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HomeMy WebLinkAbout801 Willow Ave 17-1378; ROOFr h •xr+. "., CITY OF SANFORD BUILDING & FIRE PREVENTION MAY 1 1 2017 PERMIT APPLICATION g. Application No: Documented Construction Value: S Job Address: gaz 01(,LoW At& Crn,.n 1'I L Historic District: Yes No a ParcelID: a? 57_ / 9 • 3 O • 57 A & - jODU Residential 2 Commercial Type of Work: New Addition Alteration Repair Demo Change of Use Move Description of Work: Q Ez 00'- Plan Review Contact Person: nJ1p W CJe-- Title: ` Phone: 4&7. 9 / , 0 3A_J_Fax: - 1)7. 2a L - 5.?Email: cdt.%n-ct VooFrl!a betC SOorti .hPf Property Owner Information Name 14 4, (,—yL,-,t eT Phone: Street: k0/ (/ U._'0LJ Au-2- ' Resident of property? City, State Zip: ! ,t 4 L 3','7 7 Contractor Information Name 410 l ei C-k_- Street: & U o/Yi City, State Zip: ,L: 7 7 Name: V Street: City, St, Zip: Bonding Company: il/ 4 Address: Phone: ! f 0 ' - 3 ;1_1 - 95 S d' Fax: L< u -7 . - 9s- State License No.: Architect/Engineer Information Phone: Fax: E- mail: Mortgage Lender: Ai Address: C_ CLod2S- b) 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. 1 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: 51' Edition (2014) Florida Building Code Revised: June 30, 2015 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. sk 7 Signature of er/Age t Date Signature of Co ctor/Agent Date j,, 1_3QI/l,,, ea&ka Am"cT A,/DLaelL Print Owner/Agent's Name Print Contractor/Agents Name Signatu o otary-State of Florida Date Sign ota ate f F on a Dat, DONALD RAShIMARONMARIEADCOCK , tM",'A ay P e'o lotitjl Pu01ic -Slue of Florida 9rNotary Public - State o1 Florida Commission # GG 013492 Commission # FF 221706 My Comm. Expires Jui 29. 2020 ;`.' My Comm. Expires Apr 16, 2019 Owne '•,; F• Bon a or Con r osEBonded National of Assn. yffto Me or Produce I Typjof 11311 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: New Construction: Electric - # of Amps Fire Sprinkler Permit: Yes No # of Heads APPROVALS: ZONING: ENGINEERING: COMMENTS: UTILITIES: Iy119in Flood Zone: of Stories: Plumbing - # of Fixtures Fire Alarm Permit: Yes No WASTE WATER: BUILDING: Revised: June 30, 2015 Permit Application American Land Tide Association VENTURE TITLE ALTA Universal ID 705 S. FRENCH AVE., STE B SANFORD, FL 32771 File No./Escrow No.: VEN1703032 Print Date & Time: May 2, 2017 at 02:31' PM Officer/Escrow Oflioer. AMy DUNLAP Settlement Location: 705 S. FRENCH AVE STE A SANFORD, FL 32771 Property Address: Borrower: Seller. Lender. Settlement Data: Dlsburseruent Date: 801 WILLOW AVE SANFORD; FL 32771 BRIAN GOULET MELVINA SMITH May 4, 2017 May 4, 2017 ALTA Settlement Statement - Combined Adopted 05-01-2015 Seller Description Borrower/ Buyer Debit Credit. Debit Credit finanCiaF:' 33,000.00 Sale Price of Property Deposit Prwationsbe4ustments, . 353.96 County Taxes 01/01/17 to 05/04/17 33,000.00 Title - Owner's Title Insurance $ 189.75 to VENTURE TITLE Coverage: $ 33,000.00 Premium: $ 389.75 Title - Closing Fee to VENTURE TITLE $ 400.00 Title - Search Fee to VENTURE TITLE $ 85.00 TMe - Document Storage to VENTURE TITLE $ 32.00 Fee CnmmisWon 3,000.00 353.96 Copyright 2015 American Land Title Assodation (VEN1703032.PFp/VEN1703032/2) All rights raved Printed on 05/02/17 at 02:31•PM Debit credit 990.00 Commission ALTA Settlement Statement Combined - Continued 8wroww1Buyer Debit credit Goytlnu iltReeodltlg.end:Traiitsl+ec+Cha>`ges