HomeMy WebLinkAbout17-18379 CITY OF ZEPHYRHILLS
5335-8TH STREET
(si3)78o-oozo 18379
.. BUILDING PERMIT
PERMIT INFORMATION LOCATION INFORMATION
Permit Number: 18379 Address: 5531 18TH ST
Permit Type: RE-ROOF ZEPHYRHILLS, FL.
Class of Work: ROOF REPLACEMENT Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 11-26-21-0010-14100-0010
Improv. Cost: 7,200.00 OWNER INFORMATION
Date Issued: Name: SHUTT RAYMOND & JEANNE
Total Fees: 112.50 Address: 5531 18TH ST
Amount Paid: 112.50 ZEPHYRHILLS, FL. 33542-4517
Date Paid: 4/20/2017 Phone: 727-401-7801
Work Desc: REROOF METAL
CONTRACTOR S APPLICATION FEES
A OLD TIME ROOFING REROOF RESIDENTIAL 112.50
. � �
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I ections Re uired I
DRYI ROOFINSP
TAPE JOINTS OF INSP
FINAL •�� .�
REINSPECTION FEES: (c)With respect to Reinspection fees will comply with Florida Statute 553.80 (2)(c)the
local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
first reinspection,whichever is greater,for each such subsequent reinspection.
NOTICE: In addition to the requirements of this permit, there maybe additional restrictions applicable to this properly 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, state agencies or federal agencies.
"Warning to owner: Your failure to record a notice of commencement may result in your paying twice for
improvements to your properly. If you intend to obtain financing,consult with your lender or an attorney
before recording your notice of commencement."
Complete Plans,Specifications Must Accompany Application.All work shall be pertormed in accordance with
City Codes and Ordinances. NO OCCUPANCY BEFORE C.O.
NO OCCUPANCY BEFORE C.O.
C NTRACTOR SI� NATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
A OLD TIME ROOFING 2636 22ND Street North
• ' St. Petersburg, FI 33713
'��� �� ------ (727) 824-9996
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�r,r� ,� _ - =-_____ Lic. #CCC1327304
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APRIL 20, 2017
CITY OF ZEPHRHILLS
Buildin�q Division Construction Permit
5335 8 " STREET �
ZEPHRHILLS, FLORIDA 33542
I, BLAKE BURNSIDE, QUALIFIER FOR "A OLD TIME ROOFING, INC." HOLDING
FLORIDA STATE LICENSE # CCC1327304, GIVE MY PERMISSION FOR THE
FOLLOWING PERSONS TO REGISTER, SIGN, OBTAIN AND PICK UP PERMITS
FOR"A OLD TIME ROOFING INC."
MARK SMALL - FOR THE DATE OF APRIL 20T" 2017 ONLY �
SINCERELY,
KE BURNSIDE
QUALIFIER
BEFORE ME PERSONALLY APPEARED BLAKE BURNSIDE TO ME KNOWN TO
BE THE PERSON DESCRIBED IN AND WHO EXECUTED THE FOREGOING
INSTRUMENT FOR THE PURPOSE THEREIN EXPRESSED.
