HomeMy WebLinkAbout366 Placid Lake DrHili CITY OF SANFORD
BUILDING & FIRE PREVENTION
NO IS 2016
` PERMIT APPLICATION
Application No:
Documented Construction Value: $ 2, ctoo O�
Job Address: S66 1."e !7►^ Historic District: Yes ❑ No ❑
Parcel ID: OZ-- 20 -J0-.5Z O -0000 -035C) Residential ®. Commercial ❑
Type of Work: New ❑ Addition ❑ Alteration ❑ Repair ❑ Demo ❑ Change of Use ❑ Move ❑
Description of Work: �� [ �' Ower, S Corin 1r1C1 FL 10 (0q (4 TzfGG,
Plan Review Contact Person: )gtA'-V '_V Title: ADI -l;
Phone -/Co - 2 '� <6--_�78N- Fax: &22-,3,3 � -3_36) Emailr-) C. c4 -P?
Property Owner Information tt��
NameC r Ulm Phone:
Street: o c t Resident of property?: S
City, State Zip: SCL4 EO rd' Y: L_ &qq
Contractor Information
Name4 (I- /I-itti✓v-� y Phone:
Street: 53f60 G. CO 10h'i(X_( -Dk- Fax: �O -.33 - 3361
City, State Zip: t) r l(k nc(o VL 3`z $ 07 State License No.:C(-6 (3 2-"I 651
Name:
Architect/Engineer Information
Phone:
Street: Fax:
City, St, Zip:
Bonding Company:
Address:
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. 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: 5" 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 1 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.
Signature of Owner/Agent
Print Owner/Agent's Name
Date
Signature of Notary -State of Florida Date
Signature of Contractor/Agent Date
Print Contractor/Agent's Name
Signature of Notary -State of Florida Date
Owner/Agent is Personally Known to Me or 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:
Total Sq Ft of Bldg:
Occupancy Use:
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
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.
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.
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.
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. A copy of the executed contract is required in order
to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the
plan review fee based on past permit activity levels. Should calculated charges exceed the documented
construction value when the executed contract is submitted, credits%PPlied to your permit fees when the
permit is released. I
Signature of Owner/Agent
Print Owner/Agent's Name
Date
Signature of Notary -State of Florida Date
Owner/Agent is Personally Known to Me or
Produced ID Type of ID
APPROVALS: ZONING: UTILITIES:
ENGINEERING:
COMMENTS:
FIRE:
M MW
Date
of Notary -State of Florida I Date
SAMANTHA MURRAY
MY COMMISSION # FF944322
Imptas 04cor tber Is. 2019
Contractor/Agent is Personally �Vn to Me or
Produced ID `7 ype of ID
WASTE WATER:
BUILDING:
Shall be inscribed with the date of application and the code in effect as of that date (Code 2010 Fl3C) 731.135(5)(6) Florida Statutes.
REV 07.14
Jasper Contractors, Inc.
5olonial Dr.
Orlando,.FL 32807
(407) 278-7788
($00) 337-3361 Fax
JasperRoof.com
infoQ*asperinc.org
JASPER
Je�per Mof.com
Contractor's License # CCC1329651
ROOF REPLACEMENT CONTRACT
Account Manager SaT��rr `es
Contact # �L 1 t owt o �-ka1�
Insurance Company Information
Company t�•-n H 1t 1
Policy # 273 a7'a
Claim # okot? 1$ 7 Xlf S
Mortgage Complay Information
Company a p :j�sT
Loan Number O l� 0 Sal G 30 o
Ow r(s):--�
Q rad--- 9� �' d'n azo
Phone: .
Address:
CA� ' �
Alt Phone:
City:
?
State:
--L
Zip code:
Sz 3
Shingle Color-
0A ,,-4 S
Email:dt--SC('S a0-7 t
Roof RCV amount: coDrip
Edge Color:
If Owner's Insurance C6mpanv does not aeree to pay for a full roof replacement. this contract shall be voidable.
Assignment of Insurance Benefits for the Full Roof Replacement Only: I hereby assign any and all insurance rights, benefits and proceeds
under any applicable insurance policies to Jasper Contractors, Inc. ("Jasper'), the scope of which shall be limited to a Full Roof Replacement. I
make this assignment and authorization in consideration of Jasper's agreement to perform services, supply materials and otherwise perform its
obligations under this contract, including not requiring full payment at the time of service. I also hereby direct my insurer(s) to release any and
all information requested by Jasper, 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 Jasper immediately upon receipt. I agree that any 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. Jasper 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 payment of work. In the event of a discrepancy, the deductible amount stated on the insurer's Loss Sheet shall
overrule Deductible listed above.
Deductible: $ 54Z) MUST BE PAID IN FULL, PLUS APPLICABLE SALES TAX �tg' (initial)
MORTGAGEAUTHORIZATION: I, Owner/Mortgagor, grant authorization for SH���MS't— Morteak with
Jasper on matters including, but not limited to, the claim and draw status. (initial)
PAYMENT SCHEDULE: Owner agrees to pay Jasper based on the following pay schedule: (i) Deposit in the amoudue
upon signing this contract; (ii) the Contract Price, less the Deposit and any applicable depreciation retained by Owners insurer(s), plus
Upgrade Costs, due and payable to Jasper 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 Jasper upon completion of work performed. In the event of a pending
inspection, no more than 2% of Contract Price may be withheld until inspection has passed.
Optional: UPGRADE ITEM: e5t, QTY: (5�-- PRICE: $ 15? TOTAL: $ �'y4
Replacement Work and Price: Upon insurer's approval and subject to the terms and conditions herein, Jasper agrees to fiimish 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.
