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HomeMy WebLinkAbout108 Cedar Heights CtCivLli. CITY OF SANFORD 19 2015 BUILDING & FIRE PREVENTION PERMIT APPLICATION F FAUG Application No: 5- a Documented Construction Value: $ l0, V r 07 Job Address-. log 41F6-+J2 NetGflTf el SR1vFgAQ,J` Historic District: Yes[:] No Parcel ID: 21-( `1 —3 0 — So'Z - O 660 - EIZ-26 Residential & Commercial Type of Work: New Addition Alternation o Repair Demo Change of Use Move Description of Work: R& — L_ao h ram l Plan Review Contact Person: Title: Phone: Fax: Email: Property Owner Information Name R t cl 2 Q s -+ A t? 6 r?r Phone: `fd% 3q Z — 71 ( 6 Street: 108 C_€-D A iti NC i6 Krs Gr- Resident of property? • y City, State Zip: 5,4A.A FG Z rC ( ) 2-1 Z c Contractor Information Name 1,"AR Pde-1.. RA A D #70AO - N - Phone: ®7 ` 6 7 ` g y ZCq Street: 16 L= iLOJZSE /3Lyp`' Z J(5 Fax: City, State Zip: T67 P.A (.,- k t r ! 3 ?.1197 State License No.: C_GG. 1 7 3 D V _6 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 I M[PROVEMENTS 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. j I IIII/ R MILTONte of FloridaJun3, 2018F128683 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. SignstuMofOwner/Agent Da S” kon6m"V7Cjw—t' Date Pnrt Owner/Agent's Name Print ContractajrAgent's Name Si of Notary-S Si Ndt&y S 'ite of Florida „uM%Date 111111/,, 01 YPu8("i, JASON EDGAR MILTOt, PYe't JASON EDGAR MILTON '2* ;°= c Notary Public -State of Fi 2; :` Notary Public - State of Florida ` My Comm. Expires Jun 3 My Comm. Expires Jun 3, 2018 ,,OF, F Commission # FF 12EOF Commission # FF 128683 ""' 111 Owner/Agent is Contractor/Agent is Personally Known to Me or Produced ID Type of ID 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 0 No # of Heads APPROVALS: ZONING: UTILITIES: COMMENTS: Fire Alarm Permit: Yes No WASTE WATER: ENGINEERING: FIRE: BUILDING: Oa old Johnsoai, CFA iPERTY APPRAISER SEtrhw0tZ COUNTY FLORIDA Property Record Card Parcel: 22-19-30-502-0000-0290 Owner: GARRETT RICHARD A Property Address: 108 CEDAR HEIGHTS CT SANFORD, FL 32771 I Parcel:22-19-30-502-0000-0290 1 Property Address: 108 CEDAR HEIGHTS Cr Owner. GARRETT RICHARD A Mailing: 108 CEDAR HEIGHTS Cr SANFORD, FL 32771 Subdivision Name: PRESERVE AT LAKE MONROE TaxTax` q n `WATERFRONT REDVDST Exemptions: 00-HOMESTEAD (2010) DOR Use Code: 01-SINGLE FAMILY Legal Description LOT 29 PRESERVE AT LAKE MONROE PB62PGS12-15 Taxes Value Summary 2015 Working Values 2014 Certified Values Valuation Method Cost/Market Cost/Market Number of Buildings 1 1 Depredated Bldg Value 168,705 167,055 Depredated EXFr Value Land Value (Market) 30,4D0 30,0D0 Land Value Ag Just/Market Value 199,105 197,055 Portability Adj Save Our Homes Adj 35,717 34,964 Amendment 1 Adj Assessed Value 163,388 162,091 Tax Amount without SOH: 2014 Tax Bill Amount Tax Estimator Save Our Homes Savings: Does NOT INCLUDE Non Ad Valorem Assessments 3,125.81 2,429.55 696.26 Taxing Authority Assessment Value Exempt Values Taxable Value County General Fund 163,388 50,000 113,388 Schools 163,388 25,000 138,388 City Sanford 163,388 50,000 113,388 SIWM(Saint Johns Water Management) 163,388 50,000 113,388 County Bonds 1$163,388 50,000 113,388 Sales Description Date Book Page Amount Qualified Vac/Imp CORRECTIVE DEED 9/1/2010 07444 1200 100 No Improved WARRANTY DEED 6/30/2009 07215 0313 224,700 Yes Improved WARRANTY DEED 7/1/2006 06359 0564 365,00D Yes Improved WARRANTY DEED 12/1/2003 05164 1220 227,600 Yes Improved Fina Comparanie Saies witnin this suDa vision I Land Method Frontage Depth Units Units Price Land Value LOT 1 30,400.00 30,400 Building Information Year Built Fixtures Base Area Total SF Living St Ext Wall Adj Value Reps Value Appendages Actual/Effective SINGLE 12003 13 1,5321 4,0811 3,479 I CQ/ST C0 I $ 168,705 I $176,654 FAMILY FINISH Permits Description Area GARAGE 459FINISHED OPEN PORCH 143 FINISHED UPPER STORY 1947 FINISHED Permit # Type Agency Amount CO Date Permit Date 02217 New - Residential Sanford 152,186 12/16/2003 6/1/2003 Extra Features Description Year Built Units Value New Cost No data to display Jc QLLJB,Wi AGREEMENT SUBJECT TO INSURANCE COMPANYAPPROVAL- 17 00 Custorder: Property Location. L05 C_eb 4 R PC/ 6 F1 75 C Day: IL-46T qz- -7 _1 city: ..... . EVehift., E-Mail: ROOF SPECIFICATIONS iBrand: ; Ridge Mat7eh Valley:' 0'pe-fii' -Closed :"'B" hingliebver/Alunn"num", Ice & Water Shiel <!E!ode3_tch:' -f7StCiJY'.-J:&3--WiiIIe6 No: RoofAccessories to be replaced new and/or painte Drop Instructions: o match single color. SIDING SPECIFICATIONS -Brand: Style: Color: Style: Straight Lap Elevation being -sided (looking athouse-fr.om,.gtrdet)c,Fi6nt.,Left--BackZ,'Righv_i -`-Q Drop Instructions: GUTT-ER- SPECIFIC-AT-LONS-.--Color--:,..:::- A Special Instructions: A'4 11Q_ C' AY cgv. 7-o7--e_ &r_Ae. b P & i%!f vy hL 1-c> -r.^ e- &,au, o,_mcU Y Z_ IUATIION41 nV «' 0 vfl TERMS 1. By signing this Agreement, you authorize Carroll Bradford, Inc. to be present during the insurance adjustment and negotiate the settlement with your insurance company. I Unless ot4eryisqagreed; a..writin..g, yourout-Zof-pocket co!s"4ts1will beJimiie_dtoyquF suran 4edluectblLeamountHowqer_yqL-p Rr v W pay,Car-rollBra ' I al amotRtsXqu eqjifrin Jompd fd-,iodfy. ifideseat Mipgraesa dtleOdropeoiEpropdrtyyo wlMincuraddlqqna outof-pqchenses. 