TN SS: M HAND AND OFFICIAL SEAL THIS�DAY OF I� 20 j 7
�'� `� -
MY COMMISSION EXPIRES � � �
NOTARY PUBLI , STATE OF FLORIDA
o��'�;�uei, PATHICIA V.LIPE
r o
,� �t,� * MY"COMMISSION#GG 033245
�"y�`��oe EXPIRES:September25,2D20
lFOR F�d�' eone�d T�ru Budpet Natory Semc�
� !li�ili illll�ii�i illll II�II��I�I Iilli Iilil ilill IIIII iill lill
2017056353
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Per,a�it Number F2c�st:1�549G�� Rec: 10.00
� Parcel ID Number Q�- - 2�— OOIIQ —l�IOG- �4'l DS: 0.00 IT: 0.00
04/17/2017 K. P1. , Dpty Clerk
�IATICE OF COMMERlCEMER97'
Stafe of Florida THIg,qP,EA.ISRcStP,VGDFQrCLERKOF IHcCOU?I CEP,TIFI�ATIO"J
County of Pinellas '
THE UNDERSIGNED hereby gives nofice that improvements will be made to certain real property, and in accordance with Section 713.13 of the
Florida Sfatutes,the following information is provided in th' NOTIC OF MIVI NCEMENT. ' )� G ' )
1.Description of properfy(legal description): � � l�l � �� � ✓�I��S �(� j �� � � � Z �Y%� �-6
a)Sfreet(job)Address: �j �� � � h ,/h�� S 3 �� •
2.General description of improvements: RE-ROOF
r;
�:
3,Owner Information or Les�information if t Lessee c n racted for fhe improvement: /� I ) �jf
� a)Name and address: I/{ � U SS � 1�� � ��iT ,l (/�S ( � 3����
b)Name and address of fee simple title older(if erent than Owner listed above)
, c)Interest in property: FEE SIMPLE
4.Contractor Information
a)Name and address: A OLD TIME ROOFING 2636 22ND ST N., ST PETERSBURG, FL 33713
b)Telephone No.: 727-824-9996 Fax No.:(optional) 727-824-6396
5.Surefy(if applicable,a copy of the payment bond is attached) �
a)Name and address: N/A pqUL� 5 0'NE IL F'h D PRSCO CLERK & COMPI'ROLLER
b)Telephone No.: a�/17.12017 1.0:l�am 1 of 1
U� B� ��i�� P� ���� �
c)Amounf of Bond: $ _ ,
6.Lender
a)Name and address: N/A
b)Teleplione No.: � � ' � � � � � � �
7.Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section
713.13(1)(a)7.,Florida Sta#utes: '
a)Name and address: N/A
b)Telephone No.: Fax No.:(optional)
S.a.ln addition to himself or herself,Owner designates of
to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes.
b)Phone Number of Person or entity designated by Owner:
9.Expiration date of notice of commencement(the expiration date may not be before the completion of construction and final payment to the
confractor,but will be�year from the 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
F�AYING 7WICC FCIa IM�i�Cll/�flh�N�'�TG YOUR�hdi'Ek i ir'.i�IVC7 i iCE t�r Can��ii��tCEi���l�iviiis i t��kEc,u�i�ru Ai�u r�s►r�u uiv i i-ic�
INSPECTION, IF YOU INTEND TO OBTAIN�1NANCWG,CON5UL7 YOU�t L�ND�R Ci12 AN A7T'ORN�Y�FOFtt�Gidl'NT��Zi�i 1G T�Or�K U�C
RECORDING YOUR NOTICE OF COMMENCEMENT. `
Under penalty of perjury,I d �t I ha read the forego' g notice of commencement and that the facts stated therein are true to the best of my
knowled and belief.
� � � /v .K-�'-r4 ,n .7 r% ��ry � �/ -
(5i wner or e ners or Lessee s ori _ f6cerlDirectodPartnerlManager) (PrinF Name and P ovide Signator�s1itlel0ffice)�
The oregoing instrument was acknowledged before me this � day of V� ,20
by �..,�c,��� �/„ v� 8S ���j � �uthority,e.g,ofiicer,trustee,at omey in fact)
for ,as -
(Name of Person) (typ of au ority,...e.g.ofticer,trustee,attomey in fact) �
for (nam of rty behalf f who ins u ent was executed).
Pe�sonally'Krown ❑ Produced ID
Type of ID Notary Signature
!/ Print name
ro,��pY Pu�c PATRICIAV.UPE C,i
t NP!CpMMISSION#GG 033245
* �. EXPIRES:September25,2020
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al�-�saoaza ,� Ciry af 2ePhYrhills Permit Appfiicatia � � t
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Foc S(mpte Tidehol{Ier Addros � � $T � � 1 �3 7 7�'
aosann�ss 3 f�" s '� v' r 1 S 3�`�'�r+� z.or� ! �
I $t)BQM510h1 �%� tx�U"� I�__ PARCEL ID# ('J I/�"ZI-�l� ` � t3� G�I
{48TAiNED fROM PR4PER7Yt'AX NOtiC£}
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� INSTALi. � REPAiR
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FINISHEDFLpOREIEVATIONS � FLQODZOriiEARFA QYES NO ��� . ���
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� St�NATURE REG�EREi Y F! �EE GpRitft. N �
Addtess liCenSe#
ElE4Ti�C1AF1 COMPANY
SICaNATURE ��— �G�ERFA �,fJ FEEPJRREt� Yt� �
Addfess ( � �GB�#� C
PWMBER � �_Mr� COMPANY �T� � ' I
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MECHANIGAL �.�.� � C�APANY I ^��� I
3iGNh7URE AEG��s Y!h! ff£Cu�tEts YtN
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Adatess � iP� tiCOCiSe#
OTHER �- ••_-.�" ... � COMPANY � �t'�i�I�ti l�N�i�t_-� I�I
SIGNASURE .�+''w''r �� REG153ERER ^�Yl,N f'�ECURRE2+ Y/N
�aro� u��# r 3a�3D
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R o Aaact��2}P�ot P►ar�s:R}5ets oi BuBding Ftans:(1j set 4f Ensryy Forms��o-vu aarm�rartrew construct�on,
MfNm�m ten f74)�+�QAgn4 4���bmU4al date. F(4quaed onsk0.COrstructiw�Pla�ar,Sta+mwak0r Ptans wl S�t Fence h�stslled,
Santy�ry FaGi��Ges d��dumi�ster,Site Wark Pe�mR far sub�visioraralt�arqe pro)ects
GOkIM£RGIAI. Attseh(2}campts�e SetS of Bud4in�Plans Ptus a LiC�Saibry p294:(7a Set af�rleery}r Fom�s.R�OaA'Pam�@ for new Construelion.