Recording Fees to Canty Clerk of $ 14.50 the Circam Cam Deed:$14.50 Morhgage:$0.00 273.00 RECORDING PROBATE to County Clerk of DOCUMENTS. the Circuit Court 231.00 Transfer Tax - State to County Clerk of the Circuit Court 14.50 RECORD AFFIDAVIT to County Clerk of the Circuit Court PROW, 777771 Misoel[ane0us LIEN SEARCH to GATOR LIEN $130.00 SEARCH 2,082.45 2015/2016 REAL ESTATE to SEMINOLE TAXES COUNTY TAX 94.00 CERTIFIED COPY to VENTURETITLE REQUEST REIMBURSEMENT 4,038.91 $ 33,000.00 Subtotals 33;851.25 $ 3,353.96 Balance Due FROM 30,497.29 28,961.09 Balance Due TO 33,000.00 $ 33,000.00 TOTALS 33,851.25 $ 33,851.25 Acknowledgement Wen have carefully reviewed the ALTA Settlement Statement and find it to be a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction and further certify that I have received a copy.of the ALTA Settlement State ant. Well authorize VENTURE TITLE to cause the funds to be disbursed in accordance with this statement. BRIM GOU MELVINA SMITH AMY DUN1A , E w Officer Copyright 2015 American Land Tltie Assodabon (VEr1703032.PFD/VEN170303212) All rights reserved Printed on 05/02/17 at 02:31•PM American Land Title Association VENTURE TITLE ALTA Universal ID 705 S. FRENCH AVE., STE B SANFORD, FL 32771 File No./Escrow No.: VEN1703032 Print Date & Time: May 2, 2017 at 02:31 • PM Officer/Escrow Officer: AMY DUNLAP Settlement Location: 705 S. FRENCH AVE STE A SANFORD, FL 32771 Property Address: Borrower: Seller: Lender: Settlement Date: Disbursement Date: 801 WILLOW AVE SANFORD, FL 32771 BRIAN GOULET MELVINA SMITH May 4, 2017 May 4, 2017 ALTA Settlement Statement - Combined Adopted 05-01-2015 Seller Description Borrower/Buyer Debit Credit Debit Credit Financial 33,000.00 Sale Price of Property $ 33,000.00 Deposit $ 3,000.00 Proration/A 'ustmen s 353.96 County Taxes $ 353.96 01/01/17 to 05/04/17 LoanCtiar es to 7777-77 Other Coah Cha"r es Im _ unds Title Char es & EscroW ;:Settlementi Char 'es Title - Owner's Title Insurance $189.75 to VENTURE TITLE Coverage: $ 33,000.00 Premium: $ 189.75 Title - Closing Fee to VENTURE TITLE $ 400.00 Title - Search Fee to VENTURE TITLE $ 85.00 Title - Document Storage to VENTURE TITLE $ 32.00 Fee Commission Copyright 2015 American Land Title Association (VEN1703032.PFD/VEN1703032/2) All rights reserved Printed on 05/02/17 at 02:31•PM Seller ALTA Settlement Statement Combined - Continued aorrowerlBuyer Debit Credit Debit Credit 990.00 Commission Government Recordin and Transfer -Charges Recording Fees to County Clerk of $ 14.50 the Circuit Court Deed:$14.50 Mortgage:$0.00 273.00 RECORDING PROBATE to County Clerk of DOCUMENTS the Circuit Court 231.00 Transfer Tax - State to County Gerk of the Circuit Court 14.50 RECORD AFFIDAVIT to County Gerk of the Circuit Court pa offt; Miscellaneous LIEN SEARCH to GATOR LIEN $ 130.00 SEARCH 2,082.45 2015/2016 REAL ESTATE to SEMINOLE TAXES COUNTY TAX 94.00 CERTIFIED COPY to VENTURE TITLE REQUEST REIMBURSEMENT 4,038.91 $ 33,000.00 Subtotals 33,851.25 $ 3,353.96 Balance Due FROM 30,497.29 28,961.09 Balance Due TO 33,000.00 $ 33,000.00 TOTALS 33,851.25 $ 33,851.25 Acknowledgement Well have carefully reviewed the ALTA Settlement Statement and find it to be a true and accurate statement of all receipts and disbursements made on my account or by me In this transaction and further certify that i have received a copy of the ALTA Settlement Statement. Well authorize VENTURE