3. ThisAereemenf giik_aIidors dnn, Bradford, -Inc. will be awarddd witH the V &9 ftbove& kl t4&v%C J0 C s Numnary"t i .1-• 4. YoursiFat ides.youra be q!-ppy greementto all the terms andconditions set forthonthe&ont and backofthis Agx!!eme t -and,backof read the entire front 4 tLs'A'g reement 4W.0 T 1, 6 First Check: $ Signature-(Cu_ tomer) , Date, Check. 4 R TJ-!1 'u or Q Signature (Carroll BradfordRep)' Date Agreed Price: $ 16 1 tZy.. Ili RM additib6a ip it in Name: Address: 163 E Morse Blvd Suite 1 Winter Park, FL 32789 NOTICE OF COMMENCEMENT Psmtit Number. Parcel ID Number. 2Z — IS 3 O — SG 'Z — 60 d O - d z 9 p MARYANNE PMORSEr SEMINOLE COUNTY CLERK OF C:IRC:UIT COURT & COMPTROLLER BK 8527 Ps 658 QPgs) CLERK'S A 2015089280 RECORDED 08/13/2015 i0:51:54• AM RECORDING FEES $10.00 RECORDED BY hdevore The undersigned hereby Dives 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 P jtoPERTY: (Legal description of the property and street address if ) R c Y C 7 Lf+f: L: McA.1 116 2. GENERAL DESCRIPTION OF IMPROVEMENT: Re Roof 3. OWNER INFORMATION OR LESSEE INFORMATION IF THE LESSEE CONTRACTED FOR THE RIPROVEMENT: Name and address:[ Interest in property: Owner Fee Simple Title Holler (if other than owner listed above) Name: Address: 4. CONTRACTOR_; Name: Carroll Bradford Inc Phone Number. 407-647-9420 Adder: 163 E. Morse Blvd Suite 210 Winter Park, FL 32789 6. SURETY (if applicable, a copy of the payment bond is attached): Name: Address: Amount of Bond: 6. LENDER: Name: Phone -Number. Address: 7. Persons within the State of Florkla Designated by Owner upon whom notice or other documents may be served as provided by Section 713.13(1)(a)7., Florida Stahrtes. Name: Phone Number: Address: ' S. in addition. Owner designates of to receive a copy of the Uerior's Notice as provided in Section 713.13(1)(b), Florida Statutes. Phone number. 9. Expiation Date of Notice of Conunertcenrent (The expiration is 1 year from date of recording unless a different date is specified) WARNING TO goo ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1, 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 WFTH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Z =. oe-- t$7gr aftse cf Owner or assee or Oda or O'6 rJanfe and Provide Gkpi wYt ,TALtzrimd Stabs of // C countyof The foregoing instrument rn wasacknowledgedbefore ®this f - cloy of v G w v LCO by i C G, c / ! ' Who Is personally known to me 13 OR Name . person "N" staanbntUj E who has produced idendfteatlon 0 type of Identification produced: a 1 S YPLe" JASON EDGAR MILTON r 2 " : Notar J?uklic - State of Florida Y:... a . My Comm. Expires Jun 3, 2018na4" o Q " Gov Commission # FF 128603 LL w w vgm Florida Building Code Online Page 1 of 2 F{c Ada DepMTMd BCIS Home (Log In I User Registration I Hot Topics submit Surcharge ; Stats & Facts ( Publications FBC staff ( BCIS Site Map Links ; •Search Prossi ilsaramProduct Approvalfena USER: Public User Regulation A i1 Product Aooroval Menu > Product or Application Search > Application List > Application Detail FL # FL10124-R15 Application Type Revision Code Version 2014 Application Status Approved Comments Archived 13 Product Manufacturer GAF Address/ Phone/Email 1 Campus Drive Parisppany, NJ 07054 973) 872-4421 lindareith@trinityerd. com Authorized Signature Beth McSorley lindareith@trinityerd. com Technical Representative Beth McSorley (current) Address/ Phone/Email 1 Campus Drive Parsippany, NJ 07054 973) 872-4421 bmcsorley@gaf. com Quality Assurance Representative Address/ Phone/Email Category Roofing Subcategory Asphalt Shingles Compliance Method Evaluation Report from a Florida Registered Architect or a Licensed Florida Professional Engineer R Evaluation Report - Hardcopy Received Florida Engineer or Architect Name who developed Robert Nieminen the Evaluation Report Florida License PE-59166 Quality Assurance Entity UL LLC Quality Assurance Contract Expiration Date 11/21/2016 Validated By John W. Knezevich, PE Validation Checklist - Hardcopy Received Certificate of Independence FL10124 R15 COI 2015 01 COI Nieminen.odf Referenced Standard and Year (of Standard) Standard Year ASTM D3161 2009 ASTM D3462 2009 ASTM D7158 2008 TAS 107 1995 Equivalence of Product Standards Certified By Sections from the Code https:// floridabuilding.org/pr/pr_app_dtl.aspx?param=wGEVXQwtDquracBeV CbdMQNZ... 