2012-24 111111111111111. MINIM 1111111■1 II
BOOTH ERN STRAUGH H I OTT
VIA EMAIL trichardson(a�clermontfl.orq AND U.S. MAIL
March 2, 2012
Tamara Richardson, P.E.
City Engineer
City of Clermont
685 W. Montrose Street
Clermont, Florida 34711
SUBJECT: Scope and Fee proposal for Lift Station No. 6 Replacement
Dear Ms. Richardson:
As requested, BESH has prepared the subject scope and fee proposal to prepare final
construction plans and specifications, prepare and submit permit applications and provide
construction management services for removal and replacement of Lift Station No. 6. A
detailed Scope of Services and corresponding fee estimate is provided in the attached
proposal dated March 2, 2012.
Upon approval of the Proposal, BESH will begin work within one (1) week of receiving an
executed contract and submit 90% design plans for City review within six (6) weeks of
receipt of contract. The work effort for this project is approximately 250 staff hours,
corresponding to a lump sum fee of $30,840.00 to be billed at regular intervals in
accordance with the terms as provided in the contract. BESH appreciates the opportunity
to provide design services to the City of Clermont and is looking forward to assisting you
with this project.
Should you have any questions with regards to this matter, please feel free to contact our
office.
Sincerely,
BOOTH, ERN, STRAUGHAN & HIOTT, INC.
t
Duane K. Booth, P.E., Principal
duaneboothbesandh.com
DKB1am
Enclosure
H \amy\WordPerfect -9 0 \Proposals \City of Clermont \Lift Station 6 Replacement \BESH Submittal Letter 3 -2 -12 wpd
ENGINEERS • SURVEYORS • LAND PLANNERS
350 North Sinclair Avenue • Tavares, Florida 32778
Phone 352 343 8481 • Fax 352 343 8495
E-Mail Info @besandh com • www besandh com
CIVIL ENGINEERING AND SURVEYING SERVICES
PROPOSAL /AGREEMENT
FOR
CITY OF CLERMONT
LIFT STATION NO. 6 REPLACEMENT
ENGINEERS: CLIENT:
Duane K: Booth, P.E., Principal Tamara Richardson, P.E., City Engineer
BOOTH, ERN, STRAUGHAN & HIOTT, INC. CITY OF CLERMONT
350 North Avenue 685 W. Montrose Street
Tavares, Florida 32778 Clermont, Florida 34711
(352) 343 -8481 - Phone (352) 241 -7335 - Phone
(352) 343 -8495 - Fax (352) 394 -2379 - Fax
duaneboothAbesandh.com trichardsonclermontfl.org
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
CIVIL ENGINEERING AND SURVEYING SERVICES PROPOSAL /AGREEMENT
Project Understanding:
The City of Clermont desires to remove the existing Lift Station No. 6, including pumps,
panels, valve vault and generator and construct a new triplex lift station to handle existing
flows of approximately 42,000 gallons per hour. Wet well is estimated to be 12 ft diameter
and 26 ft deep for additional storage, new valve vault, new electrical controls and panels, and
new generator.
Scope of Services:
To provide engineering design, permitting and construction management services for the
removal and replacement of Lift Station No. 6. Final product will be complete construction
documents and applicable permits ready for bidding. BESH's scope of services include the
following tasks:
TASK I DATA COLLECTION
Topo area around existing Lift Station No. 6 approximately 25 ft east, west, and south
and 50 ft north of the existing wet well. Obtain invert elevations on the existing gravity
sewer pipes coming into the lift station and two (2) manholes upstream. Survey
location of underground utilities and marked and identified by the City of Clermont.
Conduct one (1) 30 ft soil boring to determine existing water table, high water table and
suitable material for wet well. Soil Boring to be conducted by Andreyev Engineering,
Inc.
Meeting with City to collaborate on design layout, to obtain historic scada data and
scada system requirements.