Owner's Declaration of Intent: Owner acknowledges and agrees that, upon approval by insurance company for a full roof replacement, Jasper
shall perform the roof replacement upon receipt of fiords from Owner's insurance company.
CANCELLATION: If Owner elects to terminate the services of Jasper, 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 Jasper's
corporate office: 1955 Vaughn Road, Suite 209, Kennesaw, GA 30144. 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 satisfactory. I further understand that this contract constitutes the entire agreement between the parties and
that any further changes or alterations to this contract must be made in writing and agreed upon by both parties. Each party
represents and warrants to the other that it has the full power and authority to enter into the contract and that it is binding and
enf7l in accordance with its terms.
<i - 6o/&
Au J per Representative Date Owner Date
TE CONDITIONS: Acceptance of Terms: I, Owner, hereby agree to retain Jasper for a fiill roof replacement on the terms and
co ti s tated herein. I fiuther agree to provide Jasper with the Scope of Loss Report generated by my insurer and authorize and grant full
access to a property for the purpose of staging and completing all agreed upon work. Supplemental Claims: Jasper 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
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date:
I hereby name and appoint: SAMANTHA MURRAY
an agent of JASPER CONTRACTORS
(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):
O The specific permit and application for work located at:
4 a (o PI or jrq Lo, k e i7 r
(Street Address)
Expiration Date for This Limited Power of Attorney:
License Holder Name: MICHAEL STEPHEN
State License Number:
Signature of License Holder:
STATE OF FLORIDA
COUNTY OF SEMINOLE
The foregoing instrument was acknowledged before me this day of N 6 V ,
2%x, by (v1 t C 1 C 1 S i t_,p h ty� who is o personally known
to me or o who has produced +D L as
identification and who did (di a an oath.
W00 (T
Signature �, I I
(Notary Seal)an VI L Q
DANIELLE N DIAZ
'� •'� MY COMMISSION 0 GG038827
EXPIRES WOW OW 16.2020
(Rev. 08.12)
nt or type name
Notary Public - State of
Commission No. ,�,y>
My Commission Expires: X10
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford,
Seminole County, Winter Springs
Date: ll I S I 1 (D
I hereby name and appoint: 14ARI PEREZ- ARIAS
an agent of. JASPER CONTRACTORS
I Name of Compam• 1
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):
o All permits and applications submitted by this contractor.
o The specific permit and application for work located at:
d Lake or
Owl AJJreso
F..xpiration Date For This Limited Power Of Attorney:
License Holder Name: MICHAEL STEPHEN
State License Number: CCC1329651
Signature of License Holder:
STATE OF FLORIDA
COUNTY OF Q trC n (
The foregoing instrument was acknowledged before me this I f)�) day of NO
201�0_. by M j (, i) a C j ',) A-(— po e- n who is personally known to me/
or who has produced
0
as identification and who did/did not take * oath.
(Notary Seal)
gAMANT�► MURRAYF�3z2
: � • MY 6OMMISSION
•. te, zoto
exrta�a otlr.+M�
rpnw� �
�4Un.� is p'a
1.1
Print or Typc Name
Notary Public — State of
Ft
Commission Number rr01
yu;a- a
My Commission -.xpires:
)�-I1L9 -��/
11/14/2016
11PAWME6
sc.�aioourm raown�
Parcel Information
SCPA Parcel View. 02-20-30-520-0000-0350
Prooerty Record Card
Parcel: 02-20-30-520-0000-0350
Owner: RODRIGUEZ FRANCIS
Property Address: 366 PLACID LAKE DR SANFORD, FL 32771
---------- _-- � (Value Summary- - � - - -
Parcel
02-20-30-520-0000-0350
Owner
RODRIGUEZ FRANCIS
Property Address
366 PLACID LAKE DR SANFORD, FL 32771
Mailing
1002 LONG BRANCH LN OVIEDO, FL 32765 -
Subdivision Name
PLACID WOODS PH 1
Tax District
S1-SANFORD
DOR Use Code
01 -SINGLE FAMILY
Exemptions
Depreciated E)(FTValue
V ,
N
CJ1
1%0
v v
Tax Amount without SOH: $1,943.73
2016 Tax Bill Amount $1,943.73
Tax Estimator
Save Our Homes Savings: $0.00
Does NOT INCLUDE Non Ad Valorem Assessments
Seminole County GIS
Legal Description----------------- --------- ----•------ -----• ---- - •- -. ... ..--- -• --