8/ 12/2015 Florida Building Code Online Page 2 of 2 Product Approval Method Method 1 Option D Date Submitted 03/31/2015 Date Validated 04/08/2015 Date Pending FBC Approval 04/12/2015 Date Approved 06/23/2015 Summary of Products FL # Model, Number or Name Description 10124.1 GAF Asphalt Roof Shingles Fiberglass reinforced 3-tab, laminated, 5-tab and hip/ridge asphalt shingles Limits of Use Installation Instructions Approved for use in HVHZ: No FL10124 R15 II 2015 03 FINAL ER GAF Asphalt Shingles FL10124-R15.odfApprovedforuseoutsideHVHZ: Yes Impact Resistant: N/A Verified By: Robert Nieminen PE-59166 Design Pressure: N/A Created by Independent Third Party: Yes Other: Refer to ER, Section S. Evaluation Reports FL10124 R15 AE 2015 03 FINAL ER GAF Asphalt Shingles FL10124-R15.pdf Created by Independent Third Party: Yes Badc Next Contact Us :: 1940 North Monroe Street. Tallahassee FL 32399 Phone: 850-487-1824 The State of Florida is an AA/EEO employer. Copyright 2007-2013 State of Florida.:: Privacy Statement :: Accessibility Statement :: Refund Statement Under Florida law, email addresses are public records. If you do not want your e-mail address released in response to a public -records request, do not send electronic mail to this entity. Instead, contact the office by phone or by traditional mail. If you have any questions, please contact 850.487.1395. *Pursuant to Section 455.275(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department with an email address If they have one. The emails provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish to supply a personal address, please provide the Department with an email address which can be made available to the public. To determine if you are a licensee under Chapter 455, F.S., please click here . Product Approval Accepts: W ® —H M Credit rSc'1 E https:Hfloridabuilding. org/prlpr_app_dtl. aspx?param=wGEV XQwtDquracB eV CbdMQNZ... 8/ 12/2015 EVALUATION REPORT GAF 1 Campus Drive Parsippany, NJ 07054 EXTERIOR RESEARCH & DESIGN, LLC. Certificate of Authorization #9503 353 CHRISTIAN STREET, UNIT#13 OXFORD, CT 06478 PHONE: (203) 262-9245 FAX: (203) 262-9243 Evaluation Report 01506.01.08-1117 FL10124-1115 Date of Issuance: 01/03/2008 Revision 17: 03/31/2015 SCOPE: This Evaluation Report is issued under Rule 61G20-3 and the applicable rules and regulations governing the use of construction materials in the State of Florida. The documentation submitted has been reviewed by Robert Nieminen, P.E. for use of the product under the Florida Building Code and Florida Building Code, Residential Volume. The products described herein have been evaluated for compliance with the 5th Edition (2014) Florida Building Code sections noted herein. DESCRIPTION: GAF Asphalt Roof Shingles LABELING: Labeling shall be in accordance with the requirements the Accredited Quality Assurance Agency noted herein. CONTINUED COMPLIANCE: This Evaluation Report is valid until such time as the named product(s) changes, the referenced Quality Assurance documentation changes, or provisions of the Code that relate to the product change. Acceptance of this Evaluation Report by the named client constitutes agreement to notify Robert Nieminen, P.E. if the product changes or the referenced Quality Assurance documentation changes. Trinity I ERD requires a complete review of this Evaluation Report relative to updated Code requirements with each Code Cycle. ADVERTISEMENT: The Evaluation Report number preceded by the words "Trinity) ERD Evaluated" may be displayed in advertising literature. If any portion of the Evaluation Report is displayed, then it shall be done in its entirety. INSPECTION: Upon request, a copy of this entire Evaluation Report 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 Evaluation Report consists of pages 1 through 5. Prepared by: Robert J.M. Nieminen, P.E. Florida Registration No. 59166, Florida DCA ANE1983 The facsimile seal appearing was authorized by Robert Nieminen, P.E. on 03/31/2015. This does not serve as an electronically signed document. Signed, sealed hardcopies have been transmitted to the Product Approval Administrator and to the named client CERTIFICATION OF INDEPENDENCE: 1. Trinity IERD does not have, nor does it intend to acquire or will it acquire, a financial interest in any company manufacturing or distributing products it evaluates. 2. Trinity I ERD is not owned, operated or controlled by any company manufacturing or distributing products it evaluates. 3. Robert Nieminen, P.E. does not have nor will acquire, a financial interest in any company manufacturing or distributing products for which the evaluation reports are being issued. 4. Robert Nieminen, P.E. does not have, nor will acquire, a financial interest in any other entity involved in the approval process of the product. S. This is a building code evaluation. Neither Trinity IERD nor Robert Nieminen, P.E. are, in any way, the Designer of Record for any project on which this Evaluation Report, or previous versions thereof, is/was used for permitting or design guidance unless retained specifically for that purpose. I TRINITY ERD ROOFING SYSTEMS EVALUATION: 1. SCOPE: Product Category: Roofing Sub -Category: Asphalt Shingles Compliance Statement: GAF Asphalt Roof Shingles, as produced by GAF, have demonstrated compliance with the following sections of the Florida Building Code and Florida Building Code, Residential Volume through testing in accordance with the following Standards. Compliance is subject to the Installation Requirements and Limitations / Conditions of Use set forth herein. STANDARDS: Section Property Standard Year 1507.2.5, R905.2.4 Physical Properties ASTM D3462 2009 1507.2.7.1, R905.2.6.1 Wind Resistance ASTM D3161 2G09 1507.2.7.1, R905.2.6.1 Wind Resistance ASTM D7158 2008 1507.2.7.1, R905.2.6.1 Wind Resistance TAS 107 1995 REFERENCES: Entitv GAF (PDM 1915) PRI(TST 