FEE: $4,200.00
TASK II DESIGN AND PERMITTING
BESH will prepare final construction documents for the removal of existing Lift Station
No. 6 pumps, control panels, generator, valve vault and piping. Design of new 12 ft
diameter wet well approximately 26 ft deep, new valve vault, triplex pump
configuration, control panel, generator with Automatic Transfer Switch (ATS) and
piping. Existing wet well may remain for additional storage depending upon final
configuration and location of new wet well. BESH will prepare and submit FDEP
application for Construction of Domestic Wastewater Collection /Transmission System
Electrical design will be provided by Bailey Engineering Consultants (BEC). Design
work scope shall include the following:
Page -2-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
• Electrical design associated with the proposed lift station. All electrical
distribution equipment shall be installed outdoors.
• Design associated with a permanently installed stand -by generator system with
an Automatic Transfer Switch (ATS) and a base mounted tank designed to start
and run three pumps.
• Services shall also include the design of the pump control panel and RTU
system. Design will be in agreement with the City standards which we will obtain
from the City prior to initiating our final design of the lift station. Upgrades at the
City's central telemetry site will not be included in this scope of work.
• Coordination with the local power company as required to establish electrical
service for the proposed facility.
Deliverables:
• 90% Drawings and Specifications
• 100% Drawings, Specifications and Opinion of Probable Cost
• One (1) complete set of 11x17 drawings, six (6) complete sets of full size
drawings, one (1) electronic copy in Autocad v. 2011, and one (1) electronic
copy in pdf format.
• One (1) hard copy set of specifications, one (1) electronic Copy in MS Word
format and one (1) electronic copy in pdf format.
FEE: $18,400.00
TASK III POST DESIGN SERVICES
A. Bidding:
During the bidding period, BESH and BEC will provide to the City necessary
interpretations and /or clarifications of the Contract Documents as result of
Contractor questions or Request for Information (RFI).
FEE: $1,300.00
B. Shop Drawing Review:
Review and approve (or take other appropriate action in respect of) Shop
Drawings and samples, the results of tests and inspections and other data
which each Contractor are required to submit, but only for conformance with the
design concept of the project and compliance with the information given in the
Contract Documents (but such review and approval or other action shall not
exceed to means, methods, sequences, techniques or procedures of
construction or to safety precautions and programs incident thererto); and
receive and review (for general content as required by the Specifications)
maintenance and operating schedules and instruction, guarantees, bonds and
Page -3-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
certificates fo inspection which are to be assembled by the Contractor is in
accordance with the Contract Documents.
FEE: $3,000.00
C. Issue Clarifications:
Issue all instructions of City to Contractor; issue necessary interpretations and
clarifications of the Contract Documents, have authority, as CITY's
representative to require special inspection or testing of the work; act as initial
interpreter of the requirements of the Contract Documents and judge of the
acceptability of the work thereunder, and make decisions on all claims of CITY
and Contractor relating to the acceptability of the work or the interpretation of
the requirements of the Contract Documents pertaining to the execution and
progress of the work. The ENGINEER shall render all interpretations or
decisions in good faith and in accordance with the requirements of the Contract
Documents.
FEE: $1,300.00
D. Site Visits:
Make visits to the site at start up and final walk through to observe, as an
experienced and qualified professional, the progress and quality of the
executed work of Contractor(s) and to determine in general if such work is
proceeding in accordance with the Contract Documents. Prepare trip reports
to document observations made during these inspections. ENGINEER shall not
be responsible for the means, methods, techniques, sequences or procedures
of construction selected by Contractor(s) or the safety precautions and
programs incident to the work of Contractor(s). ENGINEER's efforts will be
directed toward providing a greater degree of confidence for CITY that the
completed work of Contractor(s) will conform to the Contract Drawings, but
ENGINEER shall not be responsible for the failure of Contractor(s) to perform
the work in accordance with the Contract Drawings. During such visits and on
the basis of on -site observations, ENGINEER shall keep CITY informed of the
progress of the work, shall endeavor to guard CITY against defects and
deficiencies in such work and may disapprove or reject work failing to conform
to the Contract Documents.
As -built drawings shall be provided based upon the on -site observations, field
survey as- builts, and redlines provided by Contractor, BESH shall prepare and
submit certifications of completions to the following State and local agencies as
required:
Page -4-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
1. City of Clermont
2. Florida Department of Environmental Protection
FEE: $2,640.00
Owner Responsibilities:
The Owner shall provide the following information for use by BESH in preparing the
construction documents and calculations:
• As -built information on the existing lift station, pump sizes, and force main.
