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DEMO-18-1504
it jiii 0,-- re, /Apt._ Sdijvc, , #/'b/1 1r 9 7(1-dr Pe“-o- 1'44 — isvo-s) ma- - vd--) • STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL APPLICANT: Miami Shores Village APPLICATION # : A P 1348996 PERMIT # :13-SM-1853804 DOCUMENT #:FI1198444 DATE PAID:06/11/2018 FEE PAID:100.00 RECEIPT #:13-PID-3586302 AGENT: E17 Holdings Inc PROPERTY ADDRESS: 9301 NE 2 Ave Miami, FL 33138 LOT: 10-11 SUBDIVISION: Miami Shores Sec 1 Amd BLOCK: 27 ID#: 11-3206-013-3650 CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION [01] [02] [03] [04] [05] [06] [07] [08] [09] TANK SIZE [1] TANK MATERIAL OUTLET DEVICE MULTI -CHAMBERED [ Y / N ] OUTLET FILTER [2] LEGEND 1. 2. WATERTIGHT LEVEL DEPTH TO LID DRAINFIELD INSTALLATION [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] AREA [1] DISTRIBUTION BOX NUMBER OF DRAINLINES DRAINLINE SEPARATION DRAINLINE SLOPE DEPTH OF COVER ELEVATION [ ABOVE / BELOW SYSTEM LOCATION DOSING PUMPS [2] SQFT HEADER 1. 2. ]BM AGGREGATE SIZE AGGREGATE EXCESSIVE FINES AGGREGATE DEPTH FILL / EXCAVATION MATERIAL [22] [23] [24] [25] [26] Comments: FILL AMOUNT FILL TEXTURE EXCAVATION DEPTH AREA REPLACED REPLACEMENT MATERIAL SETBACKS [27] [28] [29] [30] [31] [32] [33] [34] [35] SURFACE WATER DITCHES PRIVATE WELLS PUBLIC WELLS IRRIGATION WELLS POTABLE WATER BUILDING FOUNDATIONS PROPERTY LINES OTHER FILLED / MOUND SYSTEM [36] [37] [38] [39] DRAINFIELD COVER SHOULDERS SLOPES STABILIZATION ADDITIONAL INFORMATION [40] UNOBSTRUCTED AREA [41] STORMWATER RUNOFF [42] ALARMS [43] MAINTENANCE AGREEMENT [44] BUILDING AREA [45] LOCATION CONFORMS WITH SITE PLAN [46] FINAL SITE GRADING [47] CONTRACTOR [48] OTHER FT FT FT FT FT FT FT FT FT ABANDONMENT [ 4 9 ] TANK PUMPED 06/29/2018 [50] TANK CRUSHED & FILLED 07/24/2018 CONSTRUCTION [ FINAL SYSTEM [ APPROVED APPROVED / Dade CHD DISAPPROVED ] - Environmental Specialist II Erick Perera (Florida Department of Health / DISAPPROVED ]: (Explanation of Violations on following page) DATE : 07/25/2018 Dade CHD DATE: 07/25/2018 Environmental Specialist II Erick Perera (Florida Department of Health DH 4016, 08/09 (Obsoletes all previous editions which Incorporated: 64E-6.003, FAC EH Database v 1,0.1 may not be used) AP1348996 E1D1853804 Page 2 of 3 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL APPLICATION # : A P 1348996 PERMIT #:13-SM-1853804 DOCUMENT #: FI1198444 DATE PAID:06/11/2018 FEE PAID:100.00 RECEIPT #:13-PID-3586302 Violation Number Comment DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC EH Database v 1.0.1 A P1348995 F.101853804 Page 2 of 3 Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. DEMO-6-1 8-1504 Permit Type: Demolition Work Classification: Building Permit Status: APPROVED Issue Date: 6/7/2018 Expiration: 12/04/2018 Parcel Number Applicant 9301 NE 2 Avenue Miami Shores, FL 33138- 1132060133650 Block: Lot: MIAMI SHORES VILLAGE Owner Information Address Phone Cell MIAMI SHORES VILLAGE 10050 NE 2 Avenue MIAMI SHORES FL 33138-2304 305/751-1271 Contractor(s) G 7 HOLDING INC Phone (305)673-2847 Cell Phone Valuation: $ 6,000.00 Total Sq Feet: 3337 Type of Demo: Building Additional Info: TOTAL DEMOLITION OF SINGLE FAMILY H Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $3.60 $8.25 $5.50 $1.20 $5.00 $550.00 $9.00 $4.80 $587.35 Pay Date Pay Type Amt Paid Amt Due Invoice # DEMO-6-18-67773 06/07/2018 Money Order $ 587.35 $ 0.00 Available Inspections: Inspection Type: Final Review Building Review Building i In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an zoning. Fut ermo .I authorize the above -named contractor to do the work stated. June 07, 2018 Authorize 7-Sri§nature: Owner / Applicant / Contractor / Agent Date Building Department Copy June 07, 2018 1 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC PLUMBING ❑ MECHANICAL JOB ADDRESS: '"I 3 V I it) E City: Miami Shores Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 RECEIVED JUN011018 FBC 20n� Master Permit No.E -11 i% — (SOLA Sub Permit No. ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR 22(`' ifVLAue.._ County: Miami Dade DRAWINGS Zip: 3313E Folio/Parcel#: 1\ - 3Z0(9 ' 0\3 - 3(050 Is the Building Historically Designated: Yes NO ' Occupancy Type: Load: Construction Type:1"Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Aam, s v1 Ot - S \A al L Phone#: 36s_ 5 ZZOLI Address: 10 0 5,0 )J E V d HIV 4- • City: 1 1 l IG1. M 1;', " iz 0(.Q. S State: Cc_ Zip: 33134 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: el 4 Ao\c i Address: 'CS(90() .'U \/) 3 (cP" City: 10\ MI State: ��- Qualifier Name: G'1Y2) sv1S State Certification or Registration #: C C. 151 ck552_ Phone#: 305 . (0I}3 • Z.` 1-11 Phone#: Zip: 331y1- Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: l� Address: 97�C)S City: State: Zip: Value of Work for this Permit: $ -6, $e0.017 Square/Linear Footage of Work: 13% 1• Type of Work: ❑ Addition I 1 Alteration ❑ New ❑ Repair/Replace Description of Work: 1 di ct,I (it (no i, oP 6; n 11-(2_ Gcm ; � 1 1�vu s� Demolition Specify color ofcolor thru the rr Submittal Fee $.... Permit Fee $ 050 oe CCF $ 3 • .O Scanning Fee $ Radon Fee $ S . SO Technology Fee $ . $ 0 Training/Education Fee $ Structural Reviews $ DBPR$ S'ZS CO/CC $ Notary $ S Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) • Bonding Company's Name (if applicable) Bonding Company's Address i City "N "% State Zip +''f MortgageLender's Name (if applicable) Mortgage Lender's Address • • State Zip Application Is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of, a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2505, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person • whose property is subject•to attachment. Also, a certified copy of the recorded notice of commencement um st be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. / r Signature OWNER or AGENT Signature CONTRACTOR Theheforegoingrinstrument was acknowledged before me this The foregoing instrument was acknowledged before me this Lit day of , 20 _ _, by 16' " day of Yrj C1 / , 20 14 by 'OM QjeY1t Ciabo is personally known to aril DGv;S , who is personally known to me orwho has produced as • - me or who,has produced as identification and who did take an oath. .t:widentificationVand who did take an oath. ,\ .(. • NOTARY PUBLIC: Sign: Print: Seal: �. MY COMMISSION # GG 04460 :1 EXPIRES: November 2, 2020 F: r`cP; Bonded Tin Notary Public Underwriters ************************* * ****** APPROVED BY .