MiOifhuiri ten('[Dy workM9 dBYs tifter submitWt d0te.ROquued or�he,COnSVIMCtipn P18ft5,StOrti�wdte►Pians w1 Stlt�6noD inSi81te6,
SaaitBry FacilNes&7 dumpster.Site Wals Permit'!u atl new p[ojecfs.Alt ccmmen;ia!r2qiritametR4 must meat compGan�O
SIGN PERMIT AttaCh(2)59ts otEngineered Piana
""PR4P�RTY SURSJEY requlred tat ali NENI coristNCtia�.
.�..�..r..�.�ri t i�ii�,.�R.�.�.+�nw++.�i i���.R.�i t F t i f i i i i fi i�ti i.t'
D"uedions:
�n 4ut sPPricetlon camptstely.
Qrtner&ConVaGt4t Si41t b8ck o!applSratlon.nDta�28d
H ovor 32500.a Notiee of CommencamerR is requtrod. (AIC�p9rdp0s over 37i0C)
� �* Agent{fortlte carA�aclory or Pawer af astomey t�rthe awner}wauld be s4meone xith naWr�c9d k�tierfiam owner xuthaslrJrtg sarno
i OYER TNE COUHTER RER6Ari'TiNC� {cOgy Pf C��u�4��ed?
Rs�4pfsifshingles SewerS S�CO U09r8tles A!C Fences(PlodSurv9y/FoOtage) ,
DrNevv�ys--Affot aver Counlerff on pubUe roadxrays..�e�ads ROW
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Apr, t8. 2017 11:30AM - No. 2930 P. 8
NOTiCE OF DEED RESTRIC71oNs: The und�rsigned understands that this pennit may be subject to"deed"restrictians"
whiCh m2y be more resfiotive tRan Counry regulaUons. The undersigned assvmes rAsponsibitity for compliance with any
appticable deed resficbor�ss.
, ' UNUCEidSED CONTRACTORS AND �pNTRACTaR I�ESpONS1131LITiES: If the pwner has hired a contractor or
COntrdCtptS t0 undertake work,they may be required t0 b6 licenSed in accordanGe with Staf�d�d lOcal regulations. If the
coMractor is not liaensed as required by law,hoth the owner and cantractor may be cited for a misdemeanor violation
under sWte law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for tha
intended work,they are advised to c�ntact the Pasco Gounty Building]rtspection Division--Licensing Section at 727-847-
8009. FuRhermore, if the owner has hired a contractor or conbractors, he is advised to have the contractor(s)s�qn
' porGons of the"contractor Block"of this application for which they will be responsibl�. If you,as the oxmer sign as the
contractor,that may be an indication that he is not property iicensed and is not enUUed to permitting priviteges in t�asco
County.
TEtANSPqRTATIQN IMPACTNTII.lYIES IMPACT ANO RESQURCE RECQVERY FEES: The undersigned understands
that Trensportation Impact Fe6s and Recourse Recovery Fees may apply to the aonstrvction of new bui3dings,change of
use in e�656ng buildings,or expansion of existing buildtngs,as specified in PaSCo CountY Orclinanoe number 89-07 and
90-07,as amended_ The undersigned also understands,that such fees,as may be due,will ba identified at the time of
permitting. 12 fs further understood that TranspoRation impact Fees and Resource Recovery Fees must be paid prior to
�eceiving a°certificate of oCcupancy'or final power release. If the project does not involve a certiTicate of occupancy or
final power release,the fees must be pa�d p�or ta pennit issuance. Furthermore,if Pasco Counfy Water/Sewet fmpact
fees are due,they mast be paid priorto permit issuance in accordanc�with applicable Pasco Courtty ordinances.
