HomeMy WebLinkAbout130 Bristol Forest Tr�s J;
f' APR 2 4 2018
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No:[ 8 lq m
Documented Construction Value: $ 11,520.00
Job Address: 130 Bristol Forest Trail Sanford FL 32771 Historic District: Yes ❑ No ❑
Parcel ID• 22-19-30-502-0000-0180 Residential ❑x Commercial ❑
o
Type of Work: New ❑ Addition ❑ AlteRerratofion X❑ Repair ❑ Demo ❑ Change of Use ❑ Move ❑
Description of Work: Re Roof
Plan Review Contact Person: r)Phh'e Plyhon Title:
Phone: 407.696.7663 Fax: 407.695,7664 Email: ff _.rnoftnp,;PrvirpS com
Property Owner Information
Name Andy Rivera
Street: 130 Bristol Forest
City, State Zip: Sanford FL 32771
Phone:
Resident of property? : YE
Contractor Information
Name Roof Ton Services of Central El., Inc. Phone: 407.696.7663
Street: 1150 Belle Ave., Suite #1060 Fax: 407.695,7664
City, State Zip: Winter Springs, FL 32708 State License No.: , .C1326679
Architect/Engineer Information
Name:
Street:
City, St, Zip:
Bonding Company:
Address:
Phone:
Fax:
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 pernut 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: 511 Edition (2014) Florida Building Code
Revised: June 30, 2015 Permit Application
0141 l
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 subn-dttal.
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.
L? z
Signatu o wne Agent Date
to J yr L y e-Vc`
Print Owner/Ag 's Name
1—
yig�r-iaturc of Notary -State of Florida Jerome A Stecherr
*,Expires
NOTARY PUBLIC
STAVE OF FLORIDA
Comm' FF911625
9/11/2019
Owner/Agent is Personally Known to Me or
Produced ID )K Type of ID 0-,- P f, I,,-r-C
��'- � A -4.f[ —*& 7 Y-'n
Signature of Contractor/Agent Date
Kristal A. Wingate
Print Contractor/Agent's Name
�( P PLYBON
Signature of Notary -St
MY COMMIJeN # GG 102302
c`c EXPIRES: September 4, 2021
° Bonded Thru Notary Public Underwriters
Contractor/Agent is x Personally Known to Me or
Produced 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:
Flood Zone:
# of Stories:
New Construction: Electric - # of Amps Plumbing - # of Fixtures
Fire Sprinkler Permit: Yes ❑ No ❑
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
# of Heads
UTILITIES:
FIRE:
Fire Alarm Permit: Yes ❑ No ❑
WASTE WATER:
BUILDING:
Revised: June 30, 2015 Permit Application
1N
THIS INSTRUMENT PREPARED BY: GRANT NALOY, SE111NOLE COUNTY
Name: Kristal A. Wingate CLERK. OF CIRCUIT COURT & COMPTROLLER
Address: 1150 Belle Ave., Suite #1060 B K 911" Ps 61 (1P9s )
CLERK'S T 2018044353
Winter Springs, FL 32708-2962 RECORDED 04/24/2018 09:33:49 AM
RE(` 'RIDING FEES $10.00
NOTICE OF COMMENCEMENT RECORDED BY hdevore
Permit Number:
Parcel ID Number: 22-19-30-502-0000-0180
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.
1. DESCRIPTION OF PROPERTY: (Legal description of the property and street address if available)
Lot 18 Preserve At Lake Monroe Pb 62 Pas 12 - 15
130 Bristol Forest Trl. Sanford, FL 32771
2. GENERAL DESCRIPTION OF IMPROVEMENT:
Roof Replacement
3. OWNER INFORMATION OR LESSEE INFORMATION IF THE LESSEE CONTRACTED FOR THE IMPROVEMENT:
Name and address: Andy Rivera 130 Bristol Forest Trl. Sanford, FL 32771
Interest in property: Property Owner
Fee Simple Title Holder (if other than owner listed above) Name:
Address:
a. CONTRACTOR: Name: Roof Top Services of Central Florida, Inc. Phone Number: (407) 696-7663
Address: 1150 Belle Avenue, Suite #1060, Winter Springs FL 32708-2962
S. SURETY (If applicable, a copy of the payment bond is attached): Name:
Address: Amount of Bond:
6. LENDER: Name: P N L G Yl `� Phone Number:
Address:
7. Persons within the State of Florida Designated by Owner upon whom notice or other documents may be served as provided by Section
713.13(1)(a)7., Florida Statutes.