� sr 1/4 NOTARY PUBLIC: Sign: Print: t Seal: ,• = :3a. I 2 Crlsta Stefanfck Commission ig GG167243 Expires: February 13, 2022 Bonded thru Aaron Notary , t ' Plans Examiner Zoning J r Structural Review Clerk (Revised02/24/2014) $ 24/201 Miami -Dade Official Records - Print Document Prepared by and return to: ODELIA GOLDBERG The Law Offices of Odelia Goldberg 33 N.E. 2nd Street, Suite 100 Fort Lauderdale, FL 33301 954-832-0885 File Number: Farrow 111111111111111111111111111111111111111111111 CFN 2017R0329240 OR BK 30568 P,s 4766-4767 (2Pss) RECORDED 06/09/2017 15:58:10 DEED DOC TAX $2,670.00 HARVEY RUVINr CLERK OF COURT MIAMI-DADE COUNTY, FLORIDA [Space Above This Line For Recording Data] Warranty Deed This Warranty Deed made this ° day of June, 2017 between Lori M. Sullivan, a single woman and Kathryn A. Welch, a single woman whose post office address is 9301 NE 2nd Avenue, Miami Shores, FL 33138, grantor, and Miami Shores Village, a Florida Municipal Corporation whose post office address is 10050 NE Second Avenue, Miami Shores, FL 33138, grantee: (Whenever used herein the terms "grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: Lots 10 and 11, in Block 27, of an Amended Plat of MIAMI SHORES, SECTION NO. 1, according to the Plat thereof, recorded in Plat Book 10, at Page 70, of the Public Records of Dade County, Florida. Parcel Identification Number: 11-3206-013-3650 Grantee herein is prohibited from conveying captioned property for any sales price for a period of 30 days from the date of this deed. After this 30 day period, Grantee is further prohibited from conveying the property for a sales price greater than 120% of the short sale price until 90 days from the date of this deed. These restrictions shall run with the land and are not personal to the Grantee. Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever, and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2016. DoubleTimeo Book30568/Page4766 CFN#20170329240 Page 1 of 2 https://www2.miami-dadeclerk.con/officialrecords/PrintDocument.aspx?QS=YaoUfOzxry3u%2buOCXc%2fzkno0Ubg019%2bP53ix7CSbkB2ga13QCn... 1/2 r 1 5/24/2018 Miami -Dade Official Records - Print Document OR BK 30568 PG 4767 LAST PAGE In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. Signed, sealed and delivered in our presence: Witness Name: Mewling Diaz -Clark State of Florida County of Miami -Dade ri Sullivan Kathryn Y elch The foregoing instrument was acknowledged before me this day of June, 2017 by Lori M. Sullivan and Kathryn A. Welch, who u are personally known or [X] have produced a driver's license as identification. [Notary Seal] Warranty Deed - Page 2 //2}1,11dege-- NotaryPublic Mayling Diaz -Clark Printed Name: My Commission Expires: -7///zd /Y DoubioTime. Book30568/Page4767 CFN#20170329240 Page 2 of 2 https://www2.miami-dadeclerk.com/officialrecords/PrintDocument.aspx?QS=YaoUfOzxry3u%2buOCXc%2fzkno0Ubg019%2bP53ix7CSbkB2ga 13QCn... 2/2 10050 N.E. SECOND AVENUE MIAMI SHORES, FLORIDA 33138-2382 TELEPHONE: (305) 795-2207 FAX: (305) 756-8972 May 24, 2018 Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 Attn: Ismael Naranjo, Building Official RE: Authorization for Demolition Dear Mr. Naranjo, MacAdam Glinn MAYOR Sean Brady VICE MAYOR Jonathan Meltz COUNCILMAN Alice Burch COUNCILWOMAN Steven Zelkowitz COUNCILMAN Tom Benton VILLAGE MANAGER Richard Sarafan VILLAGE ATTORNEY Please let this letter serve as authorization from Miami Shores Village to allow G7 Holdings to demolish the house located at 9301 NE 2nd Avenue, Miami Shores, FL 33138. The folio number for this property is 11-3206-013-6350. Should you require any additional information to process the required demolition permits, please contact me directly. BY: Signature Tom Benton, Village Manager Name and Title, Typed or Printed Mailing Address: 10050 NE 2nd Avenue Miami Shores, FL 33138 Phone Number: 305-762-4851 MAHARAI K. GONZALEZ MY COMMISSION # GG 044602 EXPIRES: November 2, 2020 Bonded Thru Notary Public Underwriters Sworn to and subscribed befo e me E., this day of 20 i otary Public Signature STATE OF Cl oy \ do VIG1100Y%1 f�0 �t-3 Printed, typed or stamped name of notary public My Commission Expires1\\0'\ ? ?.O ZD 'H'EO PE®PL—ES CAS AN EMERA COMPANY G7 Holdings , Inc 1602 Alton Rd #602 Miami Beach, Fl. 33139 Proposed Demo: 9301 NE 2nd Ave May 01, 2018 After a review of our facilities within the above referenced area, we would like to inform you that TECO Peoples Gas does not presently have any, natural gas service line at said property. However, you must contact the Sunshine State One Call of Florida at 1-800-432-4770 or 811 at least 48 hours in advance, as there might be other underground utilities. By contacting SSOCOF, the risk of personal injury and property damage can be reduced. You can get the latest information on SSOCOF by visiting their web site at www.callsunshine.com Should you have any additional questions concerning the above, please contact me at 1-877-TECO PGS, extension 77247 Sincerely, Noelyn Charles done for Mr. Jesus Vega Local Dade & Broward Division Manager N Miami Division JV/grg Prepared by: Noelyn Charles PEOPLES GAS 305-957-3857 15779 W Dixie Hwy. FAX 305-957-3804 NORTH MIAMI BEACH, FL 33162 HTTP://WVWV.TECOENERGY.COM AN EQUAL OPPORTUNITY COMPANY 0 FPL May 25, 2018 To Whom It May Concern Re: 9301 NE 2ND AVE Effective 05/14/18, FPL has removed the meter and disconnected the FPL service wire to the above referenced address. However, before demolishing the structure, you should have the premises checked by a qualified individual to assure that electricity is not being supplied to the structure from any possible source. If there are any questions, or if I may be of further assistance in this matter, please contact me at the telephone number below. Sincerely, Jaimmy Cervantes Associate Engineer 305-770-5382 An FPL Group Company Ship Shape Pest Control 4624 N Powerline Rd Deerfield Beach, Fl 33073 Phone: (954) 429-9906 Toll Free Number: (800) 543-1319 www.pestdepot.com April 30, 2018 To whom this may concern; This letter is regarding the property located: 9301 NE 2nd Avenue, Miami Shores, FL. 33138 This property was inspected for an infestation of rodents and found to be free and clear of any rodent activity. if you have any questions or concerns please feel free to contact us at the numbers above. Ala Kravitsky Ship Shape Pest Control G7 Holdings, Inc. Garbage • Recycling ♦ Demolition May 14, 2018 Miami Shores Village Building Department 10050 N.E. 2nd Avenue Miami Shores, FL 33138 Re: 9301 NE 2nd Avenue — Demolition To whom it may concern, CGC1519552 This will serve as Official Notice that G7 Holdings, Inc. has worked with Miami Dade Water & Sewer Department, Florida