5878) PRI(TST 5878) PRI(TST 5878) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) UL (TST 1740) Exterior Research and Design,LLC. Certificate of Authorization #9503 Examination Letter of Equivalency ASTM D3462 ASTM D3462 Wind Driven Rain ASTM D3462 ASTM D3462 TAS 107 ASTM D3462 ASTM D3161, TAS 107 ASTM D3161 ASTM D3462 ASTM D3161, TAS 107 ASTM D3161, TAS 107 ASTM D3161 ASTM D3462 ASTM D3462 ASTM D3161 ASTM D3161 ASTM D3462 ASTM D3161 ASTM D3462 ASTM D3161 ASTM D3161, D3462 ASTM D3161, D3462 ASTM D3161, D3462 ASTM D3462 ASTM D3161, D3462 ASTM D3161 ASTM D3161 ASTM D3161 ASTM D3161, D3462 ASTM D3161, D7158, D3462 ASTM D3161, D3462 ASTM D3161, D3462 ASTM D3161, D3462 ASTM D3161, D7158, D3462 ASTM D3161, D7158, D3462 ASTM D3161, D7158, D3462 ASTM D3161, D7158, D3462 ASTM D3462 ASTM D3462 ASTM D3161, D7158, D3462 ASTM D3161, D7158, D3462 ASTM D3161, D7158, D3462 Reference Seal -A -Ridge Impact Resistant IR GAF-059-02-01 GAF-080-02-01 GAF-407-02-01 93NK6295 99NK43835 94NK9632 01NK06632 O1NK9226 01NK37122 O1NK37122 02NK12980 02NK30871 03CAS367 03NK26444 04NK13850 04NK13850 04NK30546 04NK22009 04NK22009 O5NK27924 OSNK27924 06CA18077 06CA18074 06CA35251 06CA31603 06CA41095 07NK05228 06CA31611 06CA61148 07CA31742 08CA06100 07CA55908 09CA10592 09CA06856 09NK06647 09CA27281 10CA35554 10CA13686 1OCA07264 1OCA11953 10NK11951 IONK12070 O8CA06100 Date 01/13/2012 09/02/2004 05/25/2005 O1/21/2013 11/29/1993 01/12/2000 03/29/2000 02/02/2001 05/21/2001 12/18/2001 12/19/2001 04/10/2002 09/09/2002 03/11/2003 10/17/2003 06/07/2004 06/23/2004 03/10/2005 05/06/2005 05/09/2005 02/10/2006 02/11/2006 06/05/2006 06/16/2006 10/18/2006 12/01/2006 12/27/2006 03/13/2007 04/04/2007 04/09/2007 11/08/2007 03/13/2008 04/01/2008 03/26/2009 O5/15/2009 08/01/2009 08/27/2009 03/05/2010 O5/15/2010 O5/27/2010, 10/29/2010 10/30/2010 11/04/2010 01/30/2010 Evaluation Report 01506.01.08-1117 F1.10124-1115 Revision 17: 03/31/2015 Page 2 of 5 Ka i10ILI gn!itlt Examination Reference Date UL (TST 1740) ASTM D3161, D7158, D3462 IOCA53934 03/31/2011 UL (TST 1740) ASTM D3161, D7158, D3462 11CA48924 10/22/2011 UL (TST 1740) ASTM D3161, D7158, D3462 11CA47919 12/03/2011 UL (TST 1740) ASTM D3161, D7158, D3462 11CA48408 12/08/2011 UL (TST 1740) ASTM D3161, D7158, D3462 11CA48725 12/09/2011 UL, LLC. (TST 9628) ASTM D3462 12CA34891 10/12/2012 UL, LLC. (TST 9628) ASTM D3161, D7158, D3462 12CA58151 02/15/2013 UL, LLC. (TST 9628) ASTM D3161 12CA38083 02/26/2013 UL, U.C. (TST 9628) ASTM D3161 13CA32332 06/18/2013 UL, LLC. (TST 9628) ASTM D3161 13CA37934 08/02/2013 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Mobile, AL 11/21/2014 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Myerstown, PA 02/06/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Tuscaloosa, AL 02/20/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Michigan Cty, IN 02/19/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Shaffer, CA 01/05/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Savannah, GA 02/23/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Minneapolis, MN 02/16/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Mt. Vernon, IN 02/10/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Baltimore, MD 02/11/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Tampa, FL 03/05/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Dallas, TX 02/25/2015 UL, U.C. (QUA 9625) Quality Control Inspection Report, R21, Ennis, TX 03/07/2015 UL, LLC. (QUA 9625) Quality Control Inspection Report, R21, Fontana, CA 03/02/2015 4. PRODUCT DESCRIPTION: 4.1 Asphalt Shingles: 4.1.1 Marquis® WeatherMax®, Royal Sovereign® and Sentinel® are a fiberglass reinforced 3-tab asphalt roof shingles. 4.1.2 Camelot®, Camelot® II, Country Mansion® II, Grand Canyon®, Grand Sequoia®, Grand Sequoia® IR, Monaco®, Sienna®, Timberline American Harvest®, Timberline® ArmorShield'" II, Timberline® Natural Shadow®, Timberline HD®, Timberline® Cool Series, Timberline Ultra HD® and Woodland® are fiberglass reinforced, laminated asphalt roof shingles. 4.1.3 Slateline® is a fiberglass reinforced 5-tab asphalt roof shingle. 4.2 Hip & Ridge Shingles: 4.2.1 Seal -A -Ridge® Ridge Cap Shingles, Seal -A -Ridge® IR Impact -Resistant Ridge Cap Shingles and Timbertex® Premium Ridge Cap Shingles are fiberglass reinforced, hip and ridge asphalt roof shingles. 4.3 Starter Strips: 4.3.1 Pro -Start® Starter Strip Shingles and WeatherBlocker— Premium Eave/Rake Starter Strip are starter strips for asphalt roof shingles. S. LIMITATIONS: 5.1 This is a building code evaluation. Neither Trinity IERD nor Robert Nieminen, P.E. are, in any way, the Designer of Record for any project on which this Evaluation Report, or previous versions thereof, is/was used for permitting or design guidance unless retained specifically for that purpose. 5.2 This Evaluation Report is not for use in the HVHZ. 5.3 Fire Classification is not part of this Evaluation Report; refer to current Approved Roofing Materials Directory for fire ratings of this product. 