325 ROYAL PALMS DR ROOF21-0003 Building Permit Application Updated 10/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
v 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
–On V• IS REQUIRED.
Phone: (904) 247-5826` Email: Building-Dept@coab.us 7
Job Address: ?Z5- Voy k\ Y4\.n( \ Permit Numbeiu r• -wig ROOFZI - 0003
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Legal Description –3I ' � �� – z �"" Z`1�' ��/�� `n`x'>" 5 �n.� Zrt RE# I -7% 3Z"— 0006
Valuation of Work(Replacement Cost)$ 7 O d Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair OMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Ettesidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes o
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) -1 o
Describe in detail the type
�ofwork to be performed: l
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Florida Product Approval# for multiple products use product approval form
Property Owner Information } �y
Name <tv� . S�nti�q�ry.n 3r X1eii Address q/`"1 O" 61 t€ !J
City Tt( 3'&.t . Stat -'Zip 32-5-6 Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Informatt n A
Name of Company l " acl y 1 V00 fly Qualifying Agent „idi
Address 5III �j. 2 / City fie— State FL Zip 3?t
Office Phone qb(/ 3Z -f575-- Job Site Contact Number
State Certification/Registration# CCC\33a3 h E-Mail Cnt'c' iV)/1, t3 5 ,\- c e
Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation Insurer sr.v'\\^C. cn OR Exempt o Expiration Date t (/#// to Z
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 the standards of all the 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. 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.
OWNER'S AFFIDAVIT: I certify that all 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
• ESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU Ii�
:44:4;;:-T I OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ' • rFO'E Arty"
7 . CORDING YOUR NOTICE OF COMMENCEMENT. .
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g „, (Signature of Owner or Agent) 111111111w— (nature of Contractor)
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N 5-` igned and sworn to(or affirmed)before me this 17 day of Signed and sworn to(or affirmed)before me this 1Z day of
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[ ]Personally Known OR [ ersonally Known–OR TONI GIND ERGER
[4-Produced Identification [ ]Produced Identification 1-'i;' :, MY COMMISSION#GG 333178
Type of Identification: Type of Identification: " ice:;: EXPIRES:October 6,2023
Bond ,ru`o ary''t • erwriters
` IFLORIDA DSPARTMSNT OF .1 o..
Business & Professional Regulation �1 •
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Product Approval Menu>Product or Application Search>Application List>Application Detail
OFFICE OF THE FL# FL2533-R21
SECRETARY
Application Type Revision
Code Version 2017
Application Status Approved
Comments
Archived
Product Manufacturer CertainTeed Corporation-Roofing
Address/Phone/Email 20 Moores Road
Malvem, PA 19355
(610)893-5400
mark.d.harner@saint-gobain.com
Authorized Signature Mark Harner
mark.d.harner@saint-gobain.com
Technical Representative Mark D. Harner
Address/Phone/Email 18 Moores Road
Malvern, PA 19355
(610)651-5847
Mark.D.Harner@saint-gobain.com
Quality Assurance Representative
Address/Phone/Email
Category Roofing
Subcategory Modified Bitumen Roof System
Compliance Method Evaluation Report from a Florida Registered Architect or a Licensed Florida
Professional Engineer
Evaluation Report- Hardcopy Received
Florida Engineer or Architect Name who developed the Robert Nieminen
Evaluation Report
Florida License PE-59166
Quality Assurance Entity UL LLC
Quality Assurance Contract Expiration Date 03/09/2020
Validated By John W. Knezevich, PE
Validation Checklist- Hardcopy Received
Certificate of Independence FL2533 R21 COI 2018 01 COI NIEMINEN pjf
Referenced Standard and Year(of Standard) Standard Year
ASTM D6162 2008
ASTM D6163 2008
ASTM D6164 2011
ASTM D6222 2011
ASTM D6509 2009
FM 4470 2012
FM 4474 2011
Equivalence of Product Standards
Certified By
Sections from the Code
Product Approval Method Method 1 Option D
Date Submitted 12/11/2018
Date Validated 12/17/2018
Date Pending FBC Approval 12/19/2018
Date Approved 02/19/2019
Summary of Products
FL# Model, Number or Name I Description
2533.1 Flintlastic Modified Bitumen Modified Bitumen Roof Systems
Roof Systems