LOT 35
PLACID WOODS PH 1
PB 51 PGS 23 THRU 29
Taxes
2017 Working
2016 Certified
Units
Values
Values
Vdluabon Method
Cost/Market
CosVWrket
Number of Buildings
1
1
Depreciated Bldg Value
$89,915
4 $86,313
Depreciated E)(FTValue
$1,000
$1,050
Land Value (Market)
$18,000
$18,000
;
$0
$108,915
Land Value Ag
Jusl/Market Value "
; $108,915
; $105,363
PortabilityAdj
CitySanford
Save Our Homes Adj
$0
$0
Amendment 1 Adj
--
$7,843
.$13,479
P&G Adj
$0
$0
Assessed Value
^ $101,072
$91,884
Tax Amount without SOH: $1,943.73
2016 Tax Bill Amount $1,943.73
Tax Estimator
Save Our Homes Savings: $0.00
Does NOT INCLUDE Non Ad Valorem Assessments
Seminole County GIS
Legal Description----------------- --------- ----•------ -----• ---- - •- -. ... ..--- -• --
LOT 35
PLACID WOODS PH 1
PB 51 PGS 23 THRU 29
Taxes
.and
Method
Frontage
Depth
Units
Units Price
Land Value
LOT 1 $18.000.00 ' $18.000
Taxing Authority
Assessment Value
Exam pt Values
Taxable Value
Schools
$108,915
;
$0
$108,915
CitySanford
$101,072:
$0
$101,072
SJWM(Saint Johns Water Management)
$101,072
-
$0l
$101,072
CountyBonds
$101,072
'
$0
; $101,072
County General Fund
$101,072
$0
' $101,072
• Sales ------------
----- -- -
•-----
---- --
------
--
-------- • I
Description
Date
Book
Page
Amount
Qualified
Vac/Imp
WARRANTYDEED
i 8/1/2012
;07853
1490
$78,000
No
Improved
WARRANTY DEED
12/1/2007
!06903
11175
I
`-
$182,000
Yes
Improved
CORRECTIVE DEED
- - - - - - - -
CORRECTNE DEED
.7/1/1998
- - —t- -- - -
11/1/1997
30 468
-
03320
- 1194
-
0541
- --- --
$100 No
_ - fi -- - -- -- - --
$100 , No
Improved
- -.. .--
j Improved
SPECIAL WARRANTY DEED -
- - +6/1/1997
- (3251
0
00 � 6
�_
t
�
$81,800
!Yes
t.-
1 Improved
WARRANTYDEED
' 4/1/1997
03222
;1689
$85,500
:No
Vacant
Find Comparable Sales
.and
Method
Frontage
Depth
Units
Units Price
Land Value
LOT 1 $18.000.00 ' $18.000
httpJ/parceldetaii.scpafl.org/ParceiDeWlInfo.aspx7PID=02203052000000350 1/2
Business`
Professional
Sub-lStart & racra
'.pa_ Hor6 ,p6o0T,can oernonulorn',c
tJMud: 3:tNM•al Atru > Froduo nr Apd,CalMn ilalCn > Apphut,atl t nl . Application paha
Ir -� FL 11 FL17673
='•=�=-'�
Application Type New
Code 'Jeision 2014
Application Status Approved
*Approved by DBPR. Approvals by DOPR shall be reviewed and ratified by
the POC and/or the Commission if necessary.
Comments
I
Archived'
Product Manufacturer
System Components Corporation
Address/Phone/Email
PO Brix 2432
Compliance Method
Issaquah, WA 98027
Evaluation Entity
(42S) 392.5150
Quality Assurance Entity
cshepheid@)systerneamponcnis.net
Authorized Signature
Christopher Shepherd
Validated By
cshepherd@syslemcomponents.net
Technical Representative
Chris Shepherd
Address/Phone/Emad
PO Box 2432
Referenced Standard and Year (of Standard)
Issaoualk WA 98027
Equivalence of Product Standards
(425) 392.5150
Certified Dy
cr.heplicid@systemcomponL-iiit;.net
Quality Assurance Representative
Address/hone/Email
Category
Roofing
Subcategory
Undeilaymenis
Compliance Method
Evaluation Report from a Product Evaluation Entity
Evaluation Entity
ICC Evaluation Service. LLC
Quality Assurance Entity
Quality Audiling• ristrtule Ltd.
Quality Assurance Contract Expiration Date
01/31/2018
Validated By
Chris Bowness, P E.
:
validation Checklist • Hardcopy Received
i
Cenlllcato of Independence
I
• ,� u•r ce r•eri ficate or Independence Q f
�
Referenced Standard and Year (of Standard)
Equivalence of Product Standards
Certified Dy
I
Sections loom the Code
1
1507.2.3
1507.3.3
1507.5.3
1507.7.3
1507.8.3
1507.9.3
1507.9.5
I 1518.2.1
1518.4
1
Product Approval Method
Method 2 Option A
Date Submitted 07/03/2015
Date Validated 07/03/2015
Date Peniding FOC Approval
Date Approved 07/15/2015
Summary of Products
FL Y Model. Number or Name
Description
17873 11 Coverpfo 3000 Synthetic Roofirtg
Pellounance Fell Replacement
Underlayment
1 Limits of Use - _-_- - _
Approved for use In HVHZ: Yes
r Installation Instructions
Approved for use outside Hv"z: Yes
FL17873 RO II coye[2io3000 inetaltattnn nd(
Verified By: ICC Evaluation Service. LLC
Impact Resistant: N/A
Cleated by Independent Third Pony:
Design Pressure: N/A
Evaluation Repots
Other.