5.4 Wind Classification: 5.4.1 The GAF asphalt shingles noted in Section 4.1 are Classified in accordance with FBC Tables 1507.2.7.1 and R905.2.6.1 to ASTM D3161, Class F and/or ASTM D7158, Class H, indicating the shingles are acceptable for us in all wind zones up to Vasd =150 mph (V it =194 mph). Refer to Section 6 for installation requirements to meet this wind rating. 5.4.2 The GAF hip & ridge shingles noted in Section 4.2 are Classified in accordance with FBC Tables 1507.2.7.1 and R905.2.6.1 to ASTM D3161, Class F, indicating the shingles are acceptable for us in all wind zones up to Vasd = 150 mph Vuit =194 mph). Refer to Section 6 for installation requirements to meet this wind rating. Exterior Research and Design, U.C. Evaluation Report 01506.01.08-1117 Certificate of Authorization #9503 FL10124-R15 Revision 17: 03/31/2015 Page 3 of 5 5.4.3 Classification by ASTM D7158 applies to exposure category B or C and a building height of 60 feet or less. Calculations by a qualified design professional are required for conditions outside these limitations. Contact the shingle manufacturer for data specific to each shingle. 5.5 All products in the roof assembly shall have quality assurance audit in accordance with the Florida Building Code and F.A.C. Rule 61G20-3. 6. INSTALLATION: 6.1 Underlayment: 6.1.1 Underlayment shall be acceptable to GAF and shall hold current Florida Statewide Product Approval, or be Locally Approved per Rule 61G20-3, per FBC Sections 1507.2.3, 1507.2.4 or R905.2.3. 6.2 Starter Shingles: 6.2.1 Installation of Pro -Start Starter Strip Shingles and WeatherBlocker Premium Eave/Rake Starter Strip shall comply with the manufacturer's current published instructions. 6.3 Asphalt Shingles: 6.3.1 Installation of asphalt shingles shall comply with the manufacturer's current published instructions, using minimum four 4) nails per shingle in accordance with FBC Sections 1507.2 or R905.2, with the following exceptions: Camelot, Camelot II, Grand Canyon, Grand Sequoia, Grand Sequoia IR, and Woodland require minimum five (5) nails per shingle. Slateline requires minimum six (6) nails per shingle. 6.3.2 Fasteners shall be in accordance with manufacturer's published requirements, but not less than FBC 1507.2.6 or R905.2.5. Staples are not permitted. 6.3.3 Where the roof slope exceeds 21 units vertical in 12 units horizontal, special methods of fastening are required. Contact the shingle manufacturer for details. 6.4 Hip & Ridge Shingles: 6.4.1 Installation of Seal -A -Ridge Ridge Cap Shingles and Seal -A -Ridge IR Impact -Resistant Ridge Cap Shingles shall comply with the manufacturer's current published instructions with a minimum two (2) nails, minimum 3/8-inch head diameter, per shingle and nominal 0.25-inch diameter beads of Henkel "Loctite PL S30 Roof & Flashing Sealant". 11.5" Sealant 1" {292 mm) 1" Sellante 25 mm) (25 mm) Enduit d'etancheite 1 (305 mm) Nail Clavo 6 518" - 7 5/8" Clouer 168 -194 mm) 12" 305 mm) Exterior Research and Design, I.I.C. Evaluation Report 01506.01.08-R17 Certificate of Authorization #9503 FL10124-R35 Revision 17: 03/31/2015 Page 4 of 5 6.4.2 Installation of Timbertex Premium Ridge Cap Shingles shall comply with the manufacturer's current published instructions with a minimum two (2) nails, minimum 3/8-inch head diameter, per shingle and beads of Sonneborn NP1 Gun Grade Polyurethane Sealant or Henkel PL Roofing and Flashing Sealant. 1 sealarn t;--12rnir+) 1^ Ssllanto G tam) f,25rrtmi Enduit d'6tanche bi Nan 016% 10 (9D5 mrn) i0"t 229 mm) Ll 12, MIS M- ) 6. 4.3 Fasteners shall be in accordance with the manufacturer's published requirements, but not less than FBC 1507.2.6 or R905. 2.5. Staples are not permitted. 7. LABELING: 7. 1 Labeling shall be in accordance with the requirements the Accredited Quality Assurance Agency noted herein. 7. 2 Asphalt shingle wrappers shall indicate compliance with one of the required classifications detailed in FBC Table 1507. 2.7.1 / R905.2.6.1. 8. BUILDING PERMIT REQUIREMENTS: As required by the Building Official or Authority Having Jurisdiction in order to properly evaluate the installation of this product. 9. MANUFACTURING PLANTS: Contact the named QA entity for information on which plants produce products covered by Florida Rule 61G20-3 QA requirements. 10. QUALITY ASSURANCE ENTITY: UL LLC—QUA9625; (847) 664-3281 END OF EVALUATION REPORT - Exterior Research and Design, I.I.C. Evaluation Report 01506.01.08-R17 Certificate of Authorization #9503 FL10124-R35 Revision 17: 03/31/2015 r Page 5 of 5 Florida Building Code Online Page 1 of 2 x Florida f1 +,mod BCIs Home Log In ; User Registration { Hot Topics Bus'i'nWes// Professi dal US PubiApproval Regulation Submit Surcharge ; Stats & Facts f Publications I FBC Staff It BCIS Site Map ( Links i Search j Product Aooroval Menu > Product or Aoolication Search > Application List > Application Detail FL # FL12510-115 Application Type Revision Code Version 2014 Application Status Approved Comments Archived C) Product Manufacturer PrimeSource Building Products, Inc. Address/Phone/Email 2115 East Beltline Road Carrollton, TX 75006 508) 436-6100 barregop@primesourcebp.com Authorized Signature Pete Barrego barregop@primesourcebp.com Technical Representative Pete Barrego Address/Phone/Email 333 Manley Street West Bridgewater, MA 02379 508) 436-6100 