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HomeMy WebLinkAbout159-14 RESOLUTIONRESOLUTION NO. 159-14 A RESOLUTION TO AUTHORIZE A CONTRACT WITH EVANS CONSTRUCTION AND REMODELING, LLC IN THE AMOUNT OF $32,065.00 FOR COMMUNITY DEVELOPMENT BLOCK GRANT REHABILITATION OF AN ELIGIBLE RESIDENCE LOCATED AT 1628 N. BROADVIEW DRIVE BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1. That the City Council of the City of Fayetteville, Arkansas hereby authorizes a contract with Evans Construction and Remodeling, LLC in the amount of $32,065.00 for Community Development Block Grant rehabilitation of an eligible residence located at 1628 N. Broadview Drive. PASSED and APPROVED this 2nd day of September, 2014. APPR()VPn- IC ATTEST: By:, SONDRA E. SMITH, City Clerk/Treasurer R Krrn����� G / i ``���e• CIT Y O�,•gJ'G i S lE�yi kq NSN . �1... `® 6'VM11„�` Yolanda Fields Submitted By City of Fayetteville Staff Review Form 2014-0359 Legistar File ID 9/2/2014 City Council Meeting Date - Agenda Item Only N/A for Non -Agenda Item 8/5/2014 Submitted Date Action Recommendation: Community Resources / Development Services Department Division / Department Approval to award Bid# 62123-1410 to Evans Construction & Remodeling LLC for a Community Development Block Grant (CDBG) Rehabilitation at 1628 N. Broadview Dr. and to approve a purchase order in the amount of $32,065. 2180.4940.5315.00 Account Number 62123.1410 Project Number Budgeted Item? Yes Does item have a cost? Yes Budget Adjustment Attached? No Previous Ordinance or Resolution # Original Contract Number: Comments: Budget Impact: Current Budget Funds Obligated Current Balance Item Cost Budget Adjustment Remaining Budget 2180 - CDBG Fund 1628 N Broadview Project Title $ 482,037.00 $ 119,913.84 $ 362,123.1 $ 32,065.00 330,058.16 V20140710 Approval Date: —g-1 4 ENTERED his/ / B� CITY OF ��i T Vl ARKANSAS MEETING OF SEPTEMBER 2, 2014 CITY COUNCIL AGENDA MEMO TO: Mayor and City Council �Q THRU: Jeremy Pate, Dir. Development Servicesc FROM: Yolanda Fields, Community Resources D r DATE: August 5, 2014 SUBJECT: Approval of Contract & Purchase Order for Bid# 62123-1410 RECOMMENDATION: Staff recommends approval to award Bid# 62123-1410 to Evans Construction & Remodeling LLC and approval of the attached purchase order in the amount of $32,065 for the housing rehabilitation project located at 1628 N. Broadview Dr. BACKGROUND: Community Resources has deemed the $32,065 housing rehabilitation project cost necessary in order to fully rehabilitate the home located at 1628 N. Broadview Dr. A brief scope of the project includes performing repairs to trim and electric system, replacing ceiling tiles in two rooms, installing new siding, windows, HVAC unit, deck railing, gutters and insulation. For the full scope of the project, please see the attached bid packet. DISCUSSION: In December 2013, a Fayetteville home -owner applied for a housing rehabilitation project on their home at 1628 N. Broadview Dr. After verifying that the owner qualified for the program by being within the low-income population, Community Resources conducted an environmental review of the property, performed an assessment of the property, and completed a dwelling assessment on the property. The housing structure was deemed stable, livable, and eligible for rehabilitation. In July, the bid for the rehab project was advertised in the local newspaper and emails were send out to contractors with the bid packet attached. Only one contractor, Evans Construction & Remodeling, placed a bid on the project. BUDGET/STAFF IMPACT: Project cost is $32,065 Attachments: Purchase Order Receipt of Bids and Bids Bid Invitation Packet Mailing Address: 113 W. Mountain Street www.€ayetteville-ar.gov Fayetteville, AR 72701 A RESOLUTION TO AUTHORIZE A CONTRACT WITH EVANS CONSTRUCTION AND REMODELING, LLC IN THE AMOUNT OF $32,065.00 FOR COMMUNITY DEVELOPMENT BLOCK GRANT REHABILITATION OF AN ELIGIBLE RESIDENCE LOCATED AT 1628 N. BROADVIEW DRIVE BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1. That the City Council of the City of Fayetteville, Arkansas hereby authorizes a contract with Evans Construction and Remodeling, LLC in the amount of $32,065.00 for Community Development Block Grant rehabilitation of an eligible residence located at 1628 N. Broadview Drive. PASSED and APPROVED this 2°a day of September, 2014. APPROVED: At LIONELD JORDAN, Mayor ATTEST: By: SONDRA E. SMITH, City Clerk/Treasurer a o � N N (6 L Q O ai ,' ❑ a N X LL N N H W < < d' ❑ Q O O ao J G a�i to m N O O O X W m co m ai co Z Z O Z m L L O d O' } U N} 'C m• N N Z e' am 0 `° m m 0 a O cq O a a. E S L m 7 Z M i:N C 00 .0. , • q* ID"N d (, n Cr V m m LL 0 O N O CD CD CD CD O C. O O O O O O O o �a>� '��' o a C. ,•:o N o 69 c EA o (R cs fR 0ci fR fA fc H o fR c ffT dT ' QiN sR a = a ,O EI=Ve L5 V G� a c �i c.