FL17073 RO AE ESR 1293 - Coov odf
17873.2 -- _ Coverpro Synthetic Rooting
performance Felt Replacement
Undeflayment
Limits of Use
Installation Instructions
Approved for use In HVHZ: Yes
FL 17A71 Rn 11 envernrn tmmnllntlnn nAf
Approved for use outside HVHZ: Yes
Verified By: ICC Evaluation Service. LLC
Impact Resistant: N/A
Created by Independent Third Party:
Design Pressure: N/A
Evaluation Reports
Other:
FL 17873 RO AE ESR 1293 - Cooy odf
17873.3 Feltex SA300
Synthetic Self -Adhered Root Underlayment
Limits of Use
Installation Instructions
Approved for use in HVHZ: Yes
FL17873 RO 11 feltexsa300 Installallon.odt
Approved for use outside HVHZ: Yes
Verified By: ICC Evaluation Service, LLC
Impact Resistant: N/A
Created by Independent Third Pony:
Design Pressure: N/A
Evaluation Reports
Other:
FL17873 RO AE ESR 1293-CooY.odf
17873.4 Felled Style RXl High Performance
- Synlhelic Roof Underloymenl
Limits et use •. • . - - _
• Installation Instructions
Approved for use in HVHZ: Yes
FL17873 RD 11 feltex installation.odl
Approved for use outside HVHZ: Yes
Verilted By. ICC Evaluation Service, LLC
Impoet;Resistant N/A
Created by Independent Third Party:
OesignIPressuie:N/A
Evaluation Reports
Other;
FL17873 Ito AE ESR 1293 -Copy rdf
17873.5 Fellex Style RX2 High Performance
Synthetic Roof Underloyment
Limits Of Use
Installation Instructions
Approved for use in HVHZ: Yes
FL17873 RO 11 feltex installation odf
Approved for use outside HVHZ: Yes
Verified By: ICC Evatuntion Service. LLC
Impact -Resistant N/A
Created by Independent Third Party:
Design Pressure: N/A
Evaluation Reports
Other:
FL17873 RO AF ESR 1293, Copy odf
178736 Protex Contractor Grade
Synthetic Root Underloyment
Limits 41 Use
Installation Instructions
Approved for use In HVHZ: Yes
FL17973 RO II ProTex Inslallallon.odf
Approved for use outside HVHZ: Yes
Verified By: ICC Evaluation Service, LLC
ImpaclRoslstont N/A
Cteated by Independent I bird Pony:
Deslgnil"ressuro:N/A Evaluation Reports
Other: FL 17673 RO AE ESR 1997. Coov.ndl
r U :t940 wrath starn•Svers la7aeastee el.12749 Vnene. 85n 487.1824
t
TIte SUtet/1 FtOrW rt an/WFFOemplgcr.Coorneet !007.701.1 SrtteM Fterda P,waev Sla:•menR Accss,M4v Srarrrrrnt •: P•lund Slateen•m
urge, Florida 41w. enod mdressts are WD'+C records 11 you da rtot wan: ym r o *POO aftm rrleased o response to a pubee•remds r"o"k. do not seA etecuen e
MO to this entity.Instead.CCAUnthe ollrcebypronea,"lwahoralhva dyou naveairyttwst.ans, Phrase Contact 850.487,1395 •Pur3uan1toSectmn455,275(1),
notwo Statues• elleedrt ocwber 1, 2pt7, eeenteas hcerlsed allo Chapter 455, F S roust ptowdo the Departntnt with an matt addle" if they nate ant. The em id%
prowded that, be used Ip e1f=l comrrw wtwn i llb IM ncensee wow"e, email addresea as pub:,c ,atmo. II you do nol wish to WWI a Personal add:es5, utast
po+idt the Ott�trtment wrh an cvrlad addrK{ whtCh Can o! mad! araeabk IO ler Wilbt To del0rmine d you ate o I,censee undo Chapter 455. VS.. oteaso chcs how
Madrtl Approfal Act"U:
t ® 'Cr.rl
Cred
�-- .-_ a9�AE
DIVISION: 07 00 00—THERMAL AND MOISTURE PROTECTION
SECTION: 07 30 05—ROOFING FELT AND UNDERLAYMENT
REPORT HOLDER:
SYSTEM COMPONENTS CORPORATION
POST OFFICE BOX 2432
ISSAQUAH, WASHINGTON 98027
EVALUATION SUBJECT:
FELTEX° (STYLE RX1) HIGH PERFORMANCE, FELTEX® (STYLE RX2) HIGH
PERFORMANCE; FELTEX SA3000 SELF -ADHERING, PROTEXO CONTRACTOR GRADE,
COVERPRO AND COVERPRO 3000 ROOFING UNDERLAYMENTS
ICC Icc ICC
C PMG LUSTED
Look for the trusted marks of Conformltyl
I
"2014 Recipient of Prestigious Western States Seismic Policy Council
(WSSPC) Award in Excellence"
_LWIIII
H
A Subsidiary of '"rtacunc+:!
CODFCdINCII'
A.V-V Evishrulion Repar is brc nil its he cinslrned as mprevenliog creslhel cs or rirl• other al/riheles 1101
spcc•/pici//r n h1n.,s'sed. stir r re 1/n:r tip he construed i.+• an eurlwsurwnl r f'the subject it the report or is
ry c imine nlirion pirr its rrse. T/rerc• is ii irir•runn• hr /l Y • h'rnluadon .Vemitt•. LL(*. ex/acus or implied as
it, on) -/iodine rrr ulher• nrnlreri in dtis repurr. fit - in its nm prat/rrcr eurered hr rhe repirr. s ...,,,..cc„
Copyright Q 2015
Reissued February 2015
This report is subject to renewal February 2016.
www.icC-e .Ora ( (800) 423-6587 ( (562) 699-0543 A Subsidiary o1 the International Code Council
DIVISION: 07 00 00 -THERMAL AND MOISTURE
PROTECTION
Section: 07 30 05 -Roo, ing Felt and Underlayment
REPORT HOLDER:
SYSTEM COMPONENTS CORPORATION
POST OFFICE BOX 2432
ISSAQUAH. WASHINGTON 98027
(425) 395-5150
www.systemeomoonents.net
EVALUATION SUBJECT:
FELTEX° (STYLE RX1) HIGH PERFORMANCE, FELTEX''
(STYLE RX2) HIGH PERFORMANCE, FELTEX SA300P
SELF -ADHERING, PROTEXm CONTRACTOR GRADE,
COVERPRO AND COVERPRO 3000 ROOFING
UNDERLAYMENTS
1.0 EVALUATION SC+E
Compliance with the Illollowing codes:
0 2012. 2009 and 2006 international audd/ng Codeo (18C)
0 2012. 2009 and 2006 International Residential Code*
(IRC)
Properties evaluated:
o Physical properties
o Ice barrier
o Fire classification i
2.0 USES
FelTexe (Style RX1) High Performance. FelTex" (Style
RX2) High Performan I and ProTee Contractor Grade,
CoverPro and CoverP� 3000 roofing undedayments are
used as alternatives tolthe ASTM D226, Type I and Type
II, roofing underlaymegts specified in Chapter 15 of the
IBC and Chapter 9 of the IRC. The underlayments may be
used as componentsl of classified assemblies when
installed in accordance with Sedan 4.3.