barregop@primesourcebp.com Quality Assurance Representative Address/Phone/Email Category Roofing Subcategory Underlayments Compliance Method Evaluation Report from a Florida Registered Architect or a Licensed Florida Professional Engineer rZ Evaluation Report - Hardcopy Received Florida Engineer or Architect Name who developed Robert Nieminen the Evaluation Report Florida License PE-59166 Quality Assurance Entity UL LLC Quality Assurance Contract Expiration Date 07/29/2016 Validated By John W. Knezevich, PE R Validation Checklist - Hardcopy Received Certificate of Independence FL12510 R5 COI 2015 01 COI Nieminen.odf Referenced Standard and Year (of Standard) Equivalence of Product Standards Certified By Sections from the Code 1507.2.3 1507.5.3 1507.7.3 1507.8.3 1507.9.3 1507.9.5 https://floridabuilding. org/pr/pr_app_dtl.aspx?param=wGEVXQwtDgvG4Aty8UaHdIQT... 8/ 12/2015 Florida Building Code Online Page 2 of 2 R905.2.3 R905.2.7 R905.6.3 Product Approval Method Method 2 Option B Date Submitted 04/25/2015 Date Validated 04/27/2015 Date Pending FBC Approval 05/03/2015 Date Approved 06/22/2015 Summary of Products r I FL # Model, Number or Name Description 12510.1 Grip -Rite ShingleLayment@ Synthetic roof underlayments Synthetic Roofing Underlayments Limits of Use Installation Instructions Approved for use in HVHZ: No FL12510 R5 II 2015 04 FINAL PRIMESOURCE Underlavments FL12510- R5.odfApprovedforuseoutsideHVHZ: Yes Impact Resistant: N/A Verified By: Robert Nieminen PE-59166 Design Pressure: N/A Created by Independent Third Party: Yes Other: Refer to ER Section 5 for Limits of Evaluation Reports Use. FL12510 R5 AE 2015 04 FINAL PRIMESOURCE Underlavments FL12510- R5.DdP Created by Independent Third Party: Yes Badc Next Contact Us :: 1940 North Monroe Street, Tallahassee FL 32399 Phone: 850-487-1824 The State of Florida is an AA/EEO employer. Cooyriaht 2007-2013 State of Florida.:: Privacy Statement :: Accessibility Statement :: Refund Statement Under Florida law, email addresses are public records. If you do not want your e-mail address released in response to a public -records request, do not send electronic mail to this entity. Instead, contact the office by phone or by traditional mail. If you have any questions, please contact 850.487.1395. *Pursuant to Section 455.275(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one. The emails provided may be used for official communication with the licensee. However email addresses are public record. if you do not wish to supply a personal address, please provide the Department with an email address which can be made available to the public. To determine If you are a licensee under Chapter 455, F.S., please click here_. Product Approval Accepts: CredNEAJOE https://floridabuilding. org/pr/pr_app_dtl.aspx?param=wGEVXQwtDgvG4Aty8UaHdIQT... 8/ 12/2015 EVALUATION REPORT PrimeSource Building Products, Inc. 2115 East Beltline Road Carrollton, TX 75006 EXTERIOR RESEARCH & DESIGN, LLC. Certificate of Authorization #9503 353 CHRISTIAN STREET, UNIT#13 OXFORD, CT 06478 PHONE: (203) 262-9245 FAX: (203) 262-9243 Evaluation Report P40180.01.12-113 FL12510-R5 Date of Issuance: 01/18/2012 Revision 3: 04/25/2015 SCOPE: This Evaluation Report is issued under Rule 61G20-3 and the applicable rules and regulations governing the use of construction materials in the State of Florida. The documentation submitted has been reviewed by Robert Nieminen, P.E. for use of the product under the Florida Building Code and Florida Building Code, Residential Volume. The products described herein have been evaluated for compliance with the 5th Edition (2014) Florida Building Code sections noted herein. DESCRIPTION: PrimeSource Roof Underlayments LABELING: Labeling shall be in accordance with the requirements the Accredited Quality Assurance Agency noted herein. CONTINUED COMPLIANCE: This Evaluation Report is valid until such time as the named product(s) changes, the referenced Quality Assurance documentation changes, or provisions of the Code that relate to the product change. Acceptance of this Evaluation Report by the named client constitutes agreement to notify Robert Nieminen, P.E. if the product changes or the referenced Quality Assurance documentation changes. Trinity) ERD requires a complete review of this Evaluation Report relative to updated Code requirements with each Code Cycle. ADVERTISEMENT: The Evaluation Report number preceded by the words "Trinity) ERD Evaluated" may be displayed in advertising literature. If any portion of the Evaluation Report is displayed, then it shall be done in its entirety. INSPECTION: Upon request, a copy of this entire Evaluation Report 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 Evaluation Report consists of pages 1 through 4. Prepared by: 6,,1;•.F, C f` :' The facsimile seal appearing was authorized Robert J.M. Nieminen, P.E. ioFs `: F by Robert Nieminen, P.E. on 04/25/2015 fir, `'° This does not serve as an electronically signed document. Signed, Florida Registration No. 59166, Florida DG4 ANE1983 sealed hardcopies have been transmitted to the Product Approval Administrator and to the named client CERTIFICATION OF INDEPENDENCE: 1. Trinity IERD does not have, nor does it intend to acquire or will it acquire, a financial interest in any company manufacturing or distributing products it evaluates. 