Department of Health and a licensed plumbing company to prepare the above referenced site for Total Demolition. We will be submitting a cut and cap permit with the Village of Miami Shores to disconnect the water service to the premises but have left the meter in place to provide access to water during demolition for dust control. We will also be filing a pump and abandon permit with the Florida Department of Health. Thank you for your assistance and please contact me should you have any questions. Sincerel ,1 G7 Hol•ings, Inc. Greg Davis, GM STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoing�instrument was acknowledged before me, P7 this day pf /i/ 2018, by (Signature of Notary Publi 4,; 1117, ofe Debra Snyder 14, = COMMISSION OF916751 %444,� : E RES: September 9, 2019 yhrJW.AARONNOTARY.COM 1602 Alton Road #602 www.Garbageman.com Miami Beach, FL 33139 G7 Holdings, Inc. Garbage • Recycling • Demolition May 29, 2018 Miami Shores Village Building Department 10050 N.E. 2nd Avenue Miami Shores, FL 33138 Re: 9301 NE 2nd Avenue — Demolition To whom it may concern, CGC1519552 Our firm has been contracted to demolish the subject single family house. The scheduled start date for the demolition is June 10, 2018 Thank you for your assistance and please contact me should you have any questions. Since G7'FFofdings, Inc. Greg Davis, GM STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoing instrument was acknowledged before me, this day MA7 2018, by (Signature of Notary Public) 1, mum Debra Snyder 16751 EXPIRES COMMISSION 99, 2019 YyyyW,AAMONNOTARY.GOM 1602 Alton Road #602 www.Garbageman.com Miami Beach, FL 33139 Property Search Application - Miami -Dade County Page 1 of 3 IMPORTANT MESSAGE SEARCH: When buying real estate property, you should not assume that prope assessed value of the property may reset to full market value approximate your new property taxes. The Property Appraiser does not se• information. Address 0 er ' S bdiivi 9301 NE 2nd Ave. PROPERTY INFORMATION Folio: 11-3206-013-3650 Sub -Division: MIAMI SHORES SEC 1 AMD Property Address 9301 NE 2 AVE Miami Shores, FL 33138-2806 Owner MIAMI SHORES VILLAGE Mailing Address 10050 NE SECOND AVE MIAMI SHORES, FL 33138 PA Primary Zone 0900 SGL FAMILY - 1901-2100 SQ Primary Land Use 8940 MUNICIPAL : MUNICIPAL Beds / Baths / Half Floors Living Units Actual Area Adjusted Area Lot Size Year Built Featured Online Tools Comparable Sales Tax Comparison 2/1/0 3,397 Sq.Ft 3,266 Sq.Ft 14,040 Sq.Ft 1941 Glossary Tax Estimator ASSESSMENT INFORMATION 0 set or ame Foli Non -Ad Valorem Assessments TRIM Notice 2018IMPORTANT NOTICE: The assessment and exemption values currently shown are preliminary and are subject to change until they are certified on July 1. Year Land Value 2018 2017 es w es II rerpain t could result in Suite 2016 $378,711 $378,711 $315,756 sit • e enever there rty t. es. Plea ,,ma�yy �olleptdrs _ 1 Back to Search Results own- ship, the e our Tax Estim..r to irec ' for additional 0 PeR7a Z/77-6J • • • •••••• • • • • ••• • • PA Additional Online Tools Property Record Cards Property Search Help Property Taxes Report Discrepancies Report Homestead Fraud Value Adjustment Board BENEFITS INFORMATION 0 Benefit Non -Homestead Cap Municipal Type Assessment Reduction Exemption 2018 2017 2016 $608,245 $344,936 $29,439 https://www.miamidade.gov/propertysearch/ 6/6/2018 JUN 0 6 2016th 1�--1 sZ‘( Florida Department of Environmental Protection Division of Air Resource Management NOTICE OF DEMOLITION OR ASBESTOS RENOVATION TYPE OF NOTICE (CHECK ONE ONLY) : EX ORIGINAL TYPE OF PROJECT (CHECK ONE ONLY) : D. DEMOLITION IF DEMOUTION, IS IT AN ORDERED DEMOLITION? IF RENOV ATION: IS IT AN EMERGENCY RENO VATION OPERATION? 15 IT A PLANNED RENO VATION OPERATION? i. Facility Name Miami Shores Village ❑ REVISED ❑ RENOVATION 0 YES ❑ YES ❑YES Address 9301 NE 2nd Avenue City Miami Shores State FL Zip Department of Regulatory and Economic Resources Environmental Resources Management 701 NW 1st Court, 2nd Floor 33136-3912 5-372-6954 midade.gov ❑ CANCELII ?ION ❑ ROOFING Di NO ❑ COURTES ❑ NO File # .r, ❑ NO Process# 33138 County Dade Site Consultant Inspecting Site Building Size 3,337 (Square Feet) # of Floors 1 Building Age in Years 77 Prior Use: ❑School/College/University ®Residence DSmallBusiness Other Present Use: ❑School/College/University ❑Residence ❑ Small Business Other vacant II. Facility Owner Miami Shores Village Phone Address 10050 NE 2nd Avenue City Miami Shores III. Contractor' s Name G7 Holdings, Inc. Address 8600 NW 36th Avenue City Miami State FL Zip 33138 State FL Zip 33147 Phone El NO 305.710.2359 • •••• • •••• • Demo/Renovation (mm/dd/yy) Stun. /18 Fini>;h* Q/3t)/18 V. Description of planned demolition or reno vation work to be performed and methods to be employed, including demolltioon cjr mvation ttc,bstiquei to be used and description of affected facility components. Total demolition • Is the contractor exempt from llcensure under section 469.002(4), F .5.? ❑ YES IV. Scheduled Dates: (Notice must be postmarked 10 working da ys before the project start date) Asbestos Removal (mm/dd/yy) Start: Finish: IX. Procedures to be Used (Check All That Apply): www ••• • • • •••• • • •••• Strip and Removal Glove Bag p Bulldozer ❑ , Ineililtlg Bali • • • • 0Wet Method H Dry Method ❑ Explode ❑ • �tRr l wn • . • • • OTHER: •••••• . •—• • Procedur es for Unexpected RACM: Stop work, isolate, notify DERM • •••••• Asbestos W asteTransporter: Name Phone Address • • • •• • we • • • • •• • City State Zip Waste Disposal Site: Name Sun Recyling Address 3251 SW26thTerrace f ij'4.•11+;F+s }E f ; l 1' `,, City Dania Beach State FL Zip 33312 c) (I,,t I VY 1\'I A ;Eli i '31 V;' 1 RACM or ACM: `Procedure, including analytical methods, employed to detect the presence of RACM and Category t And 11 nonfriable ACM. Amount of RACM or ACM* square feet surfacing material linear feet pipe cubic feet of RACM off facility components *Identify and describe surfacing material and other materials as applicable: 212 square feet cementitious mat ia(1i31 square feet resilient flooring square feet asphalN'T0f19,t I certify that the above Information Is correct and that an Individual trained In the provisions of this regulation (40 CFR Part 61, Subpart M) will be on - site during the demolition or renovation and evidence that the required training has been accomplished by this person will be available for inspection during normal business hours. I have read and understood the additional information provided on the back of this form. David Ettman (Print Name of Owner/Operator) D [ -Ft:m.4g, 5-30-18 305.710.2359 (Signature of Owner/Operator) (Date) (Contact phone #) RER USE ONLY Postmark/Date Received ID # 161 ©1.158 10/10 DISTRIBUTION: White-RER Yellow -Applicant Pink -Reserve Gold -Reserve s• • • • • •••+ • • • • • • • • 00000 000000 •• • 000000 • • •••••• • • PROJECT: 16767 PRE -DEMOLITION ASBESTOS -CONTAINING BUILDING MATERIALS SURVEY KAM SHORES VILA APPROVED ZONING ELECTRICAL MtCHANICAL BLDG. BY • PROJECT LOCATION: Former Sir gle-Family Residence & Doctor's Office ..