FelTex SA30e Self -adhering Roofing Underlayment
complies with ASTM D1970 and is used as an alternate to
the ASTM D226, Type I and it. roofing underlayments
specified in IBC Chapter 15 and IRC Chapter 9. The
underlayment may also be used where an ice barrier is
required by IBC Chaplet 15 or IRC Chapter 9.
3.0 DESCRIPTION 1
3.1 FelTex° (Style RX1) High Performance Rooting
Underlayment and i FelTex (Style RX2) High
Performance Roofing Underlayment:
FelTexe (Style RX1) High Performance and FelTexo (Style
RX2) High Performance roofing underlayments are cross -
woven polypropylene roofing underlayments with a two-ply
proprietary coating on one side. Total weight of the
FelTexe (Style RX1) High Performance underlayment is
3.2 pounds per 100 square feel (4.6 oz./yd' (154 g/m2))
Total weight of the FelTexe (Style RX2) High Performance
underlayment is 2.9 pounds per 100 square feet
14.1 oz.tydt (140 glint)). Standard size for the
underlayment rolls is 4 feet wide by 250 feet long (1.2 m
by 76.2 m). Other roll sizes are available. FelTexe
(Style RX1) High Performance Underlayment and FefTex°
(Style RX2) High Performance Underlayment may also
feature full-color custom -printing artwork as specified by
the end user.
3.2 ProTex Contractor Grade Roofing Underlayment:
ProTex`' Contractor Grade roofing Underlayment is a
cross -woven polypropylene roofing underlayment with
proprietary coatings on both sides. Total weight of the
undedayment is 2.6 pounds per 100 square feet
13.7 ozrydt (128 g/mt)). Standard size for the underlayment
rolls is 4 feel wide by 250 Icer long 11.2 m by 76.2 m).
Other roll sizes are available. ProTex Contractor Grade
roofing underlayment may also feature full-color custom
printing artwork as specified by the end user.
3.3 FelTex SA30e Sell -adhering Roofing Underlayment:
FelTex SA300a Self -adhering Roofing Underlayment
is a cross -woven polypropylene synthetic roofing
underlayment with a proprietary, thermally stable, adhesive
membrane backed with a release film. Total weight of
the undedayment is 9.4 2pounds per 100 square feel
(13.7 oz/yd' (459 g/m )). Standard size for the
underlayment rolls is 4 feet wide by 53.3 feet long
(1.2 m by 16.2 m). Other roll sizes are available.
3,4 CoverPro and CoverPro 3000 Roofing
Underlayment:
CoverPro and CoverPro 3000 Roofing Underlayment are
woven polypropylene fabrics coated on one side and
laminated to polypropylene spun bond fabric. Total
weight of the CoverPro underlayment is 1.9 pounds per
100 square feet 12.8 oz/yd' (94 glrrl2)). Total weight
of the CoverPro 3000 underlayment is 2.2 pounds per
100 square feet (3.2 oz/yd2 (108 g/m2)). The standard size
for the underlayment rolls is 40 inches wide by 300 feel
long (1.0 m by 91.4 m). Other roll sizes are available.
4.0 INSTALLATION
4.1 FelTexo (Style RXt) High Performance, FelTexe
(Style RX2) High Performance. ProTex° Contractor
*Revised March 2015
/Cr'•h'.�'I:.ahwnr....N.•/�..r.✓r: tri h.M•..w.rrrwvl.r•nyw.,nlinJ;,n•.r4•u:..r.u!:r✓Ir,+✓nrlMn.:.rn✓yvvHf�dlr.•66;.•nl rr,r,n: Na.r•w:NrwNrr.•,/
.r• .nr ••roR.n. md,u nI ll✓ vd/.vI ,./ lb,• n7.+10. o n1+ron+. mlrrnur A� N. uw•. I Aw i. m „urr.mrr M•!rY l:ur/n.✓ww J: n•r.v: l.Lr ::./vr. .! Joydl.:/, m
erdnr/brdun.•r wbvm,nb•rrndn'r.•p+L•.r rn n..nn /v.•/mv.vnrnvl A. r/r ny.vr '��"�
Paso 7 or 3
Copyright 2015
i
ESR -1293 1 Most Widely Accepted and Trusted Page 2 of 3
Grade, CoverPro Viand CoverPro 3000 Roofing
Underlayments:
(
Minimum roof slope i 2:12 (17%, slope). For roof slopes
from 2:12 (17%) up toIbut not including 4:12 (331/6). where
the roof is covered with asphalt shingles, two layers of
undertayment must bei applied in accordance with Section
1507.2.8 of the IBC or Section R905.2.7 of the IRC. For
roof slopes from 2'/2:12 (21%) up to but not including 4:12
(33%). where the roof is covered wilh day or concrete tiles.
two layers of underlayment must be applied in accordance
with Section 1507.3.3.1 of the IBC or Section R905.3.3.1 of
the IRC. For slopes of ;4:12 (33%) or greater, underlayment
must be a minimum of one layer applied shingle fashion.