Name: Phone Number:
6. In addition, Owner designates
of
to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Phone number:
9. Expiration Date of Notice of Commencement (The expiration 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.
Av\Jq Ziv-er,
(SignqkfeX Own or 4ssee, or Owners or Lessee's APnnt Name and Provide Signatory's Title/Office)
u rized Officer/D eclor/Partner/Manager)
State of EZ—o 9-1 o A" County of t�4A-/J6 G The foregoing instrument was acknowledged before me this )1 D day of A Y f-( t 20 1
by RngD!j t2i t1e H
Name of person making statement
who has produced identification $4 type of identification produced:
WINDI KENROY
r•�rt� MY COMMISSION # GG 070343
i-;r�'�" EXPIRES, Februe, 14, 2021
Bonded Thru Notary Pubic Underwriters
. Who is personally known to me ❑ OR
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date: 04-23-18
I hereby name and appoint: Ryan Plybon
an agent of. Roof Top Services of Central Florida, Inc.
(Name of Company)
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):
❑ All permits and applications submitted by this contractor.
or
j� The specific permit and application for work located at:
130 Bristol Forest Trail, Sanford, FL
(Street Address)
Expiration Date for This Limited Power of Attorney:
License Holder Name: Krlstal A. Wingate
State License Number: CCC1326679
Signature of License Holder'
STATE OF FLORIDA
COUNTY OF Seminole
The foregoing instrument was acknowledged before me this 23rdday of Aril
2018 , by Kristal A. Wingate who is X personally known
to me or ❑ who has produced
identification and who did (Aid -not) take an oath.
(Notary Seal)
i ''k DEBORAH PLYBON
1,. " MY COMMISSION # GG 102302
EXPIRES: September 4, 2021
Bonded Thru Notary Public Underwriters
(Rev. 8/06/13)
Signature
Deborah Plybon
Print or type name
Notary Public - State of Florida
Commission No. GG102302
My Commission Expires: Sept. 04 2021
as
3/26/2018
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SCPA Parcel View: 22-19-30-502-0000-0180
Property Record Card
Parcel: 22-19-30-502-0000-0180
Property Address: 130 BRISTOL FOREST TRL SANFORD, FL 32771
- "�`t' % i' TRACT A
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130
Seminole County GIS ? }
Legal Description
LOT 18
PRESERVE AT LAKE MONROE
PB62PGS12-15
Taxes
Taxing Authority Assessment Value
Exempt Values
Taxable Value
County General Fund ' $185 419
i $50,000
$135,419
_.__.___.._._............._________.....__..._.______._ ..-__-__. _._.-._. ____i-.__ __._ _.-_._ .___--_ . ________
Schools_ $185419
$25,000—'u
$160,419
City Sanford i $185,419
$50,000
$135,419
SJWM(Samt Johns Water Management) $185,419
$50,000
$135,419
V -
County Bonds $185,419
i $50,000
$135,419
Sales
- - — ---- —--._...-------- —
Description
-
Date
II
- -
Book Page
-------------
Amount
Qualified
----
Vac/Imp
TRUSTEE DEED
5/1/2010
07391 0433
$203,000
No
Improved
WARRANTY DEED
CORRECTIVE DEED
1/3/2009
1/1/2009
07187 1894
07391 0426
$185,000
1 $100
No
No
Improved
Improved
WARRANTY DEED
i 11/1/2005
06065 1875—
$400 000
—
Yes
Improved
WARRANTY DEED
18/1/2004 A-
05457 1694
$267,300
I
Yes
Improved
Find ComaAmblo Uks
Land
Method Frontage Depth Units Units Price Land Value
-- -
-�--
LOT — _ 1 $40,000.00 $40,000
5,
Building Information
Is Bed/Bath count incorrect? Click Here.
http://parceIdetail.scpafl.org/ParcelDetaiI Info.aspx?PI D=22193050200000180 1 /2
3/26/2018
SCPA Parcel View: 22-19-30-502-0000-0180
#
Description I Year Built
Fixtures
Bed
Bath
Base Area
Total SF Living SF
Ext Wall
Adj Value
Repl Value
Appendages
Actual/Effective
I
SINGLE j 2004
1 $�
-
—=�, 'I 5532 4-08-T 3;479
C91STUCCO i $207;782--$2T8-144
Description
Area
1 FAMILY
;
j i
FINISH
GARAGE
459.00
k ?
FINISHED
i
I I
�.-... --._.