CQNSTRUCTION LIEN LAW(Chapter 713,Flo�ida Statutes,as amended): If valuation of work Is$2,600.00 or more,I
certiiy that I, the applicant, have been provided with a copy of the 'FloridA ConstNCtian Lien Law—HomeowneYs
, protection Guide'prepared by the Florida Department of Agricu[ture and Gonsumer Affaits, If the appliC�nt is someone
other than the°owne�',I ce.�tify that!have obtained a copy of the abpve described dxument and promise in good faith to
�wlhiws i`w YMn ^� �•vi iv w�l�iiwii�iii�n.
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CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the informatian in this appEication is accurate and that all worlc
wilf be done in Compiiance with all applicable laws regulating construction,zoning and land developm�rit Application is
hprAF�l mAlle tA Aht9ilf 7 nGYrtlif/A r1A uehr4 onrl inef�ll�finn �c inMireful I nu/ifii iM4 nn�.�nrL nr 7rrMelle47n+� 1._'
commenced prior io issuance of a permit ano inai aii work wiii be periortned i0 meet Sianciarcis oT ali iaws reguiating
consttuction, CounN and Ciiv codes, zoninp requlatlons, and land develoqment reoulations in the iurisdiction. i also
certify that I understanB fhat the regulations of other govemment agencies may appfy to th6 iMended woric,and that it is
rr��i ree�n�5!�I�1l±fn i�toe�r�fii u,ft24 B�MS I!!?L�gt,�40�?b�I�Mmr�Itg^ro. 5`'Sf.h 9��t:.^,7�£C•^•C!L��,�2L�:w.�.^..^.:�II::7:�tC'
- Department of F.nvironmentai Protection-Cypress BayheaCs, Wetiand Areas and EnvironmentaAy Sensitive
Lands,Water/Wastewater Treatmen� �
- Southwest Flortda Water Management DiStriCt-We116, Cypfess Bayheads, Wettand Areas, Altering I
Watercaurses.
_ e.»; ��...�..r e.. :..........�..��.,-.n� n....�w na.,a ..ti�.,�nrY�.,... . I
i r � ..a.......... ........ ..� ..., i a� v ..�.:�,jY.
- DeparOment of Health & Rehabilitative ServicsslEmriranmental Nealth Unit-Wells, Wastewate�Treatment,
Septic Tanks. �I
- US Enwronment�l Protection Agency-Asbestos abatement. ,
Federa�qviation Authorify-Runways. '�
I understand that the follow�ng restricbons apply to the use of fill: �,
- Use of fil is not anow�d in Ftood Zor+e"V"u»less expressly permittad,
- If the fill materiai is to be used in Flood Zone "A°, it is understoad that $ drainage plan addressing a
°Compens2ting vofume"will 6e submitted at fime of permitting which is prepdred by a professional engineer
licens�d by the State of Florida.
- If ltte fill materisl is to be used in Flood 2one•A° in cannection wiih a petmitked building using stem wa1l
' rnnaM�dinn 1 r�fifv fhat fill witl hq i�caA nnly M ft1 tha ama witFdn fha ctam wa11
- If fill mdtCriEtl i5 f0 b6 USed in any area, ( Certify that use of such fill wifl not adversely affect adjacent
� properties. If u5e of fill is faund t0 adversely affact adjacent properties,lhe owner may be cited for violating
' fha rnn�litinn5 nf thp hp0�iin��wrmh ieetigrV pnrlpr tF}g pi��rhgr�Fe�(t onrlirstinn�fnr Inhc�occ ih�n nr�o(q?
acre whJch are efevated by fi11,an engineered dr8inaqe plan is required.
If I am the AGEN7 Ft7R 7H�OWNER,I promise in good faith to inform the owner of the pei'rnitting conditions set forth in
'{�:y M�{'.MMM" Itwn M w � fw.wLi.... � �..yr��nWl1Y YYy w :1 r 6� ' �14� 1�.�.!ul�.�,I�
r w w wiiii..�wiiy w�9uwuvu. uu ..�.. wfru,uiG NQ�`u u�uy v�.�bM1%liy V v� oiow���� rwn.