The deck surface must be dry and free of dust. dirt. loose
nails and other protrusions. Damaged sheathing must be
replaced. The underlayment is laid horizontally (parallel to
the eave) with the print side up. and with 3 -inch (76 mm)
horizontal and 6 -inch (152 mm) vertical laps. Overlaps
must run with the flow of water in a shingling fashion. The
underlayment must be attached to the roof deck with a
minimum of No. 12 gage 10.109 inch shank diameter
(2.77 mm � corrosion -resistant steel roofing nails having
minimum /e -inch -diameter (9.5 mm) heads; or minimum
1 -inch -diameter (25.4 mm) plastic caps, or No. 16 gage
10.065 inch leg diameter (1.65 mm)) corrosion -resistant
staples having minimum 7/10 -inch crowns (11.1 mm). The
underlayment must be fastened in accordance with the
underlayment applicaiion and high wind attachment
requirements specifredlin IBC Section 1507 or IRC Section
R905. as applicable.
For roofs required to have an ice bamer, two layers of
FelTex` (Style RXi) High Performance. FelTexa (Style
RX2) High Performance. ProTexo Contractor Grade,
CoverPro or CoverPro 3000 roofing underlayment
cemented together with a roofing cement complying with
ASTM D4586: or one layer of self -adhering polymer
modified bitumen shoe complying with ASTM D1970, such
as FelTex SA300e set -adhering roofing underlayment: or
one layer of an ice airier complying with the ICC -ES
Acceptance Criteria for Sell -adhered Roof Underlayments
for Use as Ice Barriers (AC48), must be applied. The
underlayment must bel applied over the solid substrate in
sufficient courses that the underlayment extends from the
eave's edge to a pointlat least 24 Inches (610 mm) inside
the exterior wall line of the building. The underlayment
applied in the field of Ilie root must overlap the ice barrier.
Installation of the roof covering can proceed immediately
following the underlayment application. The underlayment
is not intended to be left indefinitely exposed and must be
covered by a roof covering in accordance with the report
holder's published installation instructions. For reroofing
applications, after removal of the old roof covering and
roofing felts to expose the roof deck, the same procedures
apply as for new construction.
4.2 FelTex SA300' Self -adhering Roofing
Underlayment:
Prior to application of the underlayment, the deck surface
must be free of frost, dust and dirt, loose fasteners. and
other protrusions. Damaged sheathing must be replaced.
The underlayment must be applied to plywood or oriented
strand board (OSB) st{bstrates only when the ambient air
and substrate tempera{ures are above freezing.
Starting with a full roll of the membrane, a portion of the
membrane approximately 3 to 6 feet long (0.9 to 1.83 m) is
unrolled with the release liner left in place. while unrolling.
the upper release line' is removed and the roll is aligned
parallel to the eave of the roof and placed firmly in place
with heavy hand pressure. The subsequent courses of
membrane are applied parallel to the eave from the lower
edge of the roof upward in a shingle -lap manner. Side
(horizontal) laps must be a minimum of 3 inches (76 mm)
and end (vertical) seams must be overlapped a minimum
of 6 inches (152 mm)
In areas of the roof required to have an ice barrier under
Chapter 15 of the IBC or Chapter 9 of the IRC, starting at
the lower edge of the roof eave, the roofing underlayment
is applied over the solid substrate so that the underlayment
extends up from the eave's edge to a point at least
24 inches (610 mm) inside the exterior wall line of the
building. Following placement along the lower edge. the
membrane may be installed either vertically or horizontally.
If the membrane becomes misaligned. the roll must be cut
and restarted. Damage and fishmouths must be slit.
pressed Oat and covered with a round patch of membrane
that extends beyond the damaged area by a minimum of
6 inches (152 mm) in all directions. Flashing around
protrusions is installed over the membrane to prevent
water backup. Other flashing must be installed in
accordance with the applicable code.
Installation of the final roof covering Can proceed
immediately after installation of the underlayment is
completed. The underlayment is not intended to be left
indefinitely exposed and must be covered by the final roof
covering as soon as possible in accordance with the report
holder's published installation instructions.
4.3 Classified Roofs:
Under the 2012 and 2009 IBC and IRC. the FalTetij (Style
RX1) High Performance. FelTex9 (Style RX2) High
Performance. ProTexe Contractor Grade. CoverPro and
CoverPro 3000 roofing undertaymenls may be used as
components of classified roof assemblies consisting of
Class A glass fiber mat asphalt shingles or Class C organic
fell asphalt shingles complying with the applicable code.
when installed in accordance with this report over a
minimum z/p-inch-thick (9.5 mm) plywood deck for Fe1Tee
(Style RX1) High Performance and minimum '6/32 -inch -
thick (11.9 mm) plywood deck for FelTex" (Style RX2)
High Performance, ProTexe Contractor Grade. CoverPro
and CoverPro 3000.
Under the 2006 IBC. the FelTexa (Style RX1) High
Performance. FelTex (Style RX2) High Performance.
ProTex Contractor Grade, CoverPro and CoverPro 3000
underlaymenls may be used in Class A or Class B roof
assemblies that utilize the roof coverings specified in the
exception to Sections 1505.2 and 1505.3. Under the 2006
IRC, the FelTex (Style RX1) High Performance, FelTex",
(Style RX2) High Perlormance, ProTex° Contractor Grade,
CoverPro and CoverPro 3000 undedayments may- be
used with root coverings of brick, masonry, slate, clay or
concrete roof tile. concrete roof deck, ferrous or copper
shingles or sheets, and metal sheets and shingles where
such roof coverings are permitted to be used in lieu of a
Class A assembly under Section R902.1.