Limits of Use Installation Instructions
Approved for use in HVHZ:No FL2533 R21 II 2018 12 FINAL Al ER CERTAINTEED MODBIT FL2533-
Approved for use outside HVHZ:Yes R2Lp if
Impact Resistant:N/A Verified By: Robert Nieminen, PE PE-59166
Design Pressure: +N/A/-635 Created by Independent Third Party: Yes
Other: 1.) Refer to ER Section 5 for Limits of Use. Evaluation Reports
2.)The design pressure noted in this application FL2533 R21 AE 2018 12 FINAL ER CERTAINTEED MODBIT FL2533-
relates to one specific system. Refer to the ER R21.odf
Appendix for all systems and max design pressures. Created by Independent Third Party:Yes
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Contact Us::2601 Blair Stone Road Tallahassee FL 32399 Phone:850-487-1824
The State of Florida is an AA/EEO employer yght 2007-2013 State of Florida. ::Privacy Statement::Accessibility Statement::Refund Statement
Under Florida law,email addresses are public records.If you do not want your e-mail address released in response to a public-records request,do not send electronic
mail to this entity.Instead,contact the office by phone or by traditional mail.If you have any questions,please contact 850.487.1395.*Pursuant to Section 455.275(1),
Florida Statutes,effective October 1,2012,licensees licensed under Chapter 455,F.S.must provide the Department with an email address if they have one.The emails
provided may be used for official communication with the licensee.However email addresses are public record.If you do not wish to supply a personal address,please
provide the Department with an email address which can be made available to the public.To determine if you are a licensee under Chapter 455,F.S.,please click here_.
Product Approval Accepts:
® eC Peck111
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Safe
NOTICE OF COMMENCEMENT
Permit No. Tax Folio No.
State of Florida,County of Duval
THE UNDERSIGNED hereby give notice that the improvement will be made to certain real property in accordance with
Chapter 713,Florida Statutes,the following information is provided in this Notice of Commencement.
1. Description of property(legal description of property and address if available):
2. General Description of improvements:
3. Owner Information: 1_ q10-1- Q� /)_ v _ ! �4_ 01 J-a "Z Vci
a)Name and Address: T (� `( J� �t
b)Interest in property: 3;15- Ps. yC:, 1Y' 1 x C- L 3,aa5-0
c)Name and address of simple titleholder(if other than owner):
4. Contractor Information: 1 _
a)Name and Address: �y7�t3C\� oc ,4
b)Phone Number: q,L'1 37 -} / J
5. Surety Information:
a)Name and Address:
b)Phone Number:
c)Amount of Bond:$
6. Lender Information:
a)Name and Address:
b)Phone Number:
7. Person within the State of Florida designated by owner upon whom notices or other documents may be served as
provided by 713.13(1)(a)7,Florida Statutes:
a)Name and Address:
b)Phone Numbers of Designated Person:
8. In addition to himself/herself,Owner designates of to receive a
copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes.
a)Name and Address:
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 contractor,but will be one(1)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 PAYING TWICE FOR IMPROVEMENTS TO YOUR
PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE
BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF
COMMENCEMENT.
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cUnerferjury,I at I have read the
O z-<m p No enalty
to phe best of my declare
. •hvledge and belief.foregoing notice of commencement and that the facts stated _ ANL _
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o 0 N N Signature of Owner or Owne s Autho ' cer/Director/Partner/Manager Signatory's Primal!Name Title/Office
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nib The foregoing instrument was acknowledged before me by meansofBphysical presence orponline notarization, 7
TJ m this day of SSL 20 l ,by rJ�``�� Z ,who is personally known to • o
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e - ` r (Name ofPerson • a
0 ori me or produced 1-- L as ide 'fication,as I . )w
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rl N for •-• n T m
w (Name of Party Instrument was Executed for)
D NOT P.BLI' IGNAT STATE OF FLO DA 1,1
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Commissioned Notary Name:} t ..
(Affix Notary Seal Above)
Revised 1/1/2020