, plumbing,signs,wells,pools,air Condi�oning,gas,or other installations not specifically included in ihe application. A
pemtit issued shall be consVued to be 8 I'rcense to proceed with the work and not as authority to violate,cancel,atter,or
.. i��:J���.��.�u��' � G�A�l��L��f��J�� � L�II[��..���� �L���+r1���..�y W�A..flJt��/�fSt�f��L��a6����L��
u'y.uu�u.,m�y M�vnu:v�w��u�a wvu�nw�wYoo�+wi u��an�ovuanva�i o ycunu po.om�nc wyi�wuy vuw�m�wui uic�cm�ct
rPrnriring a rnRPntion nf annrx in nl�n�,rnn�tn,l�tinn nr viotafinne nf an;r,.nciPc Fvgty�Rf171j�{$.C�fOfl�hall I]a�[1/�lP iStyall�
unless the work authorized by such permit is cammenced within six monffis pf permit issuanpe,or'rf woric 2uthorized by
�iro prtmit is susptlndeci vr auandvnaa i�r a petiaa oi six�o�manins aiier vie ume me worx is commenCeo, run ex�ension
m�F1A fA��fPRtP¢,in�nrritin��fTnm�a�iilrii�o Off,r,�lal fp�a�1P�f)fI nRY tfl PYlY-�.O('I I�11�Pr/;G��ria�rg an�i;ySI�r9o�y+nr��,r�afa
' justifiable cause for the extension. 1f work ceases for ninety(90)consecutive days,the job is oortsiCered abandoned.
WARNING TO OWNER: YO
UR FAILURE TO RECORD A NOTICE OF COMMENCEMENY AAAY RESUL7 IN YOUR
OAYIR�Y'I111/1��CMD�MCCIv1V`N�MT�T�V�I�O OO�D`PT/ iC i�.�.v�:�:T��:.�.Tv vwT.A-.:U n�Iw�:vi�:w �v�:vv��T
WlTli YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT �V
F�natna.n iaar r�c +,�n� /�
Own1Ek CRAGENr�pu"��r'�( � CONTRAc7olt�lG K! El�t l��t lJ�
Su'osaibeo and swam ° or:ertumec i ceiore me fhts Suhr.criwari ard Awnm io(nr a�rmadl baJara mv Thic
�L��, �7r�r �n�'1 -L�— �. �:pcic ' ��'7-- --
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Neme of NOtary bped, r�ted or StampeC e Of N61ary ryped.p' tetl u stamped
+p�.!V4�, AIIRICIAKL�TE �prau PAIAICUtv,L�E
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: � �����
Date Received: �T�r �—l7
Site: �J�� I � Z5 °��1
Permit Type: �'�'t"� ''��-�
Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑
This comment sheet shall be kept with the permit andlor plans.
I✓ I 1
�
Kalvin Switzer � an iner Date Contractor and/or Homeowner '!
(Required when comments are present) �
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By order of the Builcling Of�icial: �ViCC'Zam�. �urgess
All �uilding, plumbing, electrscal and rnechani�al work
shall cea�e at the beloao�e mention�d property.
�- ��
Address: � � � � /� ��� � �
D�te: � �-- �� � / �
� _
Code Enforcement Offcer:
C011�C� t�e
� Zephyrhill� �uilcfing Departr�ent
5335 - 8th Street
�13-780-0020
Ap r, 18, 2017 11 :27AM No. 2930 P. 1
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Ted R.Williams,Enter�rrises
2b36 22nd 5tr�t No�th • St. Petersbuxg, FL �37�3
(727)8�4-9996• �`ax (727� $24-6�96
FAX T�NSMITTAL
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DATE:
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TEL,: TEL: �27-8249�96
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' Parmit Number � Rcp�:!$54956 Ree: 10.�0
Percxi la Number Y � � ll1 �t J�� U?1 R5: 0.00 IT: 0.00
04/17/2017 K. M., Dp�.y Clerk
IdQTIC�� O � COIVIIVIENCEM�NT � .. � — — —
SfStB Of F�0(Id8 THRS/�R�A.ISRESBRVE�fORC�I.EP.KOF1'HEC:auRTCERT�FICA4IQN I
Caunty of Pinellas ' '
tFl�UNR�R316NED hereby gives notice thet improvements wi�be made td c�rf�in rea(property,and in ac�xardance�ith SecEion 743.13 of the' '
Florida SlaNl�s,ttse following o�formation is�rovided'n th' NO�IG OF �M CEMENT ' �`���� �� ��� . '
i.Uescription af properEy(legaldescripSon): � Cj � ✓�!��S �� 1 �� �( �T'S G� '�,
a}s'treet�iob}Address: '�� � ,ih�l.� �f � • "•
2,G�er�l descripEion of fmpravaments: R�-RQOF
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S.4wnerinforma�ionorLesS�einfvtmation� Lessee n ctedfbriheimprovement: L ) �
, � • a)Namesnd$dd�ess: Yl � (t �'S fc�'' -�T �� (7�� � ���f�
b)Hame�nd address of fe�simpM fitl Qlder j'�f e�ent than dwner I�sled abaae) � ,
, o)fnterest in prop�r[y. FE�SIMPLE
4.Con{�actor Infatmation � .