� ca °' ❑ Q W ev m °D Y O M Q O � 5v ❑ m j-qp v FN�3 O O r� T-Rg 4 70i c . , W VG�� .C.. 2 G r C , Z_. '. ryca � �W( d d cm Q co Ix r o- .- U) U w C U � Z> m N 0 c cmU 'd' U a) co O 04 CL Cc U co ca > . • lL U ID N M at LO co I-- co01 s O O N Q. N L W 2 U 0 RECEIPT OF BIDS OWNER(S): Wes & Maggie Mouser ADDRESS: 1628 N. Broadview Dr. PROJECT No 62123-1410 PROJECT TITLE: Moderate Rehabilitation of a Residential Building BID CLOSING DAY/DATE/TIME: August 4.2014.4:00 P.M. CONTRACTOR: BID AMOUNT: � 3 z CONTRACTOR: BID AMOUNT: Certified Date: _ Form CR 118 K:\CR\NEW CR\CDBG\Housing\CDBG Hsin Forns -« Current\Bid\Form CR 118 receipt of bids ew ogo. oc STANDARD BID PROPOSAL FORM PROJECT NUMBER: 62123-1410 DATE ISSUED: 07-21-2014 DATE AND TIME OF OPENING: Monday, 4:00 pm, August 4, 2014 OWNER'S NAME: City of Fayetteville PROJECT ADDRESS: 1628 N. Broadview Dr., Fayetteville, AR 72703 ATTENTION The City has the right to select which of the items fisted below will be completed based on the amount of funds available. *In blanks below please quote price for each item and the total for project at the bottom. A) Electrical: .� B) Siding: DO Q HVAC D) Windows: '1 U o� E) Insulation: F) Gutters: G 3 0 G) Ceiling Tiles: H) Deck Railing: I) Trim & Paint (1-L J) Cleanup: LSD K) Other: boo 113 W. Mountain Street www.fayetteville-ar.gov Fayetteville, AR 72701 MY TOTAL BID PRICE FOR THIS PROJECT IS $ ) Z, 0 tD S' Upon signing this Bid, the bidder certifies that they have viewed the property, read and agree to the requirements set forth in this bid proposal, including specifications, terms and standard conditions, and pertinent information regarding the articles being bid on, and agree to furnish these articles at the prices stated. Complete Business Address: ! (2-3 Name of (AL Phone k � S30 " 08DI Residential Contractor's License number U A,G'49B l y Street address or P.O. Box, I: I ct,&, d&V._ a City / State/ Zip Code jA!� e,4 rA I Printed Name. c: r� Signature: Title: `-tli CITY OF TayARKANSAS CITY OF FAYETTEVILLE 113 W. Mountain St. Fayetteville, AR 72701 INVITATION TO BID Bid# 62123-1410 Community Resources Division (479) 575-8240 BID#: 62123-1410 DATE ISSUED: 07-21-2014 DATE & TIME OF OPENING: Monday, August 4, 2014 4:00pm CONTACT: Kyle Belt—(479) 575-8240 Mailing Address: COMMUNITY RESOURCES 113 W. MoUntain Street www.fayetteville-ar.gov Fayetteville, AR 72701 CITY OF 7ay7 T—Ikle ANAS INVITATION TO BID DATE ISSUED: July 21, 2014 RECEIPT OF BIDS: Monday, 4:00 pm, August 4, 2014 Community Resources Division 125 West Mountain Street Fayetteville, AR 72701 COMMUNITY DEVELOPMENT PROGRAMS ADMINISTRATOR: Kyle Belt CDBG Programs Administrator 113 West Mountain Street Fayetteville, Arkansas 72701 Phone (479) 575-8240 BRIEF SCOPE OF PROJECT: Install new siding, windows, HVAC unit, deck railing, gutters and insulation. Perform repairs to trim and electric system. Replace ceiling tiles in two rooms. PROJECT NUMBER: 62123-1410 PROJECT LOCATION: 1628 N. Broadview Dr., Fayetteville, AR 72703 CITY OF FAYETTEVILLE: The City of Fayetteville encourages participation of small, minority and women owned business enterprises in the procurements of goods, services, and construction, either as a general contractor or subcontractor. The City is an affirmative action / equal opportunity employer. Section 55.55 prohibits discrimination against qualified individuals because of their handicapped status. GENERAL: A copy of the Specifications is available at the Community Resources Division's office. ****** Attention! New Requirements! ****** • New permitting requirements, please see attached • Any bid of $20,000 or over must be accompanied by a certified check or bid bond in an amount not less than five percent (5%) of the amount bid. • A one hundred percent (100%) performance and payment bond is required with a contract awarded amount of over $20,000 and filed with the Washington County Circuit Clerk. • A State of Arkansas Residential Contractor's License is required for ALL bids. Mailing Address: COMMUNITY RESOURCES 113 W. MOLlntaln Street tiuwti0ayetteville-angov Fayetteville, Ali 72701 'AilyKA f ARKANS t MUNITY DEVELOPMENT BLOCK GRANT SPECIAL TERMS AND CONDITIONS 1. All bids shall be submitted in a sealed envelope and must be submitted on forms provided by the city. No employees of the Community Resources Division are allowed to fill out bid sheets for Contractors. 