Revised 10/2019 DJ
Building Construction Division
18400 Murdock Circle, Port Charlotte, FL 33948
Phone: 941.743.1201 Fax: 941.743.1213
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
For Office Use Only
Permit Number
Received Date: __________
Initials: _____________
MECHANICAL VENTILATION AFFIDAVIT
This form is required to be submitted if the ACH is less than 3.00 (FBC-R303.4 and FBC-1203.1)
Permit Number: ___________________________________
Address: __________________________________ _________________________ ________ ____________
Street City State Zip
Name of Qualifier: _____________________________________________________________________________
Mechanical/HVAC Contractor License/Certificate Number: __________________________________________________
Company Name: ___________________________________________________________________________________
Company Address: _____________________________ _________________________ _________ ____________
Street City State Zip
Phone: _________________________________________ Email: ___________________________________________
I certify that the structure located at the address listed above has been provided with the correct mechanical ventilation to
satisfy the requirements of Florida Building Code R-M1507.3 and FBC-M103.
Description of mechanical ventilation compliance method used: ___________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Qualifier's Signature:
__________________________________________________________ Date: _________________________
Qualifier’s Printed Name: ___________________________________________________________________________
This from may be emailed to PermitResubmittal@CharlotteCountyFl.gov or submitted at the Building
Construction Services office
