RF-09-22-2254 Inspection Affidavit 174 NW 100 TerrPermit # R!iF---' of 22-
Miami Shores Village - BUILDING DEPARTMENT
10050 NE 2 Ave Miami Shores, FL 33138
305-795-2204 www.msvfl.gov
DATE: t •&-3
INSPECTION AFFIDAVIT
I _L,�yCi Cti '171C `r� licensed as a(n) C ntractorj/ Engineer / Architect,
(Print name and circle License Type) \ /
License #: Ukl ! J 5, I
On or about (�2r=� I did personally inspect the roof deck nailing
(Date & time)
work at \10 I OD C-e r( N ICti ), :FL --
(Complete Job Site Address)
Based upon that examination I have determined the installation was done according to the
Hurricane Mitigatio Rt,- *1t Manual (Based 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 �S day of Tr-6 z
Notary Public, State of Florida at Large
SKARLETH GABRIELA DIAZ
rr„=, Notary Public - State of Florida
Commission # HH 145897
My Comm. Expires Jun 27, 2025
Bonded through National 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