OPEN
PORCH
143.00
j
I
-
FINISHED
rI
-----
UPPER
—-..-- -
s
f
STORY
1947.00
;
FINISHED
Permits I
Permit #
Description
Agency
Amount CO Date
Permit Date
02556
i 40 X 22 SCREEN POOL ENCLOSURE
SANFORD
v $4,282 '
7/6/2004
02274
SWIMMING POOL & SPA
j SANFORD
r
1 $20,871 ;
6/2/2004
01492
NEW -RESIDENTIAL
SANFORD
j $152,186 , 8/24/2004
2/16/2004
j Extra Features
Description Year Built Units Value I New Cost
SCREEN ENCL 2 11/1I2004 1 i $2,669 $5,000
POOL 2 11/1/2004 1.__ ......_ . $13,0001 $20,000
GAS HEATER 11/1/2004 1 i $440 ; $1,100
http://parceldetail.scpafl.org/ParcelDetaillnfo.aspx?PID=22193050200000180 2/2
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C$�RSA 499CLOOF TOP SERVICES 9037
"TEi91 OF CENTRAL FLORIDA, INC. _ • •
Florid• 0.00ln{..¢N,e. Me,•1 EIE{EI• CI®aI-�®
1150 Belle Avenue, Suite #1060, Winter Springs, FL 32708 I Skylights
www. rooftops a rvices. corn • 407.696.ROOF (7663) • Fax: 407.695.7664 • state cert.# CCC1326679
IOOFING CONSULTANT: CONSULTANT'S CELL: 41017;30'
PROPOSAL PREPARED FOR: niii%G.
INSPECTION DATE:
f'J
ADDRESS: 13 rI S ;) r,.-o
HOME PH:
CELL PH:
CITY, STATE, ZIP:
L
WORK PH:
L7 G ^I
JOB LOCATION (if different from acdrdfss above):
fl �� IZ� V e t25
AFTER A VISUAL INSPECTION OF THE JOBSITE, WE HEREBY RESPECTFULLY SUBMIT THE FOLLOWING ESTIMATE:
PREPARATION
j,ebtain necessary insurances, permits and inspections in accordance with the current Florida Building Code.
�Xnspect property and take necessary precautions to protect structure's exterior and landscaping.
4-RRemove ( /) layer(s) of existing roofing in its entirety & properly dispose of all related trash and debris.
� DECKING & WOOD REPLACEMENT
:ffispect the existing roof deck, soffit and fascia board for any rotten/damaged wood and replace as
)eeded per the following pricing schedule:
)lywood - $ 6S uy PerSheet 1X - $ sr 10' linearfoot 2X - $ J U linear foot
:ascia (Pine/Spruce) $ 6.01/ linearfoot Fascia (Cedar) $ Y-OV linearfoot
Z.Pf ovide & install additional decking fasteners as needed to ensure compliance with the current Florida
Wilding Code.
UNDERLAYMENTS
;Krovide & install a Synthetic Roof Underlaymenk to the prepared roof deck; fastened to ensure
:ompliance with the current Florida Building Code Nail Pattern.
:1 Provide & install a double layer of 15LB. UL Felt Paper Underlayment to prepared deck of low slope roof; fastened to ensure
:ompliance with the current Florida Building Code Nail Pattern.
:1 Provide & install a self -adhering Waterproof Leak Barrier to prepared roof deck.
VENTILATION
:1 Provide & install 10-ft. Aluminum Pre -Finished Ridge Vent
:1 Provide & install 4-ft. Galvanized Metal Pre -Finished Off Ridge Vent
vide & install 3.0 LF of Shingle -Over Vent
Provide & install_ 4-in. Finished Galvanized Metal Gooseneck Bath Vent
:1 Provide & install 10-in. Finished Galvanized Metal Gooseneck Kitchen Vent
:1 Provide & install r� Other Venting
:olor Selection: 1;7rowr%
"Standard factory painted finishes available for metal ventilation are Brown, Block, White or Mill Finish.
FLASHINGS & MISCELLANEOUS
❑ Provide & install 1%" pipe boot collar(s) ❑ Provide & install 3" pipe boot collars(s)
521"Provide & install_ 2" pipe boot collar(s) ❑ Provide & install 4" pipe boot collars(s)
inspect flashings and replace as needed at a replacement cost of $ rtSD linear foot
Errrovide & install LF of Self Adhering Waterproof Leak Barrier & 26-Gauge Galvanized Valley Metal
:o all valley(s). /
Ef'rrovide & install 247 LF of new standard pre -finished, 2%-in. 26-Gauge Galvanized Metal Drip Edge to
jerimeter of roof.
