally Known to me or has N Produced (type of
identification) DL as identification. .N
Si natu fNotar Pu lic >°> ' SI<YLAR B AP01i<RA.U�1
g ) _ C011ln S$lOn N FF 127890 I
State of
1 rida •. ` My COmnussion Expires I
r rau�fi 3 '�° ,°�'` •_p'�-_� June 01,2 O 1 8s
Print/ ype/Stamp Name
of Notary Public
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date: A ot
I Hereby name and appoint: Scott Meixsell, James Allen, Chris Gardner, Juan Lozano, Paul Padgett
an agent of: Jasper co r oes
(Name of Company)
to be my lawful anomey-in-fact to act for me to apply for, receipt for, sign for and do all things
necessary to this appointment for (check only one option):
® The specific pemut and application for work located at-
1'l� PT IAP IAifl ?X ci rrIt? Cat.11 fUrU sal
J (Suw Addr css) p�
Expiration Date for This Limited Power of Attorney:
License Holder Name: -068A &KV`,Ci(,{�
State License Number. OCC1331153
Signature of License Holder:
STATE OF FLORIDA -
COUNTY OF sew
The foregoing instrument, was acknowledged before me this 4-day of i(1 ;
200__IL, by oonaia Bold who is o personally known
to me or to who has produced a as
identification and who did (did not) take an oath.
NAVCJ1Jl, 1 V 111 l� Ili 011 A
(Notary Seal)
SKYLAR 0 A01 A,
s
"
(Rev. 08.12)
Print or type name
Notary Public - State
of
Commission No.
My Commission Expires: ' ' 11 i K
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