TITLE to cause the funds to be disbursed in accordance with this statement. BRRIAAN GOULET MELVINA SMITH LJ = AMY DUNLAP, Es ow Officer Copyright 2015 American Land Title Association (VEN1703032.PFD/VEN170303212) All rights reserved Printed on 05/02/17 at 02:31•PM This instrument prepared by and return to: Name: Amy Dunlap an empioyee'of VENTURE TITLE Address: 705 S. FRENCH AVE., STE B SANFORD, FL 32771 FILE NO. VEN1703032 Property Appraisers Parcel Identification Number(s): 25-19- 30-5AG-100G-0060 Grantee(s) S.S Vs: SPACE ABOVE THIS LINE FOR RECORDING DATA THIS WARRANTY DEED Made and executed the 4th day of May, 2017 by MELVINA SMITH, whose post office address is 4611 SW 20th Street, Westpark, FL 33023 hereinafter called the grantor, to BRIAN GOULET whose post office address is 806 ESCAMBIA DRIVE, SANFORD, FL 32771 hereinafter called the grantee; Wherever used herein the terms "grantor" and "grantee" include all the parties to this instrument, singular and plural, the heirs, legal representatives and assigns of individuals, and the successors and assigns of corporations, wherever the context so admits or requires.) WITNESSETH: That the said grantor, for and in consideration of the sum of ten dollars ( $10.00) and other valuable considerations, receipt whereof is hereby acknowledged, by these presents does grant, bargain, sell, alien, remise, release, convey and confirm unto the grantee all that certain land situate in SEMINOLE County, State of Florida, viz: Lot 6, Block 10, Tier G, of E.R. TRAFFORD'S MAP OF THE TOWN OF SANFORD, according to the Plat thereof as recorded in Plat Book 1, Page 115, of the Public Records of Seminole County, Florida. The property is not the homestead property of the grantor nor is it adjacent to or contiguous with their homestead property. Together, with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that it is lawfully seized of said land in fee simple; that it has good right and lawful authority to sell and convey said land; that it hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2017. FURTHER SUBJECT TO restrictions, reservations, covenants and easements of record, if any, however this reference shall not operate to reimpose same. In Witness Whereof the said grantor has signed and sealed these presents the day and year first above written. and delivered in the presence of: Printed Name MELVINA SMITH STATE OF FLORIDA, COUNTY OF &Pd The foregoing instrument was acknowledged before me this "f day of May, 2017 by MELVINA SMITH, ha/She is personally known to me or who produced IUP S— CQ as identification and who did/did not take an oath. Pit [seal] My Commission Expires: CJrJ 021,1W .. OIL 1lmb Y O1 D016a;0 THIS INSTRUMENT PREPARED BY: D fijco&,, Name: ADCOCK ROOFING Gt Address: 800 S. FRENCH AVE. SANFORD, FL 32771 NOTICE OF COMMENCEMENT Permit Number: Parcel ID Number: 25-19-30-5AG-1OOG-0060 GliAII r 11ALO Y o SE1111,I01...E COUNTY CLERK OF CIRCUIT COURT V; COMPTROLLER BK 8910 F'3 1408 (1F'3s) CLERK'S " 2017046675 1 ECORDEI) O5/11/21i17 10:16:4.1i f1171 RECORDING FEES RECORDED BY tsfli),h 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) TOWN OF SANFORD ed - f ps "'• PB 1 PG 115 2. GENERAL DESCRIPTION OF IMPROVEMENT: NRe -Roof 3. OWNER INFORMATION OR LESSEE INFORMATION IF THE LESSEE CONTRACTED FOR THE IMPROVEMENT: < FE CANameandaddress: BRIAN GOULET• 801 WILLOW AVE SANFORD FL 32771 Interest in property: OWNER Q Fee Simple Title Holder (if other than owner listed above) Name: 4. CONTRACTOR: Name: Adcock Roofing Phone Number: 407-322-9558 cs ; Address: 800 S. French Ave Sanford FL 32771 6. SURETY (If applicable, a copy of the payment bond is attached): Name: Address: 6. LENDER: Name: Phone Number: Address: Amount of Bond: L 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. Nnnna• Phone Number: 8. 