Uniform Mitigation Verification Inspection Form ( Oir-B1-1802 )

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Uniform Mitigation Verification Inspection Form
Maintain a copy of this form and any documentation provided with the insurance policy
Inspection Date:
Owner Information
Owner Name:
Contact Person:
Address:
Home Phone:
City:
Zip:
Work Phone:
County:
Cell Phone:
Insurance Company:
Policy #:
Year of Home:
# of Stories:
Email:
NOTE: Any documentation used in validating the compliance or existence of each construction or mitigation attribute must
accompany this form. At least one photograph must accompany this form to validate each attribute marked in questions 3
though 7. The insurer may ask additional questions regarding the mitigated feature(s) verified on this form.
1. Building Code: Was the structure built in compliance with the Florida Building Code (FBC 2001 or later) OR for homes located in
the HVHZ (Miami-Dade or Broward counties), South Florida Building Code (SFBC-94)?
A. Built in compliance with the FBC: Year Built _________. For homes built in 2002/2003 provide a permit application with
a date after 3/1/2002: Building Permit Application Date
____/____/________
(MM/DD/YYYY)
B. For the HVHZ Only: Built in compliance with the SFBC-94: Year Built ______. For homes built in 1994, 1995, and 1996
provide a permit application with a date after 9/1/1994: Building Permit Application Date
___/___/_______
(MM/DD/YYYY)
C. Unknown or does not meet the requirements of Answer “A” or “B”
2. Roof Covering: Select all roof covering types in use. Provide the permit application date OR FBC/MDC Product Approval number
OR Year of Original Installation/Replacement OR indicate that no information was available to verify compliance for each roof
covering identified.
No Information
Permit Application
FBC or MDC
Year of Original Installation or
Provided for
2.1 Roof Covering Type:
Date
Product Approval #
Replacement
Compliance
1. Asphalt/Fiberglass Shingle
____/____/_______
_________________________
___________________
2. Concrete/Clay Tile
____/____/_______
_________________________
___________________
3. Metal
____/____/_______
_________________________
___________________
4. Built Up
____/____/_______
_________________________
___________________
5. Membrane
____/____/_______
_________________________
___________________
6. Other______________________
____/____/_______
_________________________
___________________
A. All roof coverings listed above meet the FBC with a FBC or Miami-Dade Product Approval listing current at time of
installation OR have a roofing permit application date on or after 3/1/02 OR the roof is original and built in 2004 or later.
B. All roof coverings have a Miami-Dade Product Approval listing current at time of installation OR (for the HVHZ only) a
roofing permit application after 9/1/1994 and before 3/1/2002 OR the roof is original and built in 1997 or later.
C. One or more roof coverings do not meet the requirements of Answer “A” or “B”.
D. No roof coverings meet the requirements of Answer “A” or “B”.
3. Roof Deck Attachment: What is the weakest form of roof deck attachment?
A. Plywood/Oriented strand board (OSB) roof sheathing attached to the roof truss/rafter (spaced a maximum of 24” inches o.c.)
by staples or 6d nails spaced at 6” along the edge and 12” in the field. -OR- Batten decking supporting wood shakes or wood
shingles. -OR- Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that has an equivalent
mean uplift less than that required for Options B or C below.
B. Plywood/OSB roof sheathing with a minimum thickness of 7/16”inch attached to the roof truss/rafter (spaced a maximum of
24”inches o.c.) by 8d common nails spaced a maximum of 12” inches in the field.-OR- Any system of screws, nails, adhesives,
other deck fastening system or truss/rafter spacing that is shown to have an equivalent or greater resistance 8d nails spaced a
maximum of 12 inches in the field or has a mean uplift resistance of at least 103 psf.
C. Plywood/OSB roof sheathing with a minimum thickness of 7/16”inch attached to the roof truss/rafter (spaced a maximum of
24”inches o.c.) by 8d common nails spaced a maximum of 6” inches in the field. -OR- Dimensional lumber/Tongue & Groove
decking with a minimum of 2 nails per board (or 1 nail per board if each board is equal to or less than 6 inches in width). -OR-
Any system of screws, nails, adhesives, other deck fastening system or truss/rafter spacing that is shown to have an equivalent
Inspectors Initials _____ Property Address_____________________________________________________________
*This verification form is valid for up to five (5) years provided no material changes have been made to the structure.
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OIR-B1-1802 (Rev. 01/12) Adopted by Rule 69O-170.0155

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