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2. Please be advised this form is for customer use only. Building Services will not track, monitor or receive a copy of this request. Enter a valid email below to receive a copy for your processing.
4. Permit #*
5. Date/Time
   Date/Time
7. Name*
9. I am licensed as a(n)*

   1. Contractor*
   2. Engineer

   1. Architect
   2. Building Inspector*
11. and did personally inspect the roof deck nailing and secondary water barrier work at
13. Physical address*
15. on or about*
    on or about
    Enter mm/dd/yyyy and time
17. Based upon that examination, I have determined the installation was done according to the Hurricane Mitigation Retrofit Manual (Based on 553.844 F.S.).
    
    Signature________________________________________ License#____________________________________
19. The forgoing authorization letter was acknowledged before me this ___________ day of ________, 20____by____________________________
    
    
    ___who is personally known to me
    ___who has produced identification_________________________________________
    
    
    Notary Public Signature:______________________________________
    
    My Commission Expires ______________________________________
21. *General, Building, Residential, or Roofing Contractor or any individual certified under 489 F .S. to make such an inspection.
23. Please be advised this form is for customer use only. Building Services will not track, monitor or receive a copy of this request. Enter a valid email below to receive a copy for your processing.
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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