a)Name 8nd address: A OLD TIME RdOFING 2636 22ND�T N.,5T PHi'�RSBURG,FL 33713 �
b�Telephone Na.: 727-824-999B � Fax No.:(optional} 727-824-6386 � •
6.Surety(dappti�b►e,a�opy of th�paym�nt bo�d is a�ached� ' • , ' •
a}Nameandaddress: h11A ,__ � ___ ' AavGa s.o�n�2�,Rr.D.PASCQ t1..ERK & GOMPTROIlER
6)TelephoneNo.: ' g4/17/�0i7 �0:19am � p{ 1Ii
c)Amount of Bond: � . . . OR BK ���,� ����t�
6.Lender � . � •
, a}Nams and address; N1A
bj�eieptione No.: ' ... ...._.___._..,__. ._ _. . ... . . . . . . .
7.Persons v�tEiin the Sl�fe oF Fla�ida designsted by Owner upon whom notices or oth:r dot�ment�may be served as pfq�ided bySection
7t3.13(1)(a)7.,hlorida Stahltes: ,� �
�)hlame and addr�ss:. N/A � ,,
b)T�lephone Np.: ----- ------ Fax No.:(aptiona� - -- — —
e.a.ta add�ion to h9mseif or harsetf,Dwner desfgnates of _ _ _ •
� to receive e capy ofthg�fenor's Notioe as prauided in SeeSon 7?3.13(1�ro),Fl�rida Sbtutes. , , , �
. b)Phone Number af Person ar entiiy designated by Qwner, • ' ,� -
9,Expiration dats of riatice of commencement(the e�iration date may not he before the'xmpld6on of con'struction and final payment to�e
c�ntractor butwill be 1 ear from�te date of recardin uniess�differ�nt date is s �ciRed: � '
WARAIIMG TO OWAIER: ANY PAYW[EIdTS MA��BY'fHE OWNEf�AFTER i`HE EXPiRA7'lON OF'fHE NOTiCE OF COMMENCEtJl�NT ARE '
CQNS(DEl�ED tMPR4PER P�YM�N'rs unfo�c�aaP�R 7��,paRT t,SECTlON 7�3.43,FL4R1D/A S7A'fUT�S AN�CAN RESUL,T 1N Y4UR
PAYIIdG TWIGE FOR IMPRdVEMEN'fS TO YOUR PRBpERTY.A�ItITICE c7fi CpwiZVIEi�ICE"i�f�NT n�Eia^i i��R��GRuc�Ai�v r;�S i tG un1 i ri
INSPEC7'ION. !�Y4ll 1�1TEN0 TO OB AIN I NCIN6,Z�[OR SUL��R C�tJD�R(��'t A�1� t -I �'�ORiC OR
, REcoRplt�G YbU�NaT1GE aF COMM�AtcEM�c�T. •
Undsr psn�fry of perjury,l d t I h8 read the forego g no�ce of CCmmencemsnt and that the facts s�ated therein are Vue ta the best af my
knowled and befief.
. � x X x ,. -�'
(5' +rrr�'or ersoriz►see 16eerrolrerl.oN.PartnFtln�ac2g9r} (Prin ameand +ridaSEg�taNs �d�8ke��
The regoing inshument we5-s-cknowte,dc�g[e�d before me this , dey of l�'� 24
by Y.�L-�2a�!,�JE �er' trl.� 0s �! Z�1,+ ,� 4+pe ai eutt►odty,e.9.o�i�,�tistae,a mey in fac#}
for ,as � ' •
t�me of Persoc+a (eyP af s arity�..�e.q.atlf ee�,austte,atremey In tart} ,.
for � (nam of rty behalf wh in5 ent was executed�.
