Town of Fort Myers Beach 2525 Estero Blvd. Fort Myers Beach, FL 33931
Phone # (239) 765 -0202 Permits@fmbgov.com Fax # (239) 765-0909
Page 1 of 1 7/9/2020
ROOF INSPECTION AFFIDAVIT
This form may be completed by an Engineer / Architect, CGC, CBC, CRC, CCC, Building
Inspector (licensed under FSS 468) or Owner/Builder.
RE: Permit # ________ Date:
I , License #
(Please print name) (Put N/A if Owner/Builder)
hereby certify that based on my examination on _______________________________, the roof deck nailing and
(Date and time)
secondary water barrier for the work located at:
(Job Site Address)
was installed according to the Hurricane Mitigation Retrofit Manual (Based on 553.844 F.S.)
Under penalties of perjury, I declare that I have read the foregoing Inspection Affidavit and that the facts stated in it
are true.
___________ __________________________________
Signature Date
This form must be received by the Town of Fort Myers Beach Building Department prior to requesting the 503 Final
Roof Inspection.
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