• 9301 NE 2nd Avenue Miami Shores, FL 33138 • • EPORT DATE: May 7.2018 • • • • • • • RECEIVED JUN 0 1 2018 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • REPORit PREPARED AND CERTIFIED BY: • ....• SUBJECT TO COMPLIANCE Wail ALL PEDML STATE ANb COUNTY IbiLES At') R1JLflONSI AHERA inspector: TCG MIRA CONSIlans GROUP • Tierra Consulting Group J815 N. Andrews Way. Suite B Fort Lauderdale. Florida 33309 (954) 202-9226 Reviewed by: • • • • • • • • • • • • • • • • • • • • • • • • • • • IS • • • • • • • • • • • • • • • • • • • Jes les Scott Zednek. P.G. AHERA Inspector Florida Licensed Asbestos Consultant. AX-79 Date Date TABLE OF CONTENTS EXECUTIVE SUMMARY SURVEY RESULTS 1 MATERIAL ASSESSMENT & RECOMMENDATIONS 3 LIMITATIONS 3 APPENDICES Appendix A — Sample Locations and Photographs Appendix B — Laboratory Report and Chain of Custody Documentation Appendix C — Certifications • • •••• • • • • •• • •••• • • • • • •• • • • • • •••• •••• • • •••• •••• • • • • •• •• • • • • • • • • • • •• •• • • • •• • . • • • • • • • • • • Project # 16767/ G7 Holdings Inc. EXECUTIVE SUMMARY Tierra Consulting Group (TCG) was contracted to perform an asbestos -containing materials (ACM) survey for the following location using the protocol established in US EPA 40 CFR 763 Subpart E, AHERA (Asbestos Hazard Emergency Response Act): Former Single -Family Residence & Doctor's Office 9301 NE 2nd Avenue Miami Shores, FL 33138 The purpose of this inspection is to determine if asbestos -containing materials are present in the subject building per the requirements set forth in 40 CFR 61 U.S. EPA NESHAP (National Emission Standards for Hazardous Air Pollutants) for materials to be impacted during demolition. The following materials were identified as asbestos -containing material: • Laundry Room Linoleum Flooring & Black Mastic • Grey Vinyl Floor Tiles and Black Mastic SURVEY RESULTS Suspect materials were identified and sampled per 40 CFR 763 Subpart E (Asbestos Hazard Emergency Response Act), on May 2, 2018. Twenty -Five (25) samples of suspect material were collected by AHERA inspector Jesse Beckles. Diagrams depicting sample jocation5 • apd photographs of tested materials are included in Appendix A. Samples w&r.'an'alyzed.tesioie Polarized Light Microscopy per 40 CFR 763 Subpart E by EMLab P&K (l+vrt;l•audercialt), National Voluntary Laboratory Accreditation Program (NVLAP) accredited •1'ah ratory. The analytical results are provided in Appendix B of this report. Please refer to the<oitowing tabl D for a summary of results and additional information: . • .• •• Sample # Material Description Material Location Approximate Quantity NESHAP Category Materia4.'•Asbestos• Condition • Cont3p4., 052-1-1 Brown Vinyl Cove Base Doctor'sOffice Wall Base N/A N/A • • N/A..• I -. • Nona. . Detected. • 052-1-2 Brown Vinyl Cove Base Doctor's Office Wall Base N/A N/A N/A None Detected 052-1-3 Brown Vinyl Cove Base Doctor's Office Wall Base N/A N/A N/A None Detected 052-2-1 Exterior Stucco Exterior Walls N/A N/A N/A None Detected 052-2-2 Exterior Stucco Exterior Walls N/A N/A N/A None Detected 052-2-3 Exterior Stucco Exterior Walls N/A N/A N/A None Detected • Project # 16767/ G7 Holdings Inc. 052-3-1 Grey Vinyl Floor Tile &Black Mastic Library Floor 88 SF CAT I Good ° 3 /° Chrysotile 052-3-2 Grey Vinyl Floor Tile & Black Mastic Libra ry Floor N/A N/A N/A None Detected 052-4-1 Black Vinyl Cove Base Library Walls N/A N/A N/A None Detected 052-5-1 Kitchen Linoleum Flooring Kitchen N/A N/A N/A None Detected 052-5-2 Kitchen Linoleum Flooring Kitchen N/A N/A N/A None Detected 052-6-1 Ceramic Tile & Grout Bathroom N/A N/A N/A None Detected 052-7-1 Laundry Room Linoleum Flooring & Black Mastic Laundry Room Floor 124 SF CAT I Good 20% & 3% Chrysotile 052-8-1 Green Terrazzo Floor Front Steps N/A N/A N/A None Detected 052-9-1 Drywall & Joint Compound Walls Throughout N/A N/A N/A None Detected 052-9-2 Drywall & Joint Compound Walls Throughout N/A N/A N/A . . Non.e... Detected • i 052-9-3 Drywall & Joint Compound Walls Throughout N/A N/A • N/A• • • _ • • None. • • • Detected 052-9-4 Drywall & Joint Compound Walls Throughout N/A N/A N/A.. • • • None ' •• • Detected. 052-9-5 Drywall & Joint Compound Walls Throughout N/A N/A N/A• • •. • • • • None" e• • • Detertttl• • • None . : Detected • 052-9-6 Drywall & Joint Compound Walls Throughout N/A N/A .. • N/A• • •' . 052-9-7 Drywall & Joint Compound Walls Throughout N/A N/A N/1 .' • • . Nolte • Deteittd. • None' ' Detected 052-9-8 Drywall & Joint Compound Walls Throughout N/A N/A N/A 052-9-9 Drywall & Joint Compound Walls Throughout N/A N/A N/A None Detected 052-10-1 Red Exterior Tile & White Grout Doctor's Office Entrance N/A N/A N/A None Detected 052-1 1-1 White Concrete Roof Tile Roof N/A N/A N/A None Detected 2 Project # 16767/ G7 Holdings Inc. MATERIAL ASSESSMENT & RECOMMENDATIONS, Twobuilding materials were confirmed as ACM within the subject building as follows: • Laundry Room Linoleum Flooring & Black Mastic —124 square feet • Grey Vinyl Floor Tiles and Black Mastic — 88 square feet The materials were observed in good condition and classified as non -friable Category I ACM. In their present condition, the materials do not pose a significant health risk. A demolition contractor must abide by OSHA regulations pertaining to asbestos exposure. The contractor and owner are advised to abide by all notification requirements (10 business work -day notification) set forth in 40 CFR 61 U.S. EPA NESHAP (National Emission Standards for Hazardous Air Pollutants) regarding planned demolitions and methods proposed to control dust emissions. The owner/operator of the facility is responsible to submit notification. LIMITATIONS This survey was based on the inspection of the one story former residential structure only and does not include samples of any other structures on or within the subject property. This report is limited to: Former Single -Family Residence & Doctor's Office 9301 NE 2nd Avenue Miami Shores, FL 33138 ...• •• • . •.•• • • • .