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HomeMy WebLinkAboutroof Affidavit Planning & Development Services - _ Building & Code Regulation Division 2300 Virginia Avenue Fort Pierce, FL 34982 772-462-2165 or 772-462-2172 Fax: 772-462-6443 ROOF INSPECTION AFFIDAVIT Re: Permit#143d(O 3 S I,"DA0D S/m«"/licensed as (n)Contractor* ngineer/Architect (Please print name&circle license ty *FS468 Building Inspector General, wilding,Residential or Roofing Contractor or any individual certified under 468 F.S.to make such on inspection. On or about 40 30 (Q� I did personally inspect the roof deck nailing (Date) work at:—7 9 1 PANGln4 c.4y F • P1MC(r Fl.. 3(fQJr� (Job site address) Based upon that examination I have determined the installation was done according to the current edition of the Florida Existing Building Code Section 708 or the product approval submitted (whichever is m st strigentl. C4c S--0�9( Signature and Sea License# STATE OF FLORIDA COUNTYOF IFle-dVa�� Sworn to and subscribed before me this Z day of 20I t by ,I myi A Stiv q W-aw-, Who is personally known to me orb ho has produced as identification. Notary Public,State of Florida Signature of Notary: Commission Number: 0152 N (Seal) En A MSAMA THAION*MEEK EXPIRES February �f Mbr dN+uM. 9w Ylfi�"/r JIMMY PATRONIS CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION ** CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 3/9/2018 EXPIRATION DATE: 3/8/2020 PERSON: SIMIGRAN DAVID FEIN: 202487231 BUSINESS NAME AND ADDRESS: SIMIGRAN BUILDERS INC 115 BRISTOL STREET SEBASTIAN FL 32958 SCOPE OF BUSINESS OR TRADE: Door and Window Installation Concrete or Cement Work- Ceramic Tile,Indoor Stone, Contractor-Project Manager, All Types=Residential and Floors,Drtveways,Yards,or Marble,or Mosaic Work construction Executive, Commercial Sidewalks and Drivers Construction Manager or Construction Superintendent IMPORTANT:Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 ATE(MMfDDNYYY) ACERTIFICATE OF LIABILITY INSURANCE 03/1/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT AME Daniel Munro Munro Insurance Services, LLC. P ONEFAX C o E�d: 760-621-3844 _ 760-780-1653 (AI1285 Stone Dr. Suite 201 E-MAIL Daniel Munro@gmail.com ADDRESS: San Marcos, CA 92078 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Preferred Contractors Insurance Company 12497 INSURED Slmigran Builder Inc. INSURERS: _ David Simigran INSURER C: 115 Bristol Street INSURER D: Sebastian, FL 32958 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/ODNYYY) (MMfDDNYM LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE T-0-RrRTE9- ✓ COMMERCIAL GENERAL LIABILITY PREMISE Ea occurrence $50,000 �'7 ✓ CLAIMS-MADE EOCCUR MED EXP(Any one person) $5,000 A X PCA5025-PCCM241280 03/05/2018 03/05/2019 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 ✓ POLICY El PRO ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Es aoddent _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per acddent $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I % f OTH- AND EMPLOYERS'LIABILITY Y/N _LIMER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD