HomeMy WebLinkAbout900 Clinton StCITY OF SANFORD
' BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Application No: 140- -3/ a2-•1
Documented Construction Value: $ t)900.
Ov
Job Address: `100 (.,1'�„-; � S �. 'anQ w& 1-` Historic District: Yes ❑ No ❑
Parcel ID: N \ 13, -!2)\ 1 - b 600 CQ-1-Ja Residential [Commercial ❑
Type of Work: New ❑ Addition ❑ Alteration ❑ Repair ❑ Demo ❑ Change of Use ❑ Move ❑
Description of Work: ce- ccn
Plan Review Contact Person: �[j,r G%-7 _-e� Title: 12,rC.S
Phone4o') �n-M+6 Fax: Email: (14-t MC" t„ct
Property Owner Information��•� • CA►r•
Name
Street:
City, State Zip: agl,_tn rG
Phone:
Resident of property? :
Contr ctor Information ,�•�
Name Phone:
Street: j oS Oy rbFax:
City, State Zip State License No.
Name:
Street:
City, St, Zip:
Bonding Company:
Address:
Architect/Engineer Information
Phone:
Fax:
E-mail:
Mortgage Lender:
Address:
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE
RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
Application is hereby made to obtain a 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, beaters, tanks, and air conditioners, etc.
FBC 1053 Shall be inscribed with the date or application and the code in effect as of that date: 5t° Edition (2014) Florida Building Code /
Revised: June 30, 2015 Permit Application qR
. it
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 er/Agent Date Signature of Contractor/Agent to
Print Owner/Agent's Name
g b
of tary- tate of Florida Date
Owner/Agent is � Personally Known to Me or
Produced ID Tvve of ID
1►!! UO •''•J.-'.NE'T
f,( "
MY COIAMSSION MFF004273
(407) 398-0153
F... PIRFS July 4. 7.017
1:101rd allol iuySe rvice.cora
Print Contractor/Agent's Name
F. � oatp-1 &&evl)) i I I I I I I (/
Signature of Notary -State of Florida Date
+�`:'"`•°° P. EWNE SROEKER
MY COMMISSION 0 FF 983471
g �+r ILVIRES: A%Nh 3.2020
y�0►f11a' MhMdtIwAIYJOMNoorySr►kw
Contractor/Agent is personally Known to Me or
Produced ID Type of ID
LOW IS FOR OFFICE USE ONLY
Permits Required: Building ❑ Electrical ❑ Mechanical ❑ Plumbing[] Gas❑ Roof ❑
Construction Type: Occupancy Use: Flood Zone:
Total Sq Ft of Bldg:
Min. Occupancy Load:
New Construction: Electric - # of Amps
Fire Sprinkler Permit: Yes ❑ No ❑
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
# of Heads
UTILITIES:
FIRE:
# of Stories:
Plumbing - # of Fixtures
Fire Alarm Permit: Yes ❑ No ❑
WASTE WATER:
BUILDING:
Revised: June 30, 2015 Permit Application
SCPA Parodi View: 31-19.31-514-0000-001A
CFA Property Record Card
P3f=I';'
Parcel: 31-19-31-514-0000-001A5ii�_ Owner. DOAN CARY
s.o+o�coowtcnonax Property Address: 900 CLINTON ST SANFORD. FL 32771
Parcel
31-119-31-5114-0000-0011A
Owner
DOAN CARY
Property Address
900 CLINTON ST SANFORD, FL 32771
Mailing
900 CLINTON ST SANFORD, FL 327714506
Subdivision Name
COTTAGE HILL
Tax District
S1-SANFORD
DOR Use Code
01 SINGLE FAMILY
Exemptions
00-HOMESTEAD(1998)
Tax Amount without SOH: $2,953.01
2016 Tax Bill Amount $2,928.73
Tax Estimator
Save Our Homes Savings: $24.28
Does NOT INCLUDE Non Ad Valorem Assessments
Legal Description - -
OUT LOT NO 1 & LOTS 10 TO 19 & 32
TO 36 8 N 12 OF VACD ST ADJ ON S
OF LOTS 32 TO 36 & ALL VACD ST ADJ