• • •••• • • •• • • .. • • The results, conclusions, and recommendations in this report pertain to conditibMdbserved at'the time of inspection. Any suspect materials encountered which are not included o'r addressed ►ri ti is report must be sampled or otherwise assumed to be ACM. . ' ' ••• •• TCG conducted and prepared this survey in accordance with industry standards :Ak ther warranty expressed or implied is made. • •• • •• • •• • • •• • • • • • • • • � • • • 3 APPENDIX A Sample Location Diagram and Photographs . • • • • • • • • •. ..• .... • • • .. • • .. • • • • •••• • • • . .• .... .... .. • • •• •• • • •. • • • . • •. ..• • • • • ••• . • • .. NOTE: DRAWING NOT TO SCALE. Laundry Room Linoleum Floor & Black Mastic 052-7-1 20% & 3% Chrysotile Exterior Stucco 052-2-3 No Asbestos Detected Drywall & Joint Compound 052-9-4 No Asbestos Detected Drywall & Joint Compound 052-9-5 No Asbestos Detected Kitchen Linoleum Floor 052-5-1 No Asbestos Detected Kitchen Linoleum Floor 052-5-2 No Asbestos Detected Exterior Stucco 052-2-2 No Asbestos Detected Green Terrazzo Floor 052-8-1 No Asbestos Detected Ceramic Tile & Grout 052-6-1 No Asbestos Detected Drywall & Joint Compound 052-9-3 No Asbestos Detected Drywall & Joint Compound 052-9-1 No Asbestos Detected Black Vinyl Cove Base 052-4-1 No Asbestos Detected Grey Vinyl Floor Tile Drywall & Joint Compound • • • G52,3-2. • • • • 052-9-6 Clo Asbestos• detected : :I• No Asbestos Detected • •• • • • • •• • • •Ga Viny; Froor Tile & Black Mastic 052-3-1 3% Chrysotile Drywall & Joint Compound 052-9-2 No Asbestos Detected Brown Vinyl Cove Base 052-1-1 No Asbestos Detected Brown Vinyl Cove Base 052-1-3 No Asbestos Detected Drywall & Joint Compound 052-9-8 No Asbestos Detected Drywall & Joint Compound 052-9-7 No Asbestos Detected White Concrete Roof Tile 052-11-1 No Asbestos Detected Red Exterior Tile & White Grout 052-10-1 No Asbestos Detected Drywall & Joint Compound 052-9-9 No Asbestos Detected Brown Vinyl Cove Base 052-1-2 No Asbestos Detected Exterior Stucco 052-2-1 No Asbestos Detected •• • • • • •••• PROJECT: Residence & D. Office ?or Demslition�9301�1E2nd Ave, Miami Shores • • •• •• • • • • • • • • • •• • CLIENT: G7 Holdings Inc. . TCG TIERM CO•S0t1111G GROUP --------" •$TEGRrTY EXCELLENCE, CONIAITI+ENT SAMPLE LOCATION DIAGRAM ••• • • • • ••• • • DATE:05/2/2018 DRAWN BY: JB CO: (954) • • • • • • • 202 9226 II E: ADMIN�r7l11�,ItQAMON$ILL11NC.COM 11 WWW.TIERRACONSULTING.COM • •• •• • • • •• •• • • • ••• • 052-1-1 through 052-1-3 Brown Vinyl Cove Base Wall Base throughout Dr. Office Area 052-3-1 through 052-3-2 Grey Vinyl Floor Tile Library 052-2-1 through 052-2-3 Exterior Stucco Exterior Walls .... • • •••• . • • .. • ••• • • • • • • .. .... •:I . . . • • • • • .... .... 052-4-1 Black Vinyl Cove Base Library INIMMIST,IMIIINC0: TCGPROJECT: 9301 NE 2nd Avenue, Miami Shores 33138 CLIENT: G7 Holdings, Inc. qMwsww m PHOTOGRAPHS DATE: 05/2/2018 DRAWN BY: JB (954) 202 9226 II E: ADMINOTIERRACONSULTING.COM 11 WWW.TIERRACONSULTING.COM 052-5-1 through 052-5-2 Kitchen Linoleum Kitchen Floors 052-7-1 Yellow Linoleum Flooring Laundry Room Linoleum Floor Photograph not available 052-6-1 Ceramic Tile & Grout Bathroom Floor 052-8-1 Green Terrazzo Flooring Front steps and throughout living room GPROJECT: 9301 NE 2nd Avenue, Miami Shores 33138 CLIENT: G7 Holdings, Inc. Mawr. ------------- PHOTOGRAPHS DATE: 05/2/2018 DRAWN BY: JB .a11aiw1y waa uwa4 stirnwK 0: (9.54) 202 9226 II E: ADMIN(d)TIERRACONSULTING.COM II WWW.TIERRACONSULTING.COM 052-9-1 through 052-9-5 Walls Walls Throughout 052-10-1 Red Tile & White Grout Exterior Southwest Entrance 052-9-6 through 052-9-9 Walls Walls Throughout 052-11-1 White Concrete Roof Tile Roof Throughout .vewwRWwR �eureR,nruw TCG PROJECT: 9301 NE 2"d Avenue, Miami Shores 33138 CLIENT: G7 Holdings, Inc. . — -- -- ` m.mwer PHOTOGRAPHS DATE: 05/2/2018 DRAWN BY: JB 0: (954) 202 9226 11 E: ADMINI)TIERRACONSULTING.COM ll WWW.TIERRACONSULTING.COM APPENDIX B Laboratory Report and ... • . • •.... • ... ..• .... . • •. • •• . • • • • Chain of Custody Documentation:::. •••• • • • • •••• • • .. .... • •• . • • • • • • • • • • • • • • •. ..• ... • • • .. ..�\EMLab P&K A TestAmerica Company Report for: Ms. Jean Mazza Tierra Consulting Group, Inc. 5815 N. Andrews Way, Ste. B Fort Lauderdale, FL 33309 Regarding: Project: 16767 ACM for Demolition; Residence + Doctor's Office Demolition EML ID: 1920855 Approved by: i Approved Signatory Tracy Garcia Dates of Analysis: Asbestos PLM: 05-03-2018 •. • • • • • • • • • • • • • • •• • • • • • • • • • • ••• • • • • • • •: • • • • • • • .••. • • • • • • • • • •• •• • • • • • • • • • • • • • •• • •• • • Service SOPs: Asbestos PLM (EPA 40CFR App E to Sub E of Part 763 & EPA METHOD 600/R-93-116, SOP EM-AS-S-1267) • • • • • •• All samples were received in acceptable condition unless noted in the Report Comments portion in the body of the report. The results relate only to the items tested. The results include an inherent uncertainty of measurement associated with estimating percentages by polarized light microscopy. Measurement uncertainty data for sample results with >1 % asbestos concentration can be provided when requested. EMLab P&K ("the Company") shall have no liability to the client or the client's customer with respect to decisions or recommendations made, actions taken or courses of conduct implemented by either the client or the client's customer as a result of or based upon the Test Results. In no event shall the Company be liable to the client with respect to the Test Results except for the Company's own willful misconduct or gross negligence nor shall the Company be liable for incidental or consequential damages or lost profits or revenues to the fullest extent such liability may be disclaimed by law, even if the Company has been advised of the possibility of such damages, lost profits or lost revenues. In no event shall the Company's liability with respect to the Test Results exceed the amount paid to the Company by the client therefor. EMLab P&K, LLC EMLab ID: 1920855, Page 1 of 8 EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 CIO: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-1-1, Brown Vinyl Cove Base Total Samples Submitted: 25 Total Samples Analyzed: 25 Total Samples with Layer Asbestos Content > 1 %: 2 Lab ID -Version$: 9031172-1 Sample Layers Asbestos Content White Compound with Cream Paint ND Yellow Mastic ND Brown Baseboard ND Sample Composite Homogeneity: Good Location: 052-1-2, Brown Vinyl Cove Base Lab ID -Version$: 9031173-1 Sample Layers Asbestos Content White Compound with Cream Paint ND Yellow Mastic ND Brown Baseboard ND Composite Non -Asbestos Content: 2% Synthetic Fibers .... Sample Composite Homogeneity: Good • • - ...0000.. 