2. Trinity ERD is not owned, operated or controlled by any company manufacturing or distributing products it evaluates. 3. Robert Nieminen, P.E. does not have nor will acquire, a financial interest in any company manufacturing or distributing products for which the evaluation reports are being issued. 4. Robert Nieminen, P.E. does not have, nor will acquire, a financial interest in any other entity involved in the approval process of the product. 5. This is a building code evaluation. Neither Trinity ERD nor Robert Nieminen, P.E. are, in any way, the Designer of Record for any project on which this Evaluation Report, or previous versions thereof, is/was used for permitting or design guidance unless retained specifically for that purpose. ROOFING COMPONENT EVALUATION: 1. SCOPE: Product Category: Roofing Sub -Category: Underlayment Compliance Statement: PrimeSource Roof Underlayments, as produced by PrimeSource Building Products, Inc., have demonstrated compliance with the intent of following sections of the Florida Building Code through testing in accordance with applicable sections of the following Standards. Compliance is subject to the Installation Requirements and Limitations / Conditions of Use set forth herein. 2. STANDARDS: Section 1507.2.3,1507.5.3,1507.7.3, T1507.8, 1507.8.3, 1507.9.3, 1507.9.5 1507.2.3,1507.5.3,1507.7.3, 1507.8.3, 1507.9.3 3. REFERENCES: Entint ERD (TST6049) ERD (TST6049) ERD (TST6049) ERD (TST6049) ERD (TST6049) Miami -Dade (CER1592) ICC-ES(EVL2396) UL LLC (QUA9625) 4. PRODUCT DESCRIPTION: Properties Standard Year Unrolling, Breaking Strength, Pliability, ASTM D226 2006 Loss on Heating Unrolling, Tear Strength, Pliability, Loss ASTM D4869 2005 on Heating, Liquid Water Transmission, Breaking Strength, Dimensional Stability Examination Reference Date Physical Properties P32460.03.09 03/19/2009 Physical Properties P12460.04.09-R2 03/02/2011 Physical Properties P44880.08.13-2 08/27/2013 Physical Properties P46850.12.13 12/03/2013 Physical Properties SC5430.03.14 03/24/2014 FBC HVHZ compliance , 14-0520.11 08/14/2014 2012 IBC/IRC compliance ESR-2945 03/01/2015 Quality Control Service Confirmation, R26348 Exp. 07/29/2016 4.1 Grip -Rite ShingleLayment® is a woven 10x10 scrim polypropylene, two -side coated roof underlayment. 4.2 Grip -Rite ShingleLayment-E® is a woven 8x7 scrim polypropylene, two -side coated roof underlayment. 4.3 Grip -Rite ShingleLayment-15® is a woven 10x10 scrim polypropylene, two -side coated roof underlayment. 5. LIMITATIONS: 5.1 5.2 5.3 5.4 5.5 This is a building code evaluation. Neither Trinity IERD nor Robert Nieminen, P.E. are, in any way, the Designer of Record for any project on which this Evaluation Report, or previous versions thereof, is/was used for permitting or design guidance unless retained specifically for that purpose. This Evaluation Report is not for use in the HVHZ. Fire Classification is not part of this Evaluation Report; refer to current Approved Roofing Materials Directory or test report from accredited testing agency for fire ratings of this product. PrimeSource Roof Underlayments may be used with any prepared roof cover where the product is specifically referenced within FBC approval documents. If not listed, a request may be made to the AHJ for approval based on this evaluation combined with supporting data for the prepared roof covering. Allowable roof covers applied atop PrimeSource Roof Underlayments are follows: TABLE 1: ROOF COVER OPTIONS Slate or Underlayment Asphalt Nail -On Tile Foam -On Metal Wood Shakes Simulated Shingles Tile Shingles Slate Grip -Rite ShingleLayment® Yes No No Yes Yes Yes Grip -Rite ShingleLayment-E® Yes No No Yes Yes Yes Grip -Rite ShingleLayment-15® Yes No No Yes Yes Yes Exterior Research and Design, U.C. Evaluation Report P40180.01.12-113 Certificate of Authorization #9503 FL12510-RS Revision 3: 04/25/2015 Page 2 of 4 5.6 Exposure Limitations: 5.6.1 Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® and Grip -Rite ShingleLayment-15® shall not be left exposed for longer than 30-days after installation. 6. INSTALLATION: 6.1 PrimeSource Roof Underlayments shall be installed in accordance with PrimeSource Building Products, Inc. published installation instructions subject to the Limitations set forth in Section 5 herein and the specifics noted below. 6.2 Grip -Rite ShingleLayment®. Grip -Rite Shingle Lavment-E® or Grip -Rite ShigleLayment-15®: 6.2.1 Install Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15® iin compliance with manufacturer's published installation instructions and the requirements for ASTM D226 or D4869 underlayments in FBC Sections 1507 for the type of prepared roof covering to be installed. 6.2.2 Re -fasten any loose decking panels, and check for protruding nail heads. Sweep the substrate thoroughly to remove any dust and debris prior to application. 