ON N OF LOTS 33 TO 36 & ALL VACD ST
ADJ ON N OF LOTS 10 TO 14
COTTAGE HILL
PB 2 PG 67
Taxes
Frontage
2017 Working
2016 Certified
Taxing Authority
Assessment Value Exempt Values
Values
Values
Valuation Method
Cost/Markel
Cost/Market
Number of Buildings
3
3
Depreciated Bldg Value
$77,301
$75,227
Depredated EXFT Value
$600
$600
Land Value (Market)
$112,563
$112,563
Land Value Ag
Schools
' $188,489
Jusl/Market Value ••
$190,464
$188,390
PortabiliyAdj
$32,913
r --
Save Our Homes Adj
$1,975
$1,211
Amendment 1 Adj
P&G Adj
$0
$0
Assessed Value
$188,489
$187,179
Tax Amount without SOH: $2,953.01
2016 Tax Bill Amount $2,928.73
Tax Estimator
Save Our Homes Savings: $24.28
Does NOT INCLUDE Non Ad Valorem Assessments
Legal Description - -
OUT LOT NO 1 & LOTS 10 TO 19 & 32
TO 36 8 N 12 OF VACD ST ADJ ON S
OF LOTS 32 TO 36 & ALL VACD ST ADJ
ON N OF LOTS 33 TO 36 & ALL VACD ST
ADJ ON N OF LOTS 10 TO 14
COTTAGE HILL
PB 2 PG 67
Taxes
Sales '
t -
Description Data Book Page Amount Oualified Vac/Imp
WARRANTY DEED 911/199703300 0185 $160,000 No Improved
Find Comparable Sales ,
Method
Frontage
Depth
Units Units Price
Taxing Authority
Assessment Value Exempt Values
Taxable Value
0.00.
City Sanford
$188,489
$50,500 '
$137,989
SJWM(Saint Johns Water Management)
$188,489
$50 500
$137,989
County Bonds
$188,489
$50,500
$137,989
Count' General Fund
$188,489
$50,500
$137,989
Schools
' $188,489
$25,500-
$162,989
200.00 ;
$230.00
$32,913
Sales '
t -
Description Data Book Page Amount Oualified Vac/Imp
WARRANTY DEED 911/199703300 0185 $160,000 No Improved
Find Comparable Sales ,
Method
Frontage
Depth
Units Units Price
Land Value
ACREAGE
0.00.
0.00 1.972
$10,000.00
$14,790
FRONT FOOT & DEPTH
40.001
129.00
$230.00
$6,486
FRONT FOOT & DEPTH
200.00.
129.00
$230.00
$32,430
FRONT FOOT & DEPTH
160.001
129.00 .
$230.00 ,
$25,944
FRONT FOOT & DEPTH
159.00
200.00 ;
$230.00
$32,913
Building Information
http!/parceldetaiiscpafl.orglParcelDetWllnfo.aspx?PID=3119315140000001A 12
11/17/2016 Estimate 0000063 from American Homes Roofing Inc. RC29027427
American Homes Roofing Inc. RC29027427
1465 Grove St Apopka,Fl 32703
Cary Doan
900 Clinton St. Sanford,Fl
Item Description
Service Tear off old shingles,nail deck up to code,dry in with 30 yr.
Arktec shingles,new boots,valley metal and eve drip.
ESTIMATE
Estimate * 0000063
Estimate Date 10/23/2016
Unit Price Quantity
7800.00 1.00
NOTES: 1 yr. gu ed on labor .Rotten wood extra. Signature
Owner: Signature
Contractor:
Subtotal
Total
Amount Paid
Estimate
Amount
7,800.00
7,800.00
7,800.00
0.00
$7,800.00
t*OJ/www.aynax.com/printEstimate.php 1/1
THIS IN UMENT PREP BSI:
Name L ` ✓ `
Address:
NOTICE OF COMMENCEMENT
State of Florida
County of Seminole
Pemnit Number.
Parcel ID Number. 'JI • 1 `I • ✓ 1 - 6 1q - 000 r W
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.
GENERAL DESCRIPTI N OF IMPROVEMENT:
Address: 1,40W \��'.,��n ✓`�� --amen L;� Ii_` } \— I- "-'N d4-- 1 1
Fee Simple Title Holder (if other than owner) Name:
Address:
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)(b), Florida Statutes.
1`q
Name:
Address:
In addition to himself, Owner Designates of
To receive a copy of the Lienor's Notice as Provided in
Section 713.13(1)(b), Florida Statutes.