:olor Selection: WG 14,
k Standard factory painted finishes available for metal•drip edge are Brown, Black, White, Beige, Grey or Mill Finish.
ID Acrylic / ❑ Glass Quantity:
❑ Acrylic / ❑ Glass Quantity:
❑ SUN TUNNEL Quantity:
SKYLIGHTS & SUN TUNNELS
Size: Model #,
Size: Model #
Size: Model #
WTION #1 Initial:
Manufacturer Warranty:y
Workmanship Warranty:
Shingle Series:Jj'rI/ �rYlrLS'{J A14
Color: �t����17ff�
#1Sub-Total:
0 OPTION #2 Initial:
Manufacturer Warranty:
Workmanship Warranty:
Shingle Series:
Color:
#2 Sub -Total:
❑ OPT ION,#3: InitiaG.':
Manufacturer Warranty: _
Workmanship Warranty:
Shingle Series:
dolor.
#3 Sub -Total:
LOW SLOPEAOOF: InitiaL•-
HIT &RIDGE Manufacturer Warranty: _
❑ Provide &install Standard Ridge. CfProvicle & install High Definition Ridge.
Tapered Package/Insulation:
AnniTie-iMAI WnR1( Tn RF INC`I iinrn P nNTRAC'T
..11 __ ..—...._ .. _.....— __ ..---- —----......._.
� t%L [J V �l� i�✓IC f`%/+w Workmanship Warranty:
Material Type:
CLEAN-UP Color:
IZ,C can gutters free of all debris/waste generated by this construction. Low slope Sub -Total:
CePerform a daily magnetic sweep of entire jobsite.
2-dean up end properly dispose of all work related trash and debris generated by this construction daily.
Roof Top Services of Central Florida, Inc. t�ire+baf proposes to furnish material and labor complete and in accordance with above description
and specifications, for the total sum of $ 4 / `5A0, Ou PAYMENTIS DUE IN FULL IMMEDIATELY UPON COMPLETION OF WORK
ACCEPTANCE OF PROPOSAL: By signing this contract, I am authorizing ROOF TOP SERVICES OF CENTRAL FLORIDA, INC. to do the work as described above. The
above specifications, conditions and prices are satisfactory and hereby accepted. You are authorized to do the work as specified. I understand and agree that
payment will be made in full immediately upon completion of work. PI,;,,(/% ✓kjl" 0'�551
___1/ $162.00
Signature:
Acceptance Date: 5f )9 -1z0 )8
F TOP SERVICES IS NOT RESPONSIBLE FOR LOW SLOPE$ OR PONDING WATER.
We "-the ODie -Md &-Oie sm shire iln,
PERMIT # l*?- (` J�
City of Sanford Building Division
Residential Re -Roof Scope of Work
JOB ADDRESS: 130 Bristol Forest Trl Sanford FL 32771
STRUCTURE TYPE: 0 SINGLE FAMILY RESIDENCE/TOWNHOUSE O MOBILE HOME O APARTMENT/CONDOMINIUM
RE -ROOF TYPE: I�) REPLACEMENT (TEAR OFF EXISTING ROOF AND REPLACE WITH NEW COMPONENTS)
O RE-COVER (NEW ROOF INSTALLED OVER EXISTING ROOF)
DECK TYPE (PLEASE SPECIFY): 1 /2 inch plywood
* *PLEASE NOTE: ONLY 100 SQUARE FEET OF THE EXISTING DECK IS PERMITTED TO BE REPLACED * *
ROOF VENTILATION: 3OFF-RIDGE O RIDGE OSOFFIT OPOWERED VENT
SKYLIGHTS: O YES ® NO IF YES, PLEASE PROVIDE FLORIDA PRODUCT APPROVAL #:
MAIN ROOF AREA
ROOF SLOPE: O LESS THAN 2:12 O 2:12 —4:12 (2� 4:12 OR GREATER
OTURBINES
TYPE OF ROOF
MANUFACTURER
FLORIDA PRODUCT APPROVAL
® SHINGLE
GAF
FL# 10124-R20
O METAL
FL#
O MODIFIED BITUMEN
FL#
O TORCH DOWN
FL#
O INSULATED
FL#
O TILE
FL#
O OTHER:
FL#
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#
OTORCH DOWN
FL#
O INSULATED
FL#
O TILE
FL#
0 OTHER:
FL#
CITY OF
S..�Building & Fire Prevention Division
j V RESIDENTM RE -ROOF POLICY & PROCEDURES
FIRE DEPARTMENT
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.
Y'°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.
DATE:
CONTRACTOR (OR OWNER/BUILDER) SIGNATURE: /