004 Location: 052-1-3, Brown Vinyl Cove Base •• *tree . • • • • Lab 1D-Osionl: 9031 194--f • • • • Sample Layers Asbestos Content : • • Gray Cementitious Material •..• N'D • ••.• • White Compound with Cream Paint NA •..• • . • tree Yellow Mastic NJI •.•• • ... Brown Baseboard NO... • Sample Composite Homogeneity: Good • • • • • • • 004 • • • • •• • •• • • • • • .•• • • •• 000 • • • • • • • • The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than I% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. $ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 2 of 8 • EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 C/O: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-2-1, Exterior Stucco Lab ID -Version$. 9031175-1 Sample Layers Asbestos Content Gray Stucco with White Paint ND Composite Non -Asbestos Content: 2% Talc l% Cellulose Sample Composite Homogeneity: Good ,Location: 052-2-2, Exterior Stucco Lab ID -Version+: 9031176-1 Sample Layers Asbestos Content Gray Stucco with White Paint ND Sample Composite Homogeneity: Good . • •• • • • .••• • • • • •• • ••.• • • • • • • • • • • • • •••• • • •••• • • •• • • •• • • •••• • • • • •••• • • • • • • • .•• • • • • • • • • •• • •• • • • • • • The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval. or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than l% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. T. A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 3 of 8 EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. -Date of Sampling: 05-02-2018 CIO: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-2-3, Exterior Stucco Lab ID -Version$: 9031177-1 Sample Layers Asbestos Content Gray Stucco with White Paint ND Sample Composite Homogeneity: Good Location: 052-3-1, Grey Vinyl Floor Tile Lab ID -Version$: 9031178-1 Sample Layers Asbestos Content Black Mastic 3% Chrysotile Multicolored Floor Tile ND Sample Composite Homogeneity: Good Location: 052-3-2, Grey Vinyl Floor Tile Lab ID -Version$: 9031179-1 Sample Layers Asbestos Content Brown Debris ND Black Mastic ND Multicolored Floor Tile ND Composite Non -Asbestos Content: 3% Cellulose • • • • Sample Composite Homogeneity: Good • • • 0000 • 044 Location: 052-4-1, Black Vinyl Cove Base •s • •••• • • • • • Lab ID-,esiori!: 90311E1-f • • • Sample Layers .... Asbestos content • • ••• Multicolored Paint Nf9•...„• •.••.• ••• Yellow Mastic T�r� �"• ••••• • • • ••• Black Baseboard N4111' • • • • ... Composite Non -Asbestos Content: < 1% Cellulose < 1%Hair/Wool . • . • • • .•• Sample Composite Homogeneity: Good • _. • • •• • • ••• • ••• •• •• • •• • • • • • ••• •• • • • • • • The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than I% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. I. A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 4 of 8 EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 CIO: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-5-1, Kitchen Linoleum Lab ID -Version$: 9031181-1 Sample Layers Asbestos Content Gray Compound ND Yellow Mastic ND Yellow Linoleum ND Sample Composite Homogeneity: Good Location: 052-5-2, Kitchen Linoleum Lab ID -Version$: 9031182-1 Sample Layers Asbestos Content Brown Wood ND Yellow Linoleum ND Composite Non -Asbestos Content: 8% Cellulose Sample Composite Homogeneity: Good Location: 052-6-1, Ceramic Tile + Grout Lab ID -Version$: 9031183-1 Sample Layers Asbestos Content Cream Tape ND •••• Yellow Mastic NO • • • Off -White Ceramic Tile ND••• • •••••• • Composite Non -Asbestos Content: 5% Cellulose . " • • • Sample Composite Homogeneity: Good _ - - •• • Location: 052-7-1, Laundry Room Linoleum • • • • ••• •• ••• • ••• • •••• Lab ID- iersiot�:903118.4�1��•• Sample Layers Asbestos ppitterit . • • Brown Wood ND • Black Mastic 3% Chrysotile • • • • • White Floor Tile NP2 ••. •:• Yellow Linoleum with Fibrous Backing 20% Chrysdtile• • • • Composite Non -Asbestos Content: 8% Cellulose Sample Composite Homogeneity: Good The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. A "Version" indicated by -"x" after the Lab ID# with a value greater than I indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 5 of 8 ••• .• •••• • •••• • EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 C/O: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-8-1, Green Terazzo Floor Lab ID -Version:: 9031185-1 Sample Layers Asbestos Content Multicolored Non -Fibrous Material ND Sample Composite Homogeneity: Good Location: 052-9-1, Drywall + Joint Compound Lab ID -Version$: 9031186-1 Sample Layers Asbestos Content Gray Drywall with Brown Paper ND Gray Plaster ND White Joint Compound with Yellow Paint ND Composite Non -Asbestos Content: 15% Cellulose Sample Composite Homogeneity: Moderate Location: 052-9-2, Drywall + Joint Compound Lab 1D-Version$: 9031187-1 Sample Layers Asbestos Content Gray Drywall with Brown Paper ND Gray Plaster ND •••• • White Joint Compound with Yellow Paint ND _ • • •••• • •' Non -Asbestos Content: 15% Cellulose •Composite • • • .";'. Sample Composite Homogeneity: Moderate . `• _ Location: 052-9-3, Drywall + Joint Compound Sample Layers Asbestos gprjettt . . • • Gray Drywall with Brown Paper M?•`••` • •• Gray Plaster ND_ • White Joint Compound with Green Paint ND ~• • . . .• Composite Non -Asbestos Content: 15% Cellulose • .'. :. Sample Composite Homogeneity: Moderate " ` • • •_ • • The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. lnhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. + A "Version" indicated by -"x" after the Lab ID# with a value greater than I indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 6 of 8 ••. • .• ••• • •••• •••• . • •• Lab 1DA✓n','t903118.••. • • • • • •••• • • •••• • ••.• • • EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 C/O: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-9-4, Drywall + Joint Compound Lab ID -Version:: 9031189-1 Sample Layers Asbestos Content Gray Drywall with Brown Paper ND Gray Plaster ND White Joint Compound with Yellow Paint ND Composite Non -Asbestos Content: 15% Cellulose Sample Composite Homogeneity: Moderate Location: 052-9-5, Drywall + Joint Compound Lab ID -Version:: 9031190-1 Sample Layers Asbestos Content Beige Drywall with Brown Paper ND Beige Plaster ND White Joint Compound ND Composite Non -Asbestos Content: 12% Cellulose Sample Composite Homogeneity: Moderate Location: 052-9-6, Drywall + Joint Compound Lab ID-' sj 4: 9031191-1 Sample Layers Asbestos•Content • . Gray Drywall with Brown Paper ND' • • • • • • •• • . Gray Plaster ND . • • • • • White Joint Compound with Green Paint NO •_ _ • • • Composite Non -Asbestos Content: 20% Cellulose • • • • • • • • • • Sample Composite Homogeneity: Moderate . • • Location: 052-9-7, Drywall + Joint Compound Sample Layers Asbestos Conte&Yt • • • • Gray Plaster NI: . • . • : • White Joint Compound with Cream Paint ND' • • • • •. • • Sample Composite Homogeneity: Moderate • - Comments: There is no drywall present in this sample bag. The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than I% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 7 of 8 • - •• •- •• •• • • Lab ID -Version:: 9031192-1 • • • • EMLab P&K 6500 McDonough Dr, Suite C-10, Norcross, GA 30093 (866) 871-1984 Fax (954) 776-8485 www.emlab.com Client: Tierra Consulting Group, Inc. Date of Sampling: 05-02-2018 C/O: Ms. Jean Mazza Date of Receipt: 05-02-2018 Re: 16767 ACM for Demolition; Residence + Doctor' Date of Report: 05-03-2018 s Office Demolition ASBESTOS PLM REPORT Location: 052-9-8, Drywall + Joint Compound Lab ID -Version$: 9031193-1 Sample Layers Asbestos Content Gray Drywall with Brown Paper ND Gray Plaster ND White Joint Compound with Cream Paint ND Composite Non -Asbestos Content: 15% Cellulose Sample Composite Homogeneity: Moderate Location: 052-9-9, Drywall + Joint Compound Lab ID -Version$: 9031194-1 Sample Layers Asbestos Content Gray Drywall with Brown Paper ND Gray Plaster ND Composite Non -Asbestos Content: 15% Cellulose Sample Composite Homogeneity: Moderate Comments: There is no joint compound present in this sample bag. Location: 052-10-1, Red Exterior Tile + White Grout Lab ID-}(eisjqp$: 9031195-1 Sample Layers Asbestos•Content •••• • • • I White Grout ND••• • •••• . • • Red Ceramic Tile NE.••••• •• • ••I Sample Composite Homogeneity: Moderate • • • 4 • Location: 052-11-1, White Concrete Roof Tile .•. • • • • • • • • • •••• .••• Lab ID -Version$:• 9031 I96-1• • Sample Layers Asbestos, sift • •• White Concrete with Black/White Paint ND • Sample Composite Homogeneity: Good • _ • • • • • • • • • • •• • • •• • • • . • • • • The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to claim product certification, approval, or endorsement by any agency of the federal government. EMLab P&K reserves the right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified. Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When detected, the minimum detection and reporting limit is less than I% unless point counting is performed. Floor tile samples may contain large amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection limit and to aid in asbestos identification. $ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is reflected by the value of "x". EMLab P&K, LLC EMLab ID: 1920855, Page 8 of 8 .• , CHAIN OF CUSTODY www.EML.abPKcom EM Lab P&K .y a./P.,A TestAmerica COMpany IowJeroey: 3000 Lhcoln Orin East, Suite A, them, NJ 06053 • (866) 871.19$4 Phoenix, AZ 1501 Waal Knudsen drive, Phoenix, AZ 85027 • pp) 6M .46G2 SSF, CA 6000 Shoreline Court, Suite 205, South San Francisco, CA 84080' (866) 888.6653 Soviet Description CONTACT INFORMATION Semple Type (Below] 3Rowii VIJyt CniieRAsa 8utIl 052.-I-Z ERg1rIN VINYI coveRS- -- Q52-I-3 BROW/ V+rt Yf fir€ Ras£ a5�-2-I ;Kt eeiore SItiao 95z2-? E teR:,1t ,St&Ccs) 052 Z-3 Ea( -,2R i stucco - � 6ReY Vooyi Flo,A Tile 052-3-Z 'Rey VINy1 Race Tile .L-9ch •V1,yf Cave gPile os2`5-2. K t ie Ltnlo)(Na E1Qe tctbcketa LLNotean Ftofll� SID Waahor Fog Rain Snow Wind dear J Nano D Q 0 Light 0 0 0 0 Adadarate Heavy D 0 0 0 0 0 0 1/3 • • • • • • • • • • • SAMPLE TYPE CODES HC—BloCatisetta'• Al —Anderson SAS —Surface Air Sampler ST— Spore Trap: Zelon. T—Tape �±w wlelgenoa.Bonze ... SW- Swab sa—Sail' . - • _ - • • 2.1$ �,� ) t • • P—PotabloWatOr • •• • • • • • • • 4. _ • • Ely submitting this Chain of Ca sandy, you agreetoto bounl by the terns and conditions eel forth al IgkiNiwrr,amhdami itarmainhgrrioetetms,html 5/3 jig S=Rp ` Copyright Mae annarrva,Rai AROM.]R iwen%PpcRor1.OP- Noma ( ime of day. Tamp, RH, etc) •_••••• • • . itfateQt1IeAED ' • • •• • • 1 Non-Ctiturable 11 I I i -- 001920855 Tape SFIxe Trap Swab Sulk 1{ BloCassett& :Anderson, SAS, Swab, Water, Bdk, Dust Sail, Contact Plates Other Requests 0 o ❑ d ❑ ❑ 0 0 0 0 0 0 ❑ -0 ❑ 0 ❑❑ ❑O 2 ❑❑❑00 00000 ❑0 ❑❑ a 0CI ❑❑ioo ❑❑❑J00 .�s $' ❑❑O0 m cry 0 O❑❑0 ❑❑❑❑5Q❑ ©00❑❑0© ❑ ❑0 O ❑❑❑0❑❑❑ ❑❑000 ©❑❑0■ ❑ ❑ I❑ • ❑❑ ❑❑ 0:0 ❑ ❑ ❑ ❑ 0000 ❑ Q ❑ ■ Io OP ❑®❑ 0 CI al 0 ❑II❑ 0 ❑E❑►❑ Q 0 Cl 8 -Bulk D —Dust CP - Contact Plata HP—Non•Potabio Water CI —Celiac • • • • • • • • • ♦ • • • •• •. • •• • • • • •• • • • • • • • • • • • • • • ••• • • • • • • • • • ••• • • • • • • • • • • • • •• • • • •• •• • • ••• • • ■■i. O 0000 0 CHAIN OF CUSTODY www.EMLabPKcom EMLab P&K TeistAmerita Company Now Jersey: 3003 Llncob Drive Fast, Suite A, Marlton, NJ 08053 " (s66) 8T14984 Phoenix, AZ: 1501 Yhst Knudsen dem Ph:eras, AZ 85027 • {BOO) 631.4802 SSF, CA: 6000 Shoralbba Court Suite 205, South San Francisco, CA 94080' I580a 988 3 Weather Fog Rain Snow Wind Clear Nene 0 0 Light ❑ ❑ I•taderate tJ Ct Hea. Yy D_ 0 0 0 0 CONTACT INFORMATION Company: Tiara Coasutting Group. Inc, (6682) Address;58I5 N. Andrews Way, Sta, 13 Port Lauderdale, FL 33309 C0nlact Ms, lean Mar„cx Speeal Instructions; Phone; 954.202.9M PROJECT INFORMATIONS TURN AROUND TIME CODES (TAT) ProJer!IC: 1 6 _ 7 Ac}1 Foe Dept t i o N STD —Stetted (DEFAULT) Rushes received after or an weelorYrda, +rR tw considered recalved 111e noxtbut;lnesa achy, Ptease alert us In advance of weekend analysis needs. Project Oesuiptbn: Iee I a e ce,-D 00 pr e e , ND —Next 9ushass Day Naiad Zip Cade: # O g Samptn9 Date &Tma:'� SO— Business Rush PO Number. 16 7 6 7 SamPbad 8y 7, { WH- Weekend i Horde* Sample ID DetcriptIon Sanpla Type Akio TAT {lncze1 Total Vatume r Area tasappllcablcj Notes 052-6 I C.RAr11cIJQ+ (YRrue't. BOA I - - L. i t aot111o+etitto 0C -8-i Rees TeeRAE0 Nave j Lip. -4-I DRYWAtj "b`7Q{,yt Ct3ttPaItuO 052-9-2 052- . 052,9 -, 052,44 o52-q`S •• ••• • • • •• •• BC BloCassette TM A'S—Anderson SAS —Surface Air Sampler SAMPLE TYPE CODES ST- Spore Tray Zefon, Allergerneo, Burford P— Potable Wab r T—Tape SW- Saab CP—ContactRa e RP — Non-Potabio water B—Bulk d —Dust SO — Soil • • • • • • • ttEtff • • • 0—C1hon • • •• AL • •• 8y submitting this Chain of Custody, you agree to be hound by tha CcpyrIght ©2O1 S EML ub P&K •• • • • • • • • • • • • • • • • • • • • • •• • • • • • • • • • • • • • • • •• •• • • • Non.Culturab '1I�1I1li1'•l��1ll1ll�l1�lll r1'. III Spore 5Tapr t 401920855 Trap Bunt 1 •fin, 0 0 A D ❑, ❑ 0- 0 0 0 0 0 0 ❑ 0 0 0 0 0 0 ❑ 0 0 0' a ❑❑ 00 ❑❑ O ❑. 