Expiration Date of Notice of Commencement (The expiration date is 1 year from date of recording unless a
different date is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF
COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13,
FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A
NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST to
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY
BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. G
N
Under penalties of perjury, I declare that I have read the foregoing and that the facts stated In it are true !'t
to the best of knowledge and belief. .s . e~N
•
owners Signature Owners Printed Name C:)
Florid fatale 713.13(1)(8):The owner must sign the notice of commencement and no one else may be permitted to sign In his or her stood.' y z
State of County of
o 0
The foregoing Instrument before this day
W
was acknowledged me of . 20V o
�
by Who is personally known to mel
a $ o:
Nome of person making statement
t s
OR who has produced Identification ❑ type of identification produced:
t
8!L O
`�; JANET DORSE
O
s 0
MY COMMIiSiC:I 4.
SignatureEXPIRE`.:
F(407)
o�''Notary
,h r!: x:)170153
Floridatur::.:..•:. ....
City of Sanford
Building and Fire Prevention
Product Approval Specification Form
Permit #
Project Location Address
.► ►n
As required by Florida Statute 553.842 and Florida Administrative Code 9N-3, please provide the
information and product approval number(s) on the building components listed below if they are to be
utilized on the construction project for which you are applying for a building permit. We recommend that
you contact your local product supplier should you not know the product approval number for any of the
applicable listed products. Be aware that windows, skylights, and exterior doors must be tested in
accordance with the Florida Building Code, Section 1714.5. More information about Statewide Product
Approval can be obtained at www.floridabuildinQ.orQ.
The following information must be available on the jobsite for inspections:
1. This entire product approval form
2. A copy of the manufacturer's installation details and requirements for each product.
Category / Subcategory Manufacturer Product Florida Approval #
Description include decimal
1. Exterior Doors
Swinging
Sliding
Sectional
Roll U
Automatic
Other
2. Windows
Single Hun
Horizontal Slider
Casement
Double Hun
Fixed
Awning
Pass Through
Projected
Mullions
Wind Breaker
Dual Action
Other
June 2014
Category / Subcategory
Manufacturer
Product
Description(including
Florida Approval #
decimal
3. Panel Walls
Siding
Soffits
Storefronts
Curtain Walls
Wall Louver
Glass block
Membrane
Greenhouse
E.P.S Composite
Panels
Other
4. Roofing Products
Asphalt Shingles
Undeda ments
Roofina Fasteners
Nonstructural
Metal Roofing
Wood Shakes and
Shingles
Roofing tiles
Roofing
Insulation
Waterproofing
Built up roofing
System
Modified Bitumen
Single Ply Roof
Systems
Roofing slate
Cements/
Adhesives /
Coating
Liquid Applied
Roofing Systems
Roof Tile
adhesive
Spray Applied
Polyurethane
Roofing
E.P.S. Roof
Panels
Roof Vents
Other
June 2014
Category / Subcategory
Manufacturer Product
Description
Florida Approval #
include decimal
S. Shutters
Accordion
Bahama
Colonial
Roll u
Equipment
Other
6. Skylights
Skylights
Other
7. Structural
Components
Wood Connectors /
Anchors
Truss Plates
Engineered Lumber
Railing
Coolers/Freezers
Concrete Admixtures
Precast Lintels
Insulation Forms
Plastics
Deck / Roof
Wall
Prefab Sheds
Other
8. New Exterior
Envelope Products
Applicant's Signature
Applicant's Name \f)n
(Please Print)
June 2014
ty '13 - Florida Bullding Code Ordine
h . I 1 . 1
sb^& DEfArMillBels Mome I Login ( User Reglst ation I Hot Topla I Submit SurtAarya I Stats a Fads I Publlotlons I FSCStaff I SCIS Site Map I Unks I Search
Busines "",
ssiVf101
Profes Product Approval
®USER: Public User
Regulation
14 Product Aooroval Menu > Product or Aooliotlon Search > yogllcatlen tlst > Appacatlon Detea
FL 3
FL16543
Application Type
New
Code Version
2010
Application Status
Approved
Comments
Archived
Product Manufacturer CertalnTeed Corporation -Roofing
Address/Phone/Ercall PO Box 1100
1400 Union Meeting Rd
Blue Beg, PA 19422
(215) 274-2350
Steven.T.Lawrey@saint-gobain.com
Authorized Signature Steven Lawrey
Steven.T. Lawrey®salnt-gobain.com
