RF-03-22-578 INSPECTION AFFIDAVITPermit # f= �3zz' 5
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.ciov
DATE: 0 6/ -0/ — zZ
INSPECTION AFFIDAVIT
1 licensed as a(n) Contractor / Engineer / Architect,
(Prin name and circle Lic nse Type)
License #: lo
On or about 3 3 2,oZ2 , 1 did personally inspect the roof deck nailing
(Date A time) n ,
work at 122)1
(Complete Jolt Site Address)
Based upon that examination I have determined the installation was done according to the
Hurricane Mitigation Retrofit Manual (Based on 553.844 F.S)
jl
Signature
State of Florida, Miami Dade County:
The undersigned, being the first duly sworn, deposes and says that he/she is the contractor for
the above property mentioned.
Sworn to and subscribed before me this 30
day of Z
Notary Public, State of Florida at Large
,�xr a
Notary
n
MY IM_V,;Sa
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arty
EXp. $-22I2G25
For Forms and Applications click here:
http://bldg.miamishoresvillage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01 142021 Inspection Affidavit Page 1 of 1