5.0 CONDITIONS OF USE
The FelTexa (Style RX1) High Performance. FelTex
(Style RX2) High Performance, ProTexe Contractor Grade,
CoverPro. CoverPro 3000 Roofing Underlayments and
FelTex SA300z Self -adhering Roofing Underlayment
described in this report comply with. or are suitable
alternatives to what is specified in, those codes listed in
Section 1.0 of this report. subject to the following
conditions:
ESR -1293 1 Most Widely Accepted and Trusted Page 3 of 3
5.1 Installation must comply with this report, the report
holder's published installation instructions and the
applicable code. A copy of the report holder's
published installation instructions must be available to
the code official of the jobsite. In the event of conflict
between this repgrt and the report holder's installation
instructions, this report governs.
S.2 Installation is limited to use with approved roof
coverings that are mechanically fastened through the
underlayment to Ithe sheathing or rafters. or to use
with approved roof coverings that are mechanically
fastened to battens or counterbattens that are
mechanically fastened through the underlayment to
the sheathing or rafters.
5.3 Installation is limited to roofing systems that do not
involve hot asphalt or coal -tar pitch.
5.0 EVIDENCE SUBMITTED
6.1 Data in accordance with the ICC -ES Acceptance
Criteria for Root Underlayments (AC188), dated
FebruaEry 2012. (editorially revised February 2014), for
ProTex Contractor Grade. FelTexm (Style RXI) High
Performance. FelTex° (Style RX2) High Performance,
CoverPro and CoverPro 3000 Roofing Underlayments
and FelTex SA30e Self -adhering roofing
underlayment.
6.2 Data in accordance with the ICC -ES Acceptance
Criteria for Self -adhered Roof Underlayments for Use
as Ice Barriers (AC48), dated February 2012
(editorially revised May 2014), for FelTex SA300f
Selr•adhenng roofing underlayment; including liquid
water transmission testing in accordance with ASTM
D4869, Section 8.3.5.
5.4 Installation is limited to roofs with a slope of 2:12 6.3
(17%) or greater.
5.5 Installation is limited to roofs with ventilated attic
spaces.
5.6 FelTex SA3006 Self -adhering Roofing Underlayment
is limited to stiuclures located in areas where
nonclassified roof'coverings are permitted.
5.7 FelTex SA3000 dell -adhering Roofing Underlayment
must not be installed when frost is present on the roof
deck. 1
5.8 FelTex SA300e Self -adhering Roofing Underlayment
installation is limited to plywood and oriented strand
board IOSB) substrates.
i
5.9 FelTex' (Style RXI) High Performance, FelTex°
(Style RX2) High -Performance. FelTex SA30e Self -
adhering. ProTex . Contractor Grade. CoverPro and
CoverPro 3000 roofing underlayments are
manufactured under a quality control program with
inspections by ICC Evaluation Service, LLC.
Reports of testing in accordance with ASTM E108 for
FelTex (Style RXI) High Performance. FelTex"
(Style RX2) High Performance. ProTexe Contractor
Grade. CoverPro and CoverPro 3000 roofing
underlayments.
7.0 IDENTIFICATION
The FelTex" (Style RXI) High Performance, FelTex`
(Style RX2) High Performance, ProTex° Contractor Grade,
CoverPro and CoverPro 3000 Roofing Undedayments and
FelTex SA300" Self -adhering Roofing Underlayment are
marked at 48 -inch (1.22 m) intervals with the product
name. Each roll of the product must be labeled with the
System Components Corporation name. the product name.
the manufacturing date code. and the evaluation report
number (ESR -1293).
M Supplement*
Reissued February 2015
This report is subject to renewal February 2016.
www.icc-es.org 1 (800) 423-6587 1 (562) 699-0543 A Subsidiary of the International Code Council°
DIVISION. 07 00 00—THERMAL AND MOISTURE PROTECTION
Section: 07 30 OS—Roofing Felt and Underlayment
REPORT HOLDER:
SYSTEM COMPONENTS CORPORATION
POST OFFICE BOX 2432
ISSAQUAH. WASHINGTON 98027
(425)395-5150
www.systemeomDonents.net
EVALUATION SUBJECT:
FELTEe (STYLE RX1)1HIGH PERFORMANCE, FELTEX° (STYLE RX2) HIGH PERFORMANCE, FELTEX SA30041 SELF.
ADHERING. COVERPRO. COVERPRO 3000 AND PROTEX* CONTRACTOR GRADE ROOFING UNDERLAYMENTS
1.0 REPORT PURPOSE AND SCOPE
I
Purpose:
The purpose of this evaluation report supplement is to indicate that FetTe)y (Style RX1) High Performance. FelTexa (Style
RX2) High Perfonnande. FelTex SA306 Self -Adhering. CoverPro. CoverPro3000 and ProTexo Contractor Grade Roofing
Underlayments, recog I ixed in ICC -ES master report ESR -1293, have also been evaluated for compliance with the codes
noted bolow.
Applicable code editions:
0 2014 Florida Building Code—Building
■ 2010 Florida Building Code—Building
0 2014 Florida Building Code—Reslden1181
a 2010 Florida Building Code—Residential
2.0 CONCLUSIONS
The roofing underlaymenls, described in Sections 2.0 through 7.0 of the master evaluation report ESR -1293, comply with the
2014 and 2010 Floridi Building Code—Building and the 2014 and 2010 Florida Building Code—Residential, provided the
design and installation! are in accordance with the International Building Codot provisions noted in the master report and
Section 1507 of the Florida Budding Code - Building.