• Scada information on existing flows and pump run times.
• - Requirements for scada system.
Does not include:
• upgrades to downstream force main other than connection within 50 ft of valve
vault.
• permit fees
SUMMARY FEE SCHEDULE
TASK I $ 4,200.00
TASK II $ 18,400.00
TASK IIIA $ 1,300.00
TASK IIIB $ 3,000.00
TASK IIIC $ 1,300.00
TASK -I I ID $ 2,640.00
TOTAL 1 $ 30,840.00
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PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
HOURLY RATE SCHEDULE
(2011)
Professional Services shall be charged at the following rate schedule:
ENGINEERING
PROFESSIONAL ENGINEER (PRINCIPAL) $145.00 /HOUR
PROFESSIONAL ENGINEER $130 00 /HOUR
PROJECT ENGINEER $110.00 /HOUR
ENGINEER TECHNICIAN I $95 00 /HOUR
ENGINEER TECHNICIAN II $75.00 /HOUR
SENIOR PLANNER - AICP $110.00 /HOUR
PLANNING TECHNICIAN $75.00 /HOUR
CONSTRUCTION ENGINEER $85.00 /HOUR
FXPFRT TFSTIMONY PROFFSSIONAI FNC,INFFR $300 00 /HOUR
SURVEYING
PROFESSIONAL SURVEYOR (PRINCIPAL) $145.00 /HOUR
PROFESSIONAL SURVEYOR $110 00 /HOUR
3 MAN FIELD CREW $145.00 /HOUR
2 MAN FIELD CREW $125.00 /HOUR
CREW UTILIZING GLOBAL POSITIONING SYSTEM $150.00 /HOUR
SURVEY TECHNICIAN I $95.00 /HOUR
SURVEY TECHNICIAN II $75 00 /HOUR
SURVEY TECHNICIAN III $30 00 /HOUR
TITLE RESEARCHER $110 00 /HOUR
FXPFRT TFSTIMONY PROFFSSIONAI SIJRVFYOR $300 00 /Hot IR
Page -6-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
All printing for this project shall be billed out at the following rate schedule, plus sales tax:
(Outside Copying Services will be billed at cost)
Engineering Bond Copies
Black & White
11 x 17 .$1.25
24 x 36 $2.50
Color Copies
11 x 17.... ... .......... $2 00
24 x 36 $6 00
Black & White Copies
8 $0.10
8'/2x14 .$015
11 x 17..... .. $0.20
Color Copies
8 '/2 x 11 $1 20
8'/2 x 14 $1.45
11 x 17 $1.70
Other Printing Services
24 x 36 Vellum $9 00
24 x 36 Mylar- $12.00
24 x 36 Photo Paper, Color $36.00
24 x 36 Foam Board $20.00
Other Services
Fax $1.00 /Copy
Postage (Fed -Ex, Certified Mail, Etc) ..@ cost
Concrete Monuments $10.00
Rebar ............. .... $2 00
Mileage (T /M Projects Only) .... ........ $0 59
Page -7-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
TERMS AND CONDITIONS
I. GENERAL CONDITIONS
A. AGREEMENT:
These terms and conditions are attached to and made part of the proposal for services
(the "Proposal for Services ") by which Booth, Ern, Straughan & Hiott, Inc. ( "BESH ") has
agreed to perform certain professional engineering and /or surveying services for and
on behalf of City of Clermont ( "Client "). The Proposal for Services, these terms and
conditions, the hourly rate schedule, and the executed authorization to proceed
attached to these terms and conditions shall constitute a contract (hereinafter referred
to as the "Agreement ") for the provision of services by BESH to and on behalf of Client
B. TERMINATION:
This Agreement may be terminated by either party by furnishing written notice to the
other party at least thirty (30) days prior to the effective date of termination. In the
event that this Agreement is terminated by either party, Client shall pay BESH for all
services performed and expenses incurred through the date of termination
C. DOCUMENTS:
ENGINEERING DOCUMENTS
All original drawings, computations, details, design calculations, and electronic media
that result from engineering services performed by BESH pursuant to this Agreement
are and at all times shall remain the property of BESH Upon payment in full for
services completed, Client, at Client's expense, may obtain copies of any documents
or reproducible copies of drawings. In doing so, Client agrees that no additions,
deletions, changes or revisions shall be made to any of said documents without the
express written approval of BESH.
