RF-01-23-5 Inspection Affidavit 83 NE 103 StMiami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.Qov
Permit # F- - 2 3 r 5
DATE: 2 11 o) 2"I'D
INSPECTION AFFIDAVIT
2. licensed as a(n) Contractor / Engineer / Architect,
(Print name and circle License Type)
License #: 6- C C- l-Jt) 2 S G 5(c, -
On or about 'L l o I did personally inspect the roof deck nailing
(Date & time) 1
work at AI E I D -):�' 5--�-�"T
(Complete Job Site Address)
Based upon that examination I have determined the installation was done according to the
Hurricane Mitigation Retrofit.M-a_nua.1Based on 553.844 F.S)
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 day of-C3�—
„
Notary Public, State of Florida at Large
t�qr ape. CHRISTAL SIERRA
Notary Publ+r - State of Florida
i p Commission p GG 319222
'�o1v4 My Comm. Expires Jul 18, 2023
Bonded through Nat lonaI Notary Assn.
For Forms and Applications click here:
http://bldg.miamishoresviIlage.com/WebLink/Browse.aspx?id=118080&dbid=0&repo=Mia
miShoresVillage
Rev01 142021 Inspection Affidavit Page 1 of 1