RF-12-21-3188 INSP AFFIDAVITMiami Shores Village - BUILDING DEPARTMENT
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10050 NE 2 Ave Miami Shores, FL 33138
Permit # P-4 C-2i —:3l V
305-795-2204 www.msvfl.goy
DATE: Z
INSPECTION AFFIDAVIT
(Print name and circle License Type)
License #: �-�—�— C3 3C)1 C�-t
licensed as a(n) Contractor / Engineer / Architect,
On or about 2 t 11 100 , I did personally inspect the roof deck nailing
(Date ime)
work at L 751 NE- �4
(Com lete Job Site Address)
Based upon that ex minatio ave de rmined the installation was done according to the
Hurricane Mitigati n Retr Manual (Ba ed on 553.844 F.S)
Signature
State of Florida, Miami Dade County:
The undersigned, being the first duly swo
the above property mentioned.
Sworn to and subscribed before me this
Notary Public, State of Florida at Large
deposes and says that he/she is the contractor for
day of
V�
,:o<►�+'+°t:� MARIA R. MEDINA
r • �� rs Notary Public - State of Florida
Commission # HH 013383
or+�� My Comm. Expires Jun 22, 2024
Bonded through National Notary Assn.
For Forms and Applications click here:
http://bldg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01142021 Inspection Affidavit Page 1 of 1