SURVEYING DOCUMENTS
All original drawings, computations, details, design calculations, field notes, and
electronic media that result from surveying services performed by BESH pursuant to
this Agreement are and at all times shall remain the property of BESH. Signed and
sealed surveys may be obtained for a period of time up to ninety (90) days after
issuance of the survey, and certifications may be revised during that same period of
time for a fee of $50.00 for each revision. Upon payment in full for services completed,
and within the same period of ninety (90) days, Client, at Client's expense, may obtain
copies of any documents or reproducible copies of drawings. In doing so, Client
agrees that no additions, deletions, changes or revisions shall be made to any of said
documents without the express written approval of BESH. After ninety (90) days and
within one hundred eighty (180) days following issuance of the survey, BESH will revise
certifications and will visually inspect the subject property for the purpose of reissuing
Page -8-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
a signed and sealed survey, charging its then - current hourly rates for performing said
services and reissuing the survey.
D. FEE RENEGOTIATION:
The Proposal for Services describes the specific services to be performed and tasks
to be undertaken by BESH for and on behalf of Client, and states the fee (the contract
price) for each service and task. Except as otherwise provided in this Agreement, the
contract prices quoted in the Proposal for Services shall remain in effect for a period
of two (2) years from the date of execution of this Agreement After the expiration of
two (2) years from the date` hereof, the contract prices stated in the Proposal for
Services shall by renegotiated between BESH and Client with respect to all services
and tasks that have not been completed by that date.' The hourly rates set forth in the
hourly rate 'schedule that is part of this Agreement shall apply to all additional
services requested by Client outside the scope of the services and tasks described
in the Proposal for Services. Said hourly rates are applicable through December 31
of the year in which this Agreement was executed, and are subject to renegotiation on
January 1 of each year thereafter.
E. REGULATORY REQUIREMENTS:
The contract prices and hourly rates set forth in this Agreement have been quoted
based on all federal, state, and local regulations in effect as of the date that the
authorization to proceed work is signed by the latter of BESH and Client. If any of said
regulations change during the permitting and design phase of this project, BESH
reserves the right to increase fees for services that may be affected by regulatory
changes upon written notice to the Client.
F. PERMIT ACQUISITION
BESH cannot guarantee the acquisition of any or all of the permits and /or approvals
that shall be required for Client's project BESH agrees that it shall exercise its best
efforts try to obtain all of the necessary permits and /or approvals. Nevertheless, Client
shall be responsible for payment of all consulting fees due BESH regardless of
agency /governmental actions, including without limitation the failure of one or more
governmental agencies to give the necessary approval for the project
11. COMPENSATION
A. ADDITIONAL SERVICES:
BESH shall be fully compensated by Client for all additional services performed by
BESH, including, without limitation, the following:
1. Changes made at Client's request to the scope of services defined in this
Agreement. Client must sign a separate authorization to proceed form (a
"Change Order') for each change in scope of services requested by Client
before BESH is obligated to perform the revised scope of services In the
absence of a Change Order executed by Client, BESH shall proceed according
to the original scope of services as set forth in this Agreement
Page -9-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
Notwithstanding the foregoing, BESH may choose to proceed with a Client -
requested change in scope of services despite the absence of a Change Order
signed by Client. If BESH performs the requested change in scope of services,
BESH shall be entitled to full compensation from Client based on the prevailing
prices or the hourly rates charged by BESH for such services at the time that
BESH performs the changed scope of services for Client.
2. Revisions made necessary as a result of changes to local, state or federal
governmental requirements after the date of this Agreement
3. Redesign per Client after preliminary design has been submitted to the relevant
approving agency.
B. OUT -OF- POCKET EXPENSES:
In addition to the fee schedule set forth in the Proposal for Services and the hourly
rates to be charge for all additional services performed by BESH, BESH shall be
reimbursed for all out -of- pocket expenses incurred by BESH, including, without
limitation: blueprints, copies, plots, aerials, express deliveries, specialized postage,
overnight courier services (such as Federal Express and UPS) and travel outside of the
Central Florida area (greater than 25 miles from BESH's office located in Tavares,
Florida) Printing and mileage expenses are set forth on the hourly rate schedule that
is part of this Agreement. All other charges shall be billed to and paid by Client based
on the actual costs incurred by BESH.
