Permit Number:
Site Address:
1 of 1 Town of Fort Myers Beach May 26, 2020
2525 Estero Blvd. Fort Myers Beach, FL 33931
Phone : 239 765-0202 Permits @fmbgov.com Fax: 239 765-0909
ASBESTOS NOTIFICATION AFFIDAVIT
The National Emission Standards for Hazardous Air Pollutants (NESHAP) 40 CFR 61, Subpart M,
requires written notification 10 working days prior to a demolition and 10 working days prior to
any removal of regulated asbestos containing material (RACM). This rule also requires that any
asbestos survey be completed prior to any renovation or demolition to determine if asbestos
containing materials are present.
I, (applicant), understand the requirements stated above,
and I have completed these requirements prior to acceptance of this building permit. I further
understand that there are additional asbestos rules which may apply to me, and I have read and
understand these requirements.
Under penalties of perjury, I declare that I have read the foregoing ASBESTOS NOTIFICATION
AFFIDAVIT and that the facts stated in it are true.
I, _____ (Property Owner), hereby certify that
_______________________________________ is my authorized agent/representative of the property described
herein. All answers to the questions in this registration and any supplementary information attached to
and made part of this registration is honest and true.
Signature of Property Owner
Typed or printed name of Property Owner
STATE OF _____ _____ COUNTY OF ________________
The foregoing instrument was certified and subscribed before me
by means of __ physical presence
OR_online notarization,
this ______day of ___________________, 20___, by ______________________, ___ who is
personally known to me OR ___ who has produced ______________________ as identification.
(SEAL) Notary Public Signature