Personally'Known ❑ Produ:sd 1p
Type of lD ' /�` Notary Signam�e �
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P1qdvCt Manufacturer POLYGIr4SS USA
Aadress/Phonc/Email , 150 4yon DMve
Fernley,nn189a08
(570)39Miz34 ExC 242
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Cate9o►Y Rooftng
�+4��flo►Y Underlaymenes
[OmpllanCe Me#hod Evatuatlon qepatt from a Florida Regisiered Architect or a IJr,ensed
Plor►ea Rrofessiptfal Enpineer
Evaluat�on RepoR-Narnc4Qy Receivetl
Flor100 Englneer or Ard+ICQCt fuame who devefoped Rabert Nieminen
me Evatuarlan Reporc
Plo►1da�cC� PE59i66
Quallty axxurance Eneiry UL LLC •
Q4btttY ASgur�MB Cw�tracC gxpindon D80e o4J2a/2oss
Vandeted 6y �ofin W.K�ezevkh,PE
°. ValitlaitOsf C11lCiclfst-h18rQCDpyReCCIYeQ
CeRMcate oF indePendence� _FLS2,S�-9 R2� Cflf 2n�A pi S�I [�le¢�i�Lm.e,.�
Refereaced Standa�d a�d Yea�(ot'Standard) � �
ASTM D1970 20Qq
ASfM D22fi 2006
ASTM C6t6a 2005
, IISTM D6222 2008
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I��urida�P P, 18. 2017;�11 :37AM ��itpw:/;tl<yrid�buiidii��.org�pr�pr ���No, 2930�•'Parp. 11�rvhc�w�...
ASTM G35a 20D6
ASTM 0155 2D05 -
Ft�q aa7a 200a
FRSAJTR1Apfll2Q12 201Z
TAS 103 1995
UL I897 • 2004
Equrialence af Qrotlucs 5saooards
Certlfled 8y
Secctons Arom�e Code
ProaueSApproval Mecl►otl Mecho�i qptlon D I
Da[e Sabn+ltted 3,0/t7Jjp16
Date vafida�ed io�t8/23i6 '
flate Pendiny fBt Approval 10/39/2D36
pdte Apptovtq �,2/1SJ2016 ;'
Ddte RevlSed 03/13/2017
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FL* MoGel�Nu�nbe�o� �tsuil�en
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4259.i Potyglass Roof Roafinfl vnderlaymencs
UnGerlayme�Cs
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Appr05rodlp�u�e in FIYt!=: No FL5259 R25 Ti 20i6 ?0 FlNA eR POLvG..4SS_UNDER1,Qn+sEn17'S.F15�259-
APPRoved for u&e outlld�FNHZ:Yes R�S.odf
Impae!Re3�tenC N/A VeNFl�tl By;RObEI'C Ni�minen PE-59164
O�sigtl Pres9Nrl:3NlA/-622.5 CrELtEd t7y In�pendentThlyd PaRy:Y�
Other:1�)Tilt dEsi9�A�eSsure 1�thlS �valuatlon RepORs
appllCatlOn t�1DLCS tp qnE parLleule� FiS2$9 R A 016 i8 FlNAI, � POL�S UTJQERLAYMEN7'S FL5259
unCerlaymenc sysoem(over concrete deck) R f
for Use wtder foam-on tlle syst2ms(whtre Cr�ked by IfldlpEAtl�[7hlyd ParLy:Y4S
th3 unCtl'18yment Fom15 pAPt o�the
load-Fath).RefEr[o ER$EGtion 5.6.4 for
qther SyStEf�3,OthCr d8ck LypdS 81f6
assotbtsd maxlmw�t tleslpA pressures.2.)
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ene.11u�1�8�prorl0�d m.y be us�Q Porotf�l wmmunlaUon w�t�e lc�nsN.Nowevtr emal s�dr�e�v�a��p�e remrS.pyou oo not wbh m tuyo6�s OasoMl
aooras,v�asa Pro�a�ar ap�rtnx„e,.f��n emu�aa�os wNd,an be nude�wObr b�auene.Te a�ann�u R yeu��e s Bxnue ia+atr trop�r�55.��s„
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Ap r, 18, 2017 11 :38AM No. 2930 P. 12
� :�' '� IXTERIo�ttES�vt�N&DE.SIGN,u�.