C. PAYMENT:
BESH shall submit invoices to Client on a semi - monthly (twice per month) basis. On
each invoice, BESH will bill for its services in accordance with the hourly rate schedule
included as part of this Agreement. The invoice also will identify the task or the tasks
from the Proposal for Services on which BESH performed services during the billing
period. If the Proposal for Services states a lump sum dollar figure for any particular
task, the lump sum amount will represent a "not to exceed" figure for the task in
question, and BESH will continue to bill by the hour for its services on that task until the
"not to exceed" figure has been billed in full. Thereafter, unless the scope of services
to be performed by BESH pursuant to said task has been changed and the
compensation to be paid to BESH has been modified pursuant to Section I I A of these
Terms and Conditions, BESH will continue to perform its services under that task
without additional charges for its services until BESH has performed all work required
by that task. Client shall notify BESH in writing within ten (10) days from the date of
the invoice if Client has any questions about the services performed for the charges
for those services as reflected on the invoice. Client waives any and all challenges to
the services performed and the charges for those services not raised within said ten
(10) day timeframe All invoices shall be due and payable in full within fourteen (14)
days from the date of the invoice. All unpaid balances that remain unpaid after
fourteen (14) days from the date of the invoice shall be subject to interest on the
unpaid balance at the rate of 1.5% per month.
All outstanding invoices shall be paid in full by Client prior to plan submittal to
any permitting agency, preparation of Final Plans for building purposes, Final
Recording of Record Plat, and /or Final Certification of Completion to state and
Page -10-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
local agencies. BESH shall have no obligation under this Agreement to submit
or prepare any of the foregoing materials unless and until Client complies with
this requirement. In addition, in the event that any balance remains unpaid for
at least 45 days from the date of the invoice which included the unpaid balance,
BESH shall have the right to terminate any and all further work on the project
until Client has paid said balance in full.
111. MISCELLANEOUS
A. FORCE MAJEURE:
BESH shall not be liable for any delays or failure in performance due to contingencies
beyond BESH's reasonable control including, without limitation, acts of God, war, fire,
explosion, flood, epidemic, severe weather, earthquake, rainstorm, riots, theft,
accidents, strike, work stoppage, acts or regulations of a governmental entity,
shortages of vehicles, fuel, power, labor or material, delays of other companies or
contractors, or any other causes whatsoever whether similar or dissimilar to those
previously enumerated. In the event of delay caused by any of the foregoing, BESH's
time for performance shall be extended for such time as may be reasonably necessary
to enable BESH to perform.
B. LIMITATION OF LIABILITY:
UNDER NO CIRCUMSTANCES SHALL BESH BE LIABLE FOR ANY SPECIAL,
INCIDENTAL, INDIRECT OR CONSEQUENTIAL DAMAGES, INCLUDING WITHOUT
LIMITATION LOST PROFITS, LIQUIDATED DAMAGES, DELAYS, LOSS OF
PRODUCTIVITY, INEFFICIENCY, LOSS OF GOOD WILL, OR ANY OTHER
DAMAGES WHICH ARE SPECIAL, INCIDENTAL, INDIRECT OR CONSEQUENTIAL
THE LIABILITY OF BESH TO CLIENT, FOR ANY CAUSE OR COMBINATION OF
CAUSES ARISING OUT OF OR RELATED TO THIS AGREEMENT, SHALL BE
LIMITED TO THE TOTAL AMOUNT OF THE COMPENSATION PAID BY CLIENT TO
BESH PURSUANT TO THIS AGREEMENT.
C. ENTIRE AGREEMENT:
This Agreement constitutes the entire agreement between BESH and Client and
supercedes any and all prior or contemporaneous understandings, representations and
agreements, oral or written. No amendment, modification or waiver hereof will be
binding on BESH unless made in writing and duly executed by an authorized
representative of BESH.