6.2.3 Corrosion resistant fasteners shall be plastic cap nails or plastic cap -staples (max. 30 day exposure for plastic cap - staples) with minimum 1-inch diameter head. Ensure fasteners are installed at 90 degree angle to the deck with flush contact between the plastic cap and the upper surface of the underlayment. Fasteners shall be of sufficient length to penetrate through the underside of plywood or OSB decks, or minimum %-inch embedment into dimensional lumber / tongue -and -grove wood decks. 6.2.4 Install a leak barrier of ASTM D197O or equal holding Florida Statewide Product Approval at vulnerable leak areas, including but not limited to eaves, valleys, rakes, skylights and dormers. At eaves and valleys, install the leak barrier prior to installation of Grip -Rite ShingleLaymentm, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15®. Along the rake, install Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15®, leaving 6 to fl- inch of the deck exposed, and then install the leak barrier over the Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15® and exposed decking. At other areas, install the leak barrier over the Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15®. 6.2.5 Non -Tile Roof Installations: Single Laver; Roof Slope > 4:12: Starting at the eave, fasten the eave edge and 6-inch wide vertical laps max. 8-inch o.c., and max. 24-inch o.c. down the center of the roll. Continue upslope in a similar manner, maintaining minimum 4-inch wide horizontal and minimum 6-inch wide vertical laps. Fasten 8-inch o.c. at the laps and 24-inch o.c. down the center of the roll. Ensure all vertical laps are staggered at least 3-feet apart. In wind zones of V„ h > 142 mph per FBC Figure 1609A, 1609E or 16O9C (Vasd > 110 mph per FBC 1609.3.1), increase the fastening schedule to 4-inch o.c. at all laps and 24-inch o.c. down the center of the sheet in the field of the roof. Double Laver; 2:12 < Roof Slope < 4:12: Starting at the eave, fasten the eave-edge of a half -width starter -strip and 6-inch wide vertical laps 8-inch o.c. Continue upslope in a similar manner, with minimum 24-inch horizontal and minimum 6-inch vertical laps. Fasten 8- inch o.c. along the low edge and vertical laps and 24-inch o.c. down the center of the roll. Ensure all vertical laps are staggered at least 3-feet apart. In wind zones of V„n > 142 mph per FBC Figure 1609A, 1609E or 16O9C (Vasd > 110 mph per FBC 1609.3.1), increase the fastening schedule to 4-inch o.c. at all laps and 24-inch o.c. down the center of the sheet in the field of the roof. 6.2.6 Batten -Secured, Non -Tile Roof Covers: When battens are installed over Grip -Rite— ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment- 15®, the underlayment need only be preliminarily attached in advance of batten installation. Ensure preliminary underlayment attachment does not interfere with batten locations. PrimeSource recommends use of a pressure sensitive, double sided tape or an SBS peel and stick foil -faced or double sided tape as a gasket between the batten and the underlayment. 6.2.7 Grip -Rite ShingleLayment®, Grip -Rite ShingleLayment-E® or Grip -Rite ShigleLayment-15® may not be used in any exposed application such as crickets, exposed valleys, or exposed roof to wall details. Exterior Research and Design, LLC. Evaluation Report P40180.01.12-R3 Certificate of Authorization #9503 FL12510-RS Revision 3: 04/25/2015 Page 3 of 4 7. BUILDING PERMIT REQUIREMENTS: As required by the Building Official or Authority Having Jurisdiction in order to properly evaluate the installation of this product. 8. MANUFACTURING PLANTS: Contact the manufacturer or the named CA entity for information on plants covered under Rule 61G20-3 CA requirements. 9. QUALITY ASSURANCE ENTITY: UL LLC—QUA9625; (414) 248-6409, karen.buchmann@ul.com 14 10Z4l2:kiI11W-AIIL1l 1.14till AM Exterior Research and Design, U.C. Evaluation Report P40180.01.12-113 Certiftcate of Authorization #9503 FL32510-R5 Revision 3: 04/25/2015 Page 4 of 4 CITY OF SANFORD BUILDING SERVICES Residential Re -Roof Hurricane Mitigation Inspection Affidavit Permit #: I, J E N hereby acknowledge that I personally inspected Roof deck nailing and/or)( Secondary water barrier Work at L© CebAa bc-SG+ S.N :c''pi p , z 71 and have determined that the work Job Site Address) was done according to the Hurricane Mitigation Retrofit Manual. (based on 553.844 F.S.) I certify that my statements herein are true and accurate to the best of my belief and that I fully understand that making any false statements in writing with the intent to mislead a public servant in the performance of his or her official duty shall constitute a misdemeanor of the second degree pursuant to Section 837.06 I A Printed Name of Contractor ot/?,+ 1r Date GEC Is$9 License # License Type: General Building Residential el Roofing Contractor or any individual certified in accordance with F.S. 468 to make such an inspection. STATE OF FLORIDA COUNTY OF n r Sworn to (or affirmed) and subscribed before m '' 2 day of , 20 , by who is I1 Personally Known to me or has Produced (type of identificati as identification. SEAL) Signature of Notary Public Stye f F1ori Printr6WStamp Name of Notary Public o` STEPHEN BARNEI Notary Public - State of Fiui:, , My Comm. Expires Nov 20, 2- Commission # FF 072161nut• 3