• '�� CertificateofAuthurization#9503
�, f� �D 1A II�i�� 353 CliR1�TIAN STREEf,UIVIT#9.3
� Rfi v ox�oRo,cr os���
PHpNE:(203)262-9245
fAX:(243)�b2-9243
EVAf,UATlpN REPQRT
PolyglasS USA,1nc• Evaluation Report R7.ZD60.02.09-lt21
150 tyon Orive FI5259-itx5
Fer�11Qy.MV 984118 Date of Issuance:42/?A/2009
' Revision 21:1Oj17/2026
�CQPE:
i This Evaluation Report is issued under Rufe 51Gz0-3 and the applirable rules �nd regulatipns gavernirtg the use of
' canstruttian mater+als in the 5tate of FioEida.The dacumentatier�submitk�d has been reviQwed by Rabert Nieminer�,P.E.
, for use of the proQutt under the Florida Building Code and Florida Bailding Code, Residentiat Volume. Tfie pmducts
described herein have b�en evaluated for tpmptiance with the S�' Edition (2014� Florid2 Build9ng Code settians noted
herein.
C+��noN: Poiyglass Roof Underiayment�s
I�
Weeur�a: Cabeling sha11 be in accordance witt�the requirements th�Accredited 4uaEity Assurance Agency noted herein.
CaM1NUEo CVMr�axc�: This Evaluation Report is ualid until suth time as the named product(s) changes,t�e reierenced
�, Cluality Assurance document�tion changes,or prQv�sions af the Cade that rel�te ta the product change. Acceptance afi this
�valuation Report by the named Ctient constitutes agreement to notify Robert Nieminen,P.E.if th�produ�t changes or the
referenced Quality,4ssuran�e d�cumentatton chartges. 11tiniLy�ERD requires a complete reaieW of this Evdtuation Repart
relative to update�Cpda requirements with each Coda Lycle.
AOVERTiSEMENT: 7he Evaluation Report number prece�ed by the words "Trinity�ERD �valuated" may be displayed in
��iv�rtlsing literature. If any portio�of the�valuation Repar�;s displayerl,then it shall be done in its entirety.
INsvernoN:Upon request,�copy of this entire�valuation Report shall be provided to the user by the manufacturer Qr its
�, diStributor�and shatl be avaitable fer inspectian at th�jq�site at the request of the Butiding Official.
'� ThiS���1u�tian Repark censists 4f pages�,through 13.
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�� PfE�ll'�t�f�l: ���untupr. "'
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i ~�.r' �3?''py�=.fis
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.? . _�� ThefaalmiEesealappearingwasautfwri:edbyRob�ttPfiRlnil�tn,
' :��w a';�:z','� �u;° P.E Of11D/!7/201&7hi=dpBs not serve as an etactronically
'� RobertJ.M.Meminen,P.E. �''�.;�s'�,a��'a-` ��oethe Pro9 uA fp�loval Adm�b�tora dm�+e
Florido fteglstratron No.59A66,Ftprldq bG4 ANf1983 '�',u�,,,,;,;,,�•+
,nsmed s�ent , ,
I G£RriPIGATt01V Qf IN6EPfNDfNCE:
S. Trinity�ERD does not have,nor does it i�tend to acquire or will it atquire,a fltfancial interest in any company m�nufacturirlg or
distributing ptodutts it ewdtuates.
z. 7rinity�E80 is nat owned,ape�ated ar cantrolled byany company maaufactur�ng a�discribuung produets it evaluates,
3. Rpbe�'t Nieminen,P.f.does not have nor will acquire,a fnanciaf interest in a�y campany manufaccuring or distributing products for
which the evaluation repoRs are being i�sued.
4. Robe.rt Nieminen,P.E.does npt have,npr wi11 acquire,a finantiat ir�tetest in any oth�r entity invelved in the approval proCess of the
ptoduct. '
5. This is a building code evatuation. Nei�her Trin'dy�ERG nor Robert Niemfnen,P.E,are,in any way,the Resjgner of Record far any
prpject on whiCh this Evalqation RepoK,o�RreviouS ver�ions thereof,ts/was used for p2rmittiog pr desagn guidance unless r�tained
sperificatly for that purpose.
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