00-0734-001 NOTICE OF NESH" REQUIREMENTS AND
4 AFFIDAVIT FOR ASBESTOS SURVEY
,;•.
1 Pry.eet e: Deritolition Renovation Roofin DERM Process Number_ _ .
J•. Yp .l I l
a City: / State rL Zip CodeJl County
3. Project Dates(mm/dd./yy):Start "` Finish (n dG7
4. Contractor 1 Z Ck]i t x_'%r–R_S 1 NC.• Florida License# C r7 L Ot
5. Give a brief Description of work to be done at the above mentioned address: (Include scope of work,and the estimated
area in squart feet that will be impacted by the project)
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1 e i-dersignedereby attest that`am awe of the following:
N
uant to 4 CFR 61, subpart M,section 145(a)and 469.001-015 Florida Statutes an asbestos survey at the above
referenced property may 1 i Tequired prior to any renovation or demolition activity.
2. Pursuant to 40CFR 61, subpart M, sectdn 145 (c)and 469.001-015 Florida Statutes, all regulated asbestos containing
F materials (RACM) must be removed prior to any renovation activity that may impact the RACM at the above
referenced property.
3. Pursuant to�40CFR 61 subpart M, section•145 (c) and 469.001-015 Florida Statutes, alt regulated asbestos containing
°tz materials(Ri GMI must be rerrtoved Poor to any demolition activity that iinpaets°the(R s4CM)at:
`the above re{prenced
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Px,rsttnlb 40�lwR:61 subprart M;secttonl45 (b}and 469 001-015 Flbrrda Statutes, a.wrltten'tiattfiCatt'on must be
sttbmttted
M at least'I0 workang days pririr_to demolition or asbestos abatement activity at t4ieboe referenced
,proper=ty
'y Additionally I am aware that violations of the above referenced regulations may result in civil or criminal prosecution or
both or penalties and fines of up to$25,000 per day per violation.
Name in Print her, e o ut ize epresentative /Title Business Name
- ele bane° tether . . . :.
1gn` (Owner, L ssee or u riz res n a 1 k� r
,( arked-Authori ion Letter is required) l 1
STATE OF FLORIDA ) —
COUNTY OF DADE )ss.: Permit Applicant, if ddiiffferent(Print Name and Signature)
The f rego' g instrument was acknowledged before me this stay of 2000 by
who has produced,as7identification an who did(did not)take an oath.
chary Pub ic, ate of lorida at Lar
-
} received.the�gned Asbestos afE t front
and offered hi1 /hert With,
a opy of tlt+e`above.erntioned applicable reultio `� <f!�
dam`'( a
w
Name of DERM'Personnel/Section Dated Signature-/
' 41S IS NOT A NESHAP NOTIFICATION
See Reverse Side for Additional Information