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. irk _/_L 3e1)q'i got-, &T Signature o e or Lessee, o Owmars or Lessee's (Print Name and Provide Signatory's Title/Office) Authorized 0, er/Dhedor;Partn.r/Manager) _ State of 4:7LD(ci OA County of S t7m (u). o ' The foregoing instrument was acknowledged before me this day of by I' (Io, /\(S— Who is personally k own to me 8—OR a Name of person making statement S who has produced identification type of identification produced: T MARJORIE MARIE ADCOCK Notary My Coirnn eandedlhrou NN O K N PERMIT # City of Sanford Building Division Residential Re -Roof Scope of Work JOB ADDRESS: DI G41 PLC !?( i G"` b' r, -7 STRUCTURE TYPE: (D-SINGLE FAMILY RESIDENCE/TOWNHOUSE O MOBILE HOME O APARTMENT/CONDOMINIUM RE -ROOF TYPE: ©"REPLACEMENT (TEAR OFF EXISTING ROOF AND REPLACE WITH NEW COMPONENTS) O RE-COVER (NEW ROOF (INSTALLED OVER EXISTING ROOF) DECK TYPE (PLEASE SPECIFY): // ,( Lw'060 PLEASE NOTE. ONLY 100 SQUARE FEET OF THE EXISTING D CK IS PERMITTED TO BE REPLACED** ROOF VENTILATION: OOFF-RIDGE O RIDGE SOFFIT OPOWERED VENT SKYLIGHTS: O YES QAO IF YES, PLEASE PROVIDE FLORIDA PRODUCT APPROVAL #: MAIN ROOF AREA ROOF SLOPE: O LESS THAN 2:12 all.12 - 4:12 O 4:12 OR GREATER OTURBINES l' ,,I I '-C TYPE OF ROOF MANUFACTURER FLORIDAPRODUCTAPPROVAL SHINGLE Taivx V,o FL# D J O METAL FL# O MODIFIED BITUMEN FL# OTORCH 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# O TORCH DOWN FL# O INSULATED FL# OTILE FL# Q OTHER: FL# City of Sanford Building Division Residential Re -Roof Inspection Policy & Procedures 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: dW / AV + City of Sanford Building and Fire Prevention RESIDENTIAL RE -ROOF INSPECTION AFFIDAVIT NAILING, ISHEATHING, DRY -IN, FLASHING, AND ALL FINAL ROOF COVERINGS PERMIT#: ` / { ADDRESS: Y01 I fU-60j I )q p isa-( A:o"cA- , AS A(N) GENERAL, BUILDING, RESIDENTIAL, OR ROOFING CONTRACTOR, ENGINEER, ARCHITECT, OF F.S. CHAPTER 468 BUILDING INSPECTOR, 1 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 #: cy /-& COMPANY / CONTRACTOR: CONTRACTOR SIGNATURE: ` DATE: ~ 2 MUST BE SIGNED BY LICENSE HOLDER OR NER/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 l day of etl 20 1-7 by: 11 J_' A191 IW A40 Who is personally Known to me or has Produced (type of i n ' n) Sig a ure of Notary Public State of Florida Print/ Type/Stamp Name of Notary Public as identification. DONALD RASH rP`6' Notary Public - State of Florida 49 o • Commission # FF 221706 My Comm. Expires Apr 16, 2019 Bonded through National Notary Assn. V , CREEK TECHNICAL SERVICES, LLC TAMKO BUILDING PRODUCTS Asphalt Shingles LIMITATIONS 1) Fire Classification is not within the scope of this evaluation. 2) The roof deck and the roof deck attachment shall be designed by others to meet the minimum design loads established for components and cladding and in accordance with FBC requirements. 