Technical Representative Mark Hamer
Address/Phone/Email 1400 Union Meeting Road
P.O. Box 1100
Blue Beg, PA 19422
(215) 274-2443
Mark.D.Hamer@saint-gobein.com
Quality Assurance Representative
Address/Phone/Email
Category Roofing
Subcategory Underlayrrents
Compliance Method Evaluation Report from a Florida Registered Architect or a Ucensed Florida
Professional Engineer
123 Evaluation Report - Hardcopy Received
Flodda Engineer or Architect Name who developed the Robert Nierrinen
Evaluation Report
Florida License PE -59166
Quality Assurance Entity Intertek Testing Services NA Inc. - ETL/Wamock Hersey
Quality Assurance Contract Expiration Date 07/29/2014
Validated By John W. Knezevkh, PE
2 Validation Checklist - Hardcopy Received
Certificate of Independence
Referenced Standard and Year (of Standard)
Equivalence of Product Standards
Certified By
Sections from the -Code
1507.2.3
1507.3.3
1507.5.3
1507.7.3
1507.8.3
1507.9.3
1507.9.5
___ "' a, r aca wu�
11/6113
- -- Product Approval Method
Date'Submitted
Date Validated
Date Pending FBC Approval
Date Approved
Summary of Products
Florida Building Code Online
Method 2 Option B
06/16/2012
06/19/2012
06/24/2012
08/07/2012
FL #
Model, Number or
Name
Description
15692.1
CertainTeed Synthetic
Roof underfayments
Underlayrrents
Units of Use
Installation Instructions
Approved for use in HVHZ: No
FL15692 RO D er061612FINAL CERTAINTEED SYNTHETIC UNDERLAYMENTS FL15692.odf
Approved for use outside HVHZ: Yes
Verified W: Robert Nieminen PE -59166
Impact Resistant: N/A
Created try Independent Third Party: Yes
Design Pressure: WA
Evaluation Reports
Other. Refer to ER Section 5 for Undts
FLL5692 RQ -AE er061612FINACCERTAINTEEDSYNTHET.IC,UNDERCk MENLS-Ft15692.i,
of Use.
Created by Independent Third Party: Yes
Dock Moat
Contact Us :: 1900 North Monroe Street. Tallahassee FL 32399 Phone: 850-487-1820
The State of Florida Is an AA/EE-0 employer. Copyright 2007-2013 State of Florida.:: Privacy Statement :c Accessibility Statement :: Refund Statement
Under Florida la% 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 mall 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 455.27S(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department Mth an email address If
they have one. The emalls provided may be used for official communication with the licensee. However email addresses are public record. If you do not dsh to
supply a personal address, please provide the Department with an email address wAidr can be made available to the public. To determine If you aro a licensee
under Chapter 455, F.S., please dick hg-.
Product Approval Accepts:
®®®®
Crcdit Card
SAFE,
floridaWIding.org/pr/pr app dtl.aspOwarrrwGEVXQtMDgmAH8jlpV7pH3pAuHOVVrrwMgqPkTviuLYCgMTGIlou&63d%3d 212
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,iC... ,Gt "? 'y�'sa ''� �f�ti!':.�•,. :.�� ... �+�r, i,—yam. �t Vit..= 't;E.•_�� -
+�-'f,. O• �3;:'.�'e3 �c�• .'..fin+�SI'�•.i _t;r,.� -�,�:.,af•n .c•••'.•::. •,�;
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.. ... ,b r.�✓f;'... 3 --:'�.:: �' ..d•:. .. off" �T'a�: y....ar. •'..: •C..,: i.._ .a,.; . >.. _ •
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FL f FLS444-R7 :
,: JJ `,Tr^.•}fir '
Application Type
RevWon
Code Version 2010
Applk_tlorr Status ' Approved
t7ommen6
Anddved
Product NamdecbaW
Addi alt
Auttwrboe+d SignaOie
Teddw&W Representative
Addi
Quality Assumnae Rive
li
Category
Subcategory
Compliance NetMd
�i
CertalnTeed
18 Moores Road `'` ' -
Malvern, PA 19355
(610) 651-5647
mark.d.harrier9saint gobaln.com
Mark Harrier
mar Ld.harrre OsOnt-aobain.com
Steven 18wrey
1400 union Meeting Road
Mus Bell, PA 19422
(2151 274-2425
Roofing
r '. A5ptmltSl"eS
Eiraluatlon Report from a Ronda Regisftrod Arddted or a•Liaert9ed
Rorids Proliesslonai'bgineer
emkodon-Report -. Hardcopy Received
Rorlds Engineer or Architect Name who developed Robert Nlernlnen
the Evaluation Report
Rorlda License PE -50166
Quality Assurance Entity UL Lit
Quality Assurance Contract Expiration Oate 07/00/7017
Validated By John W. Knezevidr, PE
Validation Cheddist - Hard6o0; i.ecPJved
bertiflfabe of Independence 65444 R7 COI 2014 04 COI Nieminen.odf
Reference I Standard and Year (of Standard)
ASTM 03161, Class F
ASTM 07158, Class H
Epulvalem of Product Standards
Cerfifled By
Sedlmrs from tM Code
.. i
d
' f
Y»
2006 .
