Broward County
ENVIRONMENTAL PROTECTION AND GROWTH MANAGEMENT DEPARTMENT
Pollution Prevention Division
STATEMENT OF RESPONSIBILITIES REGARDING
ASBESTOS
IF YOU ARE PLANNING TO DEMOLISH OR RENOVATE ANY EXISTING STRUCTURE, YOU MAY BE SUBJECT TO FEDERAL
AND COUNTY RULES RELATING TO THE DEMOLITION AND THE HANDLING OF ASBESTOS CONTAINING MATERIAL.
PLEASE FILL OUT THIS FORM TO DETERMINE IF THE ASBESTOS RULES AND A FEE APPLY TO YOU. SEE REVERSE SIDE
FOR ADDITIONAL INFORMATION.
I. PROJECT INFORMATION:
Facility Owner: Phone:
Mailing Address: City: Zip:
Project Address: City: Zip:
Contractor Performing Work: Phone:
Email: _ Building Department Jurisdiction:
Estimated Start Date: (MM/DD/YY) _ Estimated Finish Date: (MM/DD/YY)
II. MARK THE APPROPRIATE BOX(ES) IF APPLICABLE:
1. Single-family residential home (not for commercial purpose) – If you check this box, skip sections 2 and 3.
Review the back of this form and then sign and date this form at the bottom. SRRA review fee exempt.
2. FACILITY: (Check One)
Commercial, industrial, or public building School/ College/ University
Any residential building with more than four dwelling units Unsafe structure
Two or more residential structures at the same site Emergency
Any residential property being demolished for commercial purposes or by government order
3. ACTIVITY: (Check all that apply)
Renovations: Built-up roofing removal (>5580 ft
2
):Removal Method: Hand Tools Power Saw
Exterior alteration (>160ft
2
): Stucco/Finishes Other
Interior alteration (>160ft
2
): Floor covering Wall Board Ceiling Piping Floor/Wall Mastic Wall Finishes
HVAC Other
_
Demolition: Total Partial Column Tie Beam Truss(es) Exterior Wall(s) Other
III. IF ANY BOX IS MARKED UNDER FACILITY AND ACTIVITY THEN THE FOLLOWING ITEMS ARE REQUIRED:
1. An original Notice of Demolition or Asbestos Renovation using DEP form 62-257.900(1)* or electronic
notification* must be completed and submitted at least ten (10) working-days before start of project, for:
•
all demolitions
•
all renovations involving at least 160 ft
2
, 260 Lft. or 35 ft
3
of regulated asbestos containing material
2. The asbestos survey report must be done in accordance with Broward County Code Chapter 27, Section 180
to indicate the presence or absence of asbestos containing material.
3. Payment of the applicable fees.
I have received information regarding the use of a Florida licensed asbestos professional and understand that I may be
subject to the ten (10) working-day advanced notification requirement under the Federal Law regarding demolitions and
renovations (See reverse side).
Owner/Authorized Agent (print) Title:
Signature Date
*Notice of Demolition or Asbestos Renovation form and fee schedule information at: www.broward.org/epermits
For Official Use: An Asbestos Survey Is Required Is NOT Required $50 SRRA Review Fee Due
Electronic Form SRRA-001 (02/15)