3) The mean roof height shall be restricted to a maximum 33 ft in the HVHZ. 4) Classification to ASTM D 7158 applies to exposure B & C with a building mean roof height of 60-ft or less. 5) Deck substrates shall be clean, dry, and free from any irregularities and debris. All fasteners in the deck shall be checked for protrusion and corrected prior to underlayment application. 6) Shingles shall be installed starting at the eave in horizontal layers such that the laps shed water from the deck. 7) Installation of the evaluated products shall comply with this report, the FBC, and the manufacturer's published application instructions. Where discrepancies exist between these sources, the more restrictive and code compliant detail shall prevail. 8) All products listed in this report shall be manufactured under a quality assurance program in compliance with Rule 61G20-3. COMPLIANCE STATEMENT The products evaluated herein by Zachary R. Priest, P.E. have demonstrated compliance with the Florida Building Code 51h Edition (2014) as evidenced in the referenced documents submitted by the named manufacturer. ttv%111111111j`, P•'. CEN SF•'Sj No 74021 2017.05.09 15:06:10 STATE OF I-04'00' k< pp'Zachary R. Priest, P.E. O R . • %% Florida Registration No. 74021 NA E,• Organization No. ANE11669 CERTIFICATION OF INDEPENDENCE CREEK Technical Services, LLC does not have, nor will it acquire, a financial interest in any company manufacturing or distributing products under this evaluation. CREEK Technical Services, LLC is not owned, operated, or controlled by any company manufacturing or distributing products under this evaluation. Zachary R. Priest, P.E. does not have, nor will acquire, a financial interest in any company manufacturing or distributing products under this evaluation. Zachary R. Priest, P.E. does not have, nor will acquire, a financial interest in any other entity involved in the approval process of the product. TBP15001.3 END OF REPORT FL18355-R3 Page 11 of 11 This evaluation report is provided for State of Florida product approval under Rule 61G20-3. The manufacturer shall notify CREEK Technical Services, LLC of any product changes or quality assurance changes throughout the duration for which this report is valid. This evaluation report does not express nor imply warranty, installation, recommended use, or other product attributes that are not specifically addressed herein. Specialty Structural Enc;11nL=L=rinq CBUCK, Inc. Certificate of Authorization #8064 Evaluation Report Mid -States Asphalt QUIK-STICK" Roof Underlayments Manufacturer: Mid -States Asphalt & Cant Strip, Inc. 1637 51si Avenue Tuscaloosa, AL 35402 800) 489-2391 for Florida Product Approval FL 17401.1 R3 Florida Building Code 5th Edition (2014) Method: 1- D Category: Sub - Category: Product(s): Description: Prepared by: James L. Buckner, P.E., SECB Florida Professional Engineer # 31242 Florida Evaluation ANE ID: 1916 Project Manager: Diana Galloway Report No. 15-180-QS-ER Revises 15-180-QS-ER) Date: 10 / 27 / 15 Contents: Evaluation Report Pages 1— 6 Roofing Underlayment QUIK-STICK" Self -Adhered Underlayment Digitally signed by James L. Buckner, P.E. Electronically signed and sealed documents shall comply with the provisions of FAC Rule 61G15-23.\\11111 11/ CENS '• F No 31242 70 W 0T'•• 44/ STATE OF FCORIOP.•' r` 2015.11.02 13:38:15-05'00' CBUCK, Inc. - Palm Beach County, Florida Phone: (561) 491-9927 - Email: cbuck@cbuckinc.net • Website: www.cbuckinc.net Mailing Address: 2637 E. Atlantic Blvd, #34069, Pompano, FL 33062