Fillable Coronavirus Disease 2019 (COVID-19)

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Coronavirus Disease 2019 (COVID-19)

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The Coronavirus Disease 2019 (COVID-19) form is 1 page long and contains:

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  • 3 check-boxes
  • 14 other fields

Country of origin: OTHERS
File type: PDF

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REV 07/2/20 INSPECTIONS BY AFFIDAVIT FOR OCCUPIED SPACES | Planning & Development
COVID‐19TEMPORARYRELIEFMEASURE
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PROJECTINFORMATION
ProjectNumber:
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ScopeofWork:
VERIFICATION
IherebycertifythatIamaregisteredArchitectand/orEngineerandthatIpersonallyinspectedthepremisesat
the project address listed above on the date of this statement. In my professional opinion, based on my
knowledge,information,andbelief,Ihavedeterminedtheworkperformedmeetstheminimumrequirements
setforthintheFloridaBuildingCode.IalsounderstandthatIwillonlyusethisaffidavitduringtheCOVID‐19
Emergencyperiod.
IhaveuploadedtherequiredphotodocumentationtotheAccelarecord.
Date:
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LicenseNo.:
____________________________
___________________________________ ______________________________________
LicenseHolderName(Printed)

LicenseHolderName(Signature)
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DigitalSignature
NOTE:NotaryisrequirediftheVERIFICATIONisnotdigitallysigned.
STATEOFFLORIDA
COUNTYOF________________________________
Swornto(oraffirmed)andsubscribedbeforemebymeansof
physicalpresenceoronlinenotarization,this_______dayof
_________,__________,by_____________________________.
_____________________________________________________
SignatureofNotaryPublic–StateofFlorida
_____________________________________________________
Print,Type,orStampCommissionedNameofNotaryPublic
PersonallyKnownORProducedIdentification
TypeofIdentificationProduced:_______________________
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Coronavirus Disease 2019 (COVID-19)

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Completed 5 August 2020

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