2087
- 2007
62412015
Product Approval Method
Date Submitted
Date Validated
Date Pending FOC Approval
Date Approved
Data Revised
Florida Bulding Coda Ordina
Met1wd 1 Option 0
04/29/2014
05/05,2014
05/07/2014
06/223/2014
03/16/2015
FL* M xK Number or Name Description
5444.1 i� CertainTeed Asphalt Roofing 3 -tab, 4 -tab, ship (no -cut-outs), laminated and arWtectural
t shingles I asphalt roof shingles
L6n8s of Use Instalation LLst uctlons
Approved for use In HVHZ No FL5444 R7 11 2014 05 FINAL ER CERTAINTEED Asphalt
Approved for use outside HVH D Yes Shingle FL5444-R7.Ddf
Impact Resistants WA Verified By: Robert Nieminen, PE PE -59166
Design Pressure: N/A Created by Independent Third Party: Yes
Other.. Refer to ER Section 5 for Limits of Use evaluation Reports
FL5444 R7 AE 2014 05 FINAL ER CERTAINTEED Asphalt
Shingle FL5444-R7.Ddf
Created by Independent Third Party: Yes
[ME
CortedIti :: 1940 111oft Pbmw StreM MdUffiessee R. 32M Phone,• BSD -487-1824
The Starve d P Adds Is an AlyM emdorer• : B
Under Rodds Isar, crag addresses are polnc retards U you do not want yatir anal 1 1 -4 released In response W a pub- rnsor I neryxes& do not send eledseric
mag to pis edgy tdesdr t- - - ' the ofnce by phase or by t odit el mag. u you Nave any owns, please cmad 850.487.7395. 'Punt to Section
455.27517), Roddo Stabil;, etfemve oaobei 1, 2D72, hceaees licensed aider aepter 455, F.S. meat WmIde tie Depanmet with an emelt 1 " m 1 If they have
tee. The malt povWed may be used for aniael ammotonon won the Boeaee However emalt addreaes are pttft ret,, 1 O you do rot vAsh to uepply a
persvd addles, please provide the Deparument with an en it address which mn be made avaf We to rhe public To dem .iboe If you are a lkao a ,, 1, cepte►
4SS, F.S., please C" ftM,
product App -1 A -opts
wvunt :::
hUMJ wWaWIdMar9hxlpr e0p_d6.aspoCiW m=wGEV1(QwI gMlgO7C'.AsW"28CWCypNcWeUzk%3d 22
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date: j • a0 - \,-Q
I hereby name and appoint: � yV—
".
'
an agent
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:
(street Address)
Expiration Date for This Limited Power of Attorney: Qn�
License Holder N
State License Number:
Signature of License
STATE OF FLORIDA
COUNTY OF S e.mi n 01-e
t -i
The foregoing instrument was acknowledged before me this(9(9 day of,
200��I, %�Z C' 2 who is 4ersonally known
to me or o who has produced as
identification and who did (did not) take an oath.
(Rev. 08.12)
P. ua_�v 9466a
Signature
(Notary Sea])
(� p
LA I hP_ 1 r o eve t
Print or type name
¢My�M ss BRNEaR
Notary Public -State of
• �� � EXPIRES: Match 9.2020
Commission No. F F q1P 3 q % /
-��oo'v W'*d'"ry&iW"0M
My Commission Expires:/' -Z0' -j0
(Rev. 08.12)
CITY OF SANFORD BUILDING SERVICES
Residential Re -Roof
Hurricane Mitigation Inspection Affidavit
Permit #:
Aa, —3J a
l,�[Y1iC i�C:� ���=u Z�r` hereby acknowledge that 1 personally inspected
®'Roof deck nailing and/or O Secondary water barrier work
at
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 F.S.
IY� P�C n�e
Signature of Contractor
�c bc,:ee� tA�ka,,e r
Printed Name of Contractor
II 2�1
Date
License #
License Type: n General n Building n Residential n Roofing Contractor
0 or any individual certified in accordance with F.S. 468 to make such an inspection.
STATE OF FLORIDA COUNTY OF Se Yn► n O L e -
Sworn to (or affirmed) and subscribed before me this ,j� 0 4-l. day of W d Ve- MAMA , 20 by
% C d_ Q.l.+; z e e , who is 0 Personally Known to me or has O Produced (type of
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