| Inspection Date: 07/10/2026 | ||
| Owner Information: | ||
| Owner Name: Sample Customer | Contact Person: Sample Customer | |
| Address: 123 Sample Street | Home Phone: +15555550100 | |
| City: Sample City | Zip: 00000 | Work Phone: ___________ |
| County: ___________ | Cell Phone: ___________ | |
| Insurance Company: ___________ | Policy #: ___________ | |
| Year of Home: 2005 | # of Stories: 1 | Email: sample.customer@example.com |
NOTE: Any documentation used in validating the compliance or existence of each construction or mitigation attribute must accompany this form. At least one photograph or document providing proof must accompany this form to validate each attribute marked in questions 2 through 9. A FORTIFIED Home® □ Roof, □ Silver, or □ Gold Certificate may be used to validate the attributes marked in questions 4 through 6, and questions 8 through 9 (check type of certificate and attach photocopy). The insurer may ask additional questions regarding the mitigated feature(s) verified on this form.
1. Building Code: What version of the Florida Building Code "FBC" (FBC 2001 & 2004 OR FBC 2007 or later) OR for homes located in the High-Velocity Hurricane Zone ("HVHZ") (Miami-Dade or Broward counties), South Florida Building Code (SFBC-94) was in force at the time of original permit application?
☑ A. Code in force at time of permit application was the FBC 2001 & 2004: Year Built 2005. For homes built in 2002/2003, provide a permit application with a date after 3/1/2002: Building Permit Application Date (MM/DD/YYYY) 03/04/2005.
☐ B. Code in force at time of permit application was the FBC 2007 and later: Year Built 2005. For homes built in 2007/2008, provide a permit application with a date after 12/8/2006: Building Permit Application Date (MM/DD/YYYY) 03/04/2005.
☐ C. For the HVHZ Only: Code in force at time of permit application was the SFBC-94: Year Built 2005. 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) 03/04/2005.
☐ D. Unknown or does not meet the requirements of Answer "A" or "B" or "C".
2. Region: Location based on design windspeed. See ASCE 7-22 (700-year MRI) Risk Category 2 (www.ascehazardtool.org).
☐ HVHZ
☐ Region 1 (≥ 140 mph)
☑ Region 2 (130 mph – 139 mph)
☐ Region 3 (< 130 mph)
3. Roof Slope: For single-family homes with multiple slopes, indicate the slope that is at least two thirds of the main roof area when determining greater than or equal to 6:12, OR less than 6:12.
☐ Greater than or equal to (≥ 6:12)
☑ Less than (< 6:12)
4. Roof Covering: Select all roof covering types in use. Provide the permit application date OR FBC/MDC Product Approval number AND Year of Original Installation/Replacement OR indicate that no information was available to verify compliance for each roof covering identified.
| 4.1 Roof Covering Type: | Permit Application Date | FBC or MDC Product Approval # | Year of Original Installation or Replacement | No Information Provided for Compliance |
|---|---|---|---|---|
| ☑ Asphalt/Fiberglass Shingle | 10/14/2025 | 2025100669 | 2025 | ☐ |
| ☐ Concrete/Clay Tile | ____/____/______ | ________________ | ________________ | ☐ |
| ☐ Synthetic/Composite Tile | ____/____/______ | ________________ | ________________ | ☐ |
| ☐ Metal | ____/____/______ | ________________ | ________________ | ☐ |
| ☐ Built Up | ____/____/______ | ________________ | ________________ | ☐ |
| ☐ Membrane | ____/____/______ | ________________ | ________________ | ☐ |
| ☐ Other | ____/____/______ | ________________ | ________________ | ☐ |