0 0 ❑ 0 0 0 O 0 0 ❑ 0 ❑ 0 0 0 ❑ 0 0 0 0 0 0 0 0 t 0 0 ❑0 0 a, 1 a Other Requests 1 1 CD ❑ ❑ 0 ❑❑ ❑0 ❑❑ ❑ ❑ 0 00 .❑ 0 0 0 112 ❑ 0 0 ❑ 0 b O ❑ ❑ 0 0 ❑ 0 0 O 0 ❑ 0 0 0 O ❑r 0 00 ❑ 0 0 ❑ 0 op 0000 0 0 0 0 walla, t - - - DATE a TIME _ RECEIVED BY DATE & TIME ••• • ,~ -i$` ,iY/ & 5 /2-1It' I'i . • • . • • • • •••.• r• • • .••• • • • / Dcc, ks1 DZ Ron 32. Redid 11rr BM Not d7, OA 0 • CHAIN OF CUSTODY EM Lab P&K www.EMLabPk.com .. ,ATeutAnserice Camny Now Jersey: 3000 Lincoln Drive East, Slit A, Marlton, NJ 08053 (865)871-1984 Phoenix. AZ11501 West Knudsen Ohm,. Phoenix, AZ85027(800)G51.480Z SSF, CA: 8000 Shor86w Court, Suite 205, South San Render* CA 940$0 • {856) 805.6653 CONTACT INFORMATION INWather -Norio Fog Rein Snow Wind Gear 0 0 0 0 Light Q D Modorate Harm). ❑. 0 C Q 3/3 Company: Tierra Consulting Group, inc. (5632) meres5;581S N. Andrews Way, Sts. B Foot Laudordulc, FL 33309 Contact: Ms, deora Mena Phone: 934-2024228 Spacial Instructions: PROJECT INFORMATION TURN AROUND TIME CODES (TAT) Protract ID: 1676 Project piton: �1 ef �eN ' 5 ice Project Sampling Coder 33132, Date & The: POWEINr, 16767 Sampled By: STD - Standard (DEFAULT) - ND- Nod Business Day SD -Same Business Day Rush INK -Wovkend /Holiday Rushes received or* 2 pin or an weekends, wIII by con:Adored received the next business day. Please alert us In advance or weekend analysis needs, Sample ID as21 1 Description eD Foe rQ7kt, aka 25]- Wh ct e wade Occil le S nipIoType wow] Belt (Atic TAT SIT TOGA Velum t Area fee abplceda] - Notes Jima orday, Tomb RH,Ito. • Al -Anderson SAS - Surface Air Sampler CP - Contact Plate SAMPLE TYPE CODES P -Potable Water T-Tape SW -Swab B - Bulk NP-Nan-Poteble Water 0 -Other: t7-Dwt SO- Soli • .• ••: •' • • • • ••..•.•__ • • • • • • • 000 00400000 AElNtalsyrt:1 ar—' •• • • • Non-Culturabia Spore Trap Tape Swab Sulk D ❑ 0 ❑ ❑ a 0 E ;g au W I 1 ❑0 ❑ 0 ❑ ❑ 0 a 0, 0019, nffl 0855 BIoCassettee1, Andersen, SAS, swag, Water, Sulk Dug Boll, Contact Plates 1 ❑❑❑ 0 t� 0000 ❑ a ❑ 0 ❑ 0 ❑ w 0 0 1 a 1 0 ❑0 El ❑ 0 0 Other Repasts ❑ ❑ ❑ 010 ❑a ;❑ 0 0 D ❑ ❑❑ a 0 0 a ❑ 0 Ja ❑i❑ 00 ❑0 0 0 0 0 a, a ❑ 0 DATE &TIME •Sp ? /( • • • • • • • • • • • • • • • • • •• • • • • •• •• • • • • • Ire— - - •-� By suomltting this Chain of Custody. you agree to be bound by the ttmns and conditions ser forth ai h Copyright 2015EMLabP 1 000 • • • • • • • • • • • • • • • • • • • • 000 • • • • • • • • • • • • • • •• •• • • • •• •• • • • • • • 000 • • Lib 00 a ❑ ❑ C ❑[❑ 00 00 0 0 ❑ 0 0 0 0 a ❑ ❑ ❑❑ 0 �0 ❑ 0 0 ❑C1 0 a ❑❑O 0 ❑ ❑ ❑ 0 00 0 ❑ 0 0 a ❑❑ ❑ ❑2 ❑ 00 DATE &IIME 1,1(17' /iI; 9 a4w. r. Doe, A11pQ, Rut D2, Raaoad 1$90113, Papa 1 di, CIA • APPENDIX C Certifications .... • • • • •••• • • • •• • ... • • . • •• • • . • •• .... .... • • • •••• •••• • • .. •• •• • •• • • .. • • • • • . •• • •. •• • •• • • • • .. RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY dbpr STATE OF FLORIDA DEPARTMENT OF BUSINE SLAA .3.0. FESSIONAL REGULATION THE ASBESTOS BU PROVI i SED UNDER THE UTES L at . ; 4 a quo A EXPIRATIO� MEMBER 2019 Always verify Iianses ante*It NI 'FotidaLicense.com ••• .. . • • ..... •• • .... . •••• .. • • • .... .. . . .. ... Do ngtthis3joturnen.tform. • • .. • This is your license. It is unlawful for anyone other than the licensee to use this document. •••• ••••••• . • • •• • • • • • • • ... . • . • 6. 40E, C4) ite) • tW, *WA 4€4) CO)AM. **251 4e) 4YY77jj(( Asbestos owl.Lwe Tra titivug, LIZ 13527_94ti AvetAme t -1 Sev1vt.Lvc,ol,e, FL 3.377o 72-593-30o - Asbestos <Surve j . Megaw%caL (AffeRA g4.1,1 v tw.spector) Re freskier Traivuvt,t� r kLs Ls to certL f f that Jesse IecIR,Les •••• TraLv�,LVLci was crn, accore wLth TLtLe I( of TsC,47 4o C • Part Y-&3. Appev1od Lx C to s u bpa rt E as reJi; �e • • • • • • •• s •••• •••• • it ate of Co:.crse EXawF.i.wat%ovA,122j ,�1 :.•..• • • • •• • Daze of Cow rse ov tpLetGo0,1.-2/2 -/1.. . •• • E cp%ratLoo Date 12/27/10 CertL f cate 7q 1. j 1 j°-06o Corse # FL-490000359 ProvLoter /f FL-4-90005-400 1 Ns t k.i.ACTOR. • .• . • • • ••• • at* .1(4r* 01* (g.*E* ref* •• • • •• • ••• • • • •• •• • • • •• • ••• • (1411. at* risl* (4aCt* YNO1'-1So9 G7 Holdings, Inc. Demolition • Land Clearing ♦ Environmental Restoration CGC1519552 CLIENT: Miami Shores Public Works Dept. PROJECT: 9301 NE 2nd Avenue Attn: Scott Davis ADDRESS: 1701 NW 103rd Street Miami, FL 33147 TELEPHONE: 305.3795.2210 EMAIL: DavisS©msvfl.gov THIS AGREEMENT made and entered into April 13, 2018 by and between G7 Holdings, Inc. and the Client identified herein is for the Services described in the Scope of Services. 1. Project Location: ii9301 NE 2^d Avenue.,, I _,,,,, ______ Miami 4011 2. Scope of Services to be provided by G7 Holdings, Inc.: PLEASE SEE & SIGN THE ATTACHED SCOPE OF WORK. 3. The compensation to be paid G7 Holdings, Inc. for providing the described services and payment schedule shall be: A lump sum fee of $18.550.00 & Deposit of $4.637.50 due upon execution of contract. Balance due upon job completion. Payment is due upon receipt. Invoices not paid within thirty (30) days shall incur interest thereafter at 1%% per month (15% per annum) on the unpaid balance. If G7 Holdings, Inc. retains an attomey to collect unpaid fees, the CLIENT agrees to pay attorneys' fees, court costs, and any other expenses associated with the collection of unpaid fees. IN WITNESS HEREOF, this Agreement is accepted on the date first above written subject to the terms and conditions above stated. G7 Holdings, Inc. Signature Signature Client Name Typed Name Date Date 1602 Alton Road No. 602 • MIAMI BEACH. FLORIDA 33139 • TELEPHONE 305-673-2847 G7 Holdings, Inc. CGC1519552 Demolition • Land Clearing ♦ Environmental Restoration 9301 NE 2nd. Avenue Scope of Work Complete demolition of, existing single family house, foundations, footings driveway, walkways and concrete slabs, removal of chain -link fence and bushes and shrubs around house. Also indudes permit processing and [perinit'fe s,, asbestos survey, rodent inspection, 1 septic tank abandonment, disconnecting of all utilities, freon recovery, installation of hose bib for water source for dust control during demolition (Village to confirm water meter on -site), removal and disposal of all demolition debris and fine grading site upon completion of demolition. Client to provide boundary survey required for permit Excludes the following: '1. Asbestos abatement, if required, can be provided via change order. 2. Removal of trees. Cost $18,55O.O0 Thls cost proposal is only good for 30 days. Client Name Authorized Agent Signature Printed Authorized Agent Name Date 1602 Alton Road No. 602 • MIAMI BEACH, FLORIDA 33139 • TELEPHONE 305-673-2847