D. WAIVER:
The failure of BESH to enforce any provision of this Agreement or to exercise any right
accruing through the default of the Client hereunder, shall not constitute a waiver of
any other rights of BESH with respect to this Agreement.
Page -11-
PROJECT City of Clermont Lift Station No 6 Replacement
CLIENT Tamara Richardson, P E , City Engineer, City of Clermont
DATE March 2, 2012
E. COSTS AND ATTORNEY'S FEES:
In the event of any litigation to enforce the terms of this Agreement, BESH shall be
entitled to recover court costs and reasonable attorney's fees for all proceedings,
including at the trial court level, on appeal, and in connection with bankruptcy court
proceedings In the event that BESH retains the services of an attorney to collect from
Client any sums due hereunder, BESH shall be entitled to recover from Client all fees
and costs incurred with said attorney, whether suit is brought or not
F. GOVERNING LAW; VENUE:
This Agreement shall be governed by and construed under the laws of the State of
Florida. Venue for any proceeding based upon this Agreement shall lie exclusively in
the state court of competent jurisdiction in Lake County, Florida
G. SEVERABILITY:
If any provision of this Agreement is held invalid or otherwise unenforceable, the
enforceability of the remaining provisions shall not be impaired thereby but rather this
Agreement shall be construed as if not containing the particular invalid or
unenforceable provision or provisions and the rights and obligations of the parties shall
be construed and enforced accordingly.
Page -12-
PROJECT: City of Clermont Lift Station No. 6 Replacement
CLIENT: Tamara Richardson, P.E., City Engineer, City of Clermont
DATE: March 2, 2012
AUTHORIZATION TO PROCEED
PROPOSAL FOR CIVIL ENGINEERING AND SURVEYING SERVICES
AS DESCRIBED IN THE ATTACHED PROPOSAL
To acknowledge your agreement with the terms and conditions set forth in this Agreement (consisting
of the Proposal for Services, the Terms and Conditions, the Hourly Rate Schedule and this
Authorization to Proceed), and to provide Booth, Ern, Straughan & Hiott, Inc. (BESH) with Client's
authorization to proceed with the work described in the Agreement, please fill out and sign the
Authorization to Proceed below and return it to our office. We will schedule the work upon receipt of
the executed Authorization to Proceed. The contract prices, hourly rates, and costs for printing and
similar expenses set forth in this Agreement shall be valid for ninety (90) days from the date of this
proposal. If this Agreement is not accepted by Client within said period of ninety (90) days, BESH
reserves the right to modify any and all of the contract prices, hourly rates and cost figures set forth
herein.
Retainer Amount: $ N/A
THIS PROPOSAL /AGREEMENT ACCEPTED THIS c 2 ,/7 DAY OF 4C)ri , 2012
Booth, Ern, Straughan & Hiott, Inc. Client
Signature Signature to
By: Duane K. Booth, P.E. By: • , S , T {`
Title: Principal Title: (Or
Page -13-
PROJECT: City of Clermont Lift Station No. 6 Replacement
CLIENT: Tamara Richardson, P.E., City Engineer, City of Clermont
DATE: March 2, 2012
CLIENT INFORMATION FORM
To assist Booth, Ern, Straughan & Hiott, Inc., to prepare the requested proposal, please
complete the information below:
.1 )
PRINT NAME & TITLE: Lee,TirCi(6
COMPANY NAME: C1 Of l . CirY1 0 n+
BILLING ADDRESS: O
dtj<. 12 02_19
CI errnvin +- FL. 3 Lt-1 12-
PHONE: 2 - 2.4d - 733
FAX: * 5Z 3923T7 /
E -MAIL: j +h5e CE( rO11+ri . 0 r
DATE:
p 0 2012
CLIENT REPRESENTATIVE: w a rO I"1 1 Gho v 5011
IS CLIENT THE OWNER OF THE SUBJECT PROPERTY ?: /
YES: V
NO:
(If no, Booth, Ern, Straughan & Hiott, Inc., reserves the right to require a retainer prior to
commencing services.)
Is the property accessible? If gated /locked, who shall BESH contact to gain access to the
property?
NAME AND PHONE NUMBER:
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY
KNOWLEDGE.
SIGNATURE: � � ��� - 777
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