Use of the roofing undedayments has also been found to be in compliance with the High -Velocity Hurricane Zone
provisions of the 2014 and 2010 Florida Building Code—Building and the 2014 and 2010 Florida Building Code—Residential
under the condition that the underlayment is installed to the master report, the manufacturer's installation instructions and the
minimum requirements of Section 1518 of the Florida Building Codo—Building
For products falling under Florida Rule 9N-3. verification that the report holder's quality assurance program is audited by a
quality assurance entity approved by the Florida Building Commission for the type of inspections being conducted is the
responsibility of an approved validation entity (or the code official when the report holder does not possess an approval by
the Commission).
This supplement expires concurrently with the master report. reissued February 2015, revised March 2015.
*Revlsed March 2015
1('r'•hl fir.✓u.IlnwR�nl..In•mile/,•.•..n.r.rnLl.rrl.ryluury;.n•.✓w•!ir•I.r.nn.Mlyt OIIIIhIO:.I1.Y 1fY.'I�,.11l1 I�Ab:.•ul. n.r ru: lJ�;'Irl JL•*IrlNn11•d
.I. ...I: rMh./.:nM•.J ../I� .I.rY✓I'I•�I/1•I.(.Yll�.1 l.1.r1,MI:l��llNrll l.✓'11. R..' IM'II'1.n`r llllflllllll'A\'JI'I'I.IIIJIIII/Frll �r'f11:r: I.l.r I'fr•I: ,IM III �Ili.I 11. --_.
J.•J.Ir li.hax—IIIInv—,It.T 111%!.n/..11../.nl.•.I..1/N.••/u1ll..r\'I:./�I'l/I.•I,/.M! 4is7MI ,.
Page 7 of 7
GoDYrlgnt G 2015
• THIS INSTRUMENT PRI
1� 1
Warne': JASPER CONTI
•) v Address: 5380 E COLO
NOTICE OF C
l
Permit Number:
I
ParcelIID Number: ba . a(,
The undersigned hereby gives not
followi A g information is provided in
1. DESCRIPTION OF PROPERT
2.
OF
3. OWNER INFORMATION OR
Name and address: Frar
Interest in property:
Fee Simple Title Holdei (if o
4.
111l11111lfi !1!9!,1!119 !till lllll illi 1111
DBY: MARYANNE 11ORSEr SEMINOLE COUNTY
RS CLERK OF CIRCUIT COURT & COMPTROLLER
IR BK 8805 P9 1416 (1f;•9s )
CLERK'S v 2016118661
= RECORDED 11/15/2016' 10:38:06 AM
RECORDING FEES t1i►!OO
RECORDED BY
OWENCEMENT
Q, 6 --D - DOW - 03 Sid
that improvement will be made to certain real property, and in accordance with Chapter 713', Florida Statutes, the
pis Notice of Commencement.
(Legal description of the property and street address if available) i
INFORMATION IF THE LESSEE CONTRACTED FOR THE IMPROVEMENT: �' cX/
ednaU r_ � . Alelo PU ciLl LD V -C Or. �['i�`�Ci /-71
than owner,listed above) Name:
Address: 5380 E COLONIAL DR ORLANDO FL 32807
Phone Number.
S. SURETY (If applicable,ta copy of the payment bond Is attached): Name:
Address: Amount of Bond:
I
6. LENDER: Name: Phone Number:
I I _
Address:
I I •
7. Persons within the State of Florida Designated by Owner upon whom notice or other documents may be served as prof
713.13(1)(a)7., Florida Statutes. ;
Name: I Phone Number:
Address:
8. In addition, Owner designates of
to ri ceive a copy of the Lienors 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 PF
CONSIDERED IMPROPER>PAYM
PAYING TWICE FOR IMP90VEM
JOB SITE BEFORE THE FIRST I
BEFORE COMMENCING WORK (
Audrodred
State of
The foregoing Instrument was a
by 1.
m n G��
I Name of
who has produced identifit:atior
ts• •= MY
rr `
RENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF
ITS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND
ITS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED
�PECTION.:IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LEND
RECORDING YOUR NOTICE OF COMMENCEMENT.
_
r
(Print Name and Provide signatory's Tit Kce)
or
IMENCEMENT ARE
RESULT IN YOUR
3 POSTED ON THE
OR AN ATTORNEY
_ County of V r K ! <
nowledged before me this day of AM y/ + 20
(-Q u e f1 Who is personally known to me O OR
;on makln ement
type of identification produced: A CL
IANTHA MURRAY I
I
)MMISSION p FF944322 .
RES December 16, 2019'
Florida 0111130 vloe.dom Notary Signature �
I
CITY OF SANFORD BUILDING SERVICES
Residential Re -Roof
Hurricane Mitigation Inspection Affidavit
Permit #: 1 b ' S061
c J�
I, J DZ .�� _" hereby acknowledge that I personally inspected
Af deck nailing and/or�ondary water barrier work
at 366
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
understand that making any false statemt
performance of his or her official du
Section 837.06 F.
7,
atu�f Contractor
Printed Name of Contractor
true and accurate to the best of my belief and that I fully
Iain writing with the intent to mislead a public servant in the
all constitute a misdemeanor of the second degree pursuant to
1 114
Date
C -L(— 13 -) !
License #
License Type: 0 General 0 Buildin esidentiRoofing Contractor
0 or any individual certified in accordance with F.S. 46 make such an inspection.
VhIVIAIO
STATE OF FLORIDA COUNTY OF n f
Sworn to (or affirmed) and su scribed before me is ay of I V o VC , 20 by
S , who is 0 Personally Known to me or has 04roduced (type of
idekation as identification.
C12M1(2j2d6VVA_ (SEAL)
Signature of Notary Public
State of F1 *da
pcmigrF
Print/Type/Stamp Name
of Notary Public
; LN DANIELLE N DIAZ
W COMMISSION 0 00038827
EXPIRES October 18, 2020
Revised: February 2015