2. The company or contractor name and project # shall be stated on the face of the sealed bid envelope. 3. Bidders shall include all applicable local, state, and federal sales tax in the bid. The responsibility of payment shall remain with the successful bidder. 4. Prices shall include all labor, materials, profit, insurance, etc., to cover the furnishing of the items of the bid. 5. Bids received after the date and time set for receiving bids will not be considered. 6. The Owner reserves the right to accept or reject any and all bids, waive formalities in the bidding and make a bid award deemed to be in the best interest of the Owner. The Owner shall be able to purchase more or less than the quantity indicated subject to availability of funds. 7. The bid price shall remain good and firm for a period of thirty (30) calendar days from bid opening date; however, the -prices may remain firm for a longer period of time if mutually agreeable between bidder and the Owner. 8. All products delivered shall comply with applicable standards of quality. 9. Any exceptions to the requirements of the City of Fayetteville must be noted on the Bid Form or on an attached form. 10. In the event of two or more identical low bids, the contract may be awarded arbitrarily or for any reason to any such bidders, at the discretion of the Owner. 11. The Contractor is to supply the City with evidence of the following: 1) Current and valid Certificate of Liability Insurance that includes coverage for a) Workman's Compensation and Employer Liability in accordance with the laws of the State of Arkansas, b) Commercial General Liability that covers public liability and property damage and c) Automobile Liability, if applicable. All premiums and 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 117 COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM costs shall be paid by the Contractor. In no way will the Owner be responsible in case of accident. 2) Current and valid license from the State of Arkansas Contractors Licensing Board. 3) EPA/HUD Approved Lead Safety Training Program certification. 12. Specifications furnished with this invitation are intended to establish a desired quality or performance level, or other minimum dimensions and capacities, which will provide the best product at the lowest possible price. Other than designated brands and/or models approved as equal to designated products shall receive equal consideration. 13. The City reserves the right to request any additional information it deems necessary from any or all bidders after the submission deadline. 14. Quality, time and probability of performance may be factors in making an award. 15. Any ambiguity in any bid as a result of omission, error, lack of clarity or non-compliance by the bidder with specifications, instructions, and all conditions of bidding shall be construed in the light most favorable to the Owner. 16. Bidders must provide the City with their bids signed by an employee having legal authority to submit bids on behalf of the bidder. 17. The request for bid is not to be construed as an offer, a contract, or a commitment of any kind; nor does it commit the city to pay for any costs incurred by bidder in preparation of bid. 18. Bids must be hand delivered or received by mail in the Community Resources Office, 125 West Mountain St. Fayetteville, and AR. 72701, on or before the time of closing listed on the Bid Form: Under no circumstances will faxed bids be allowed. 19. The successful bidder will be required to enter into a contract with the Owner and shall provide a certificate of insurance to the Community Resources Division within ten (10) days of notice of bid award. 20. In the event a contract is entered into pursuant to the "Invitation to Bid", the bidder shall not discriminate against any qualified employee or qualified applicant for employment because of race, sex, color, creed, national origin, or ancestry. The bidder must include in any and all subcontracts a provision similar to the above. 21. The contractor must be prepared to commence work on start date per Notice to Proceed issued by the City Community Resources Division, and must complete the work within Thirty (30) calendar days. Exceptions as noted in the Rehabilitation Contract. 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 117 CITY OF Fayql -Ile COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM 22. A Maximum of three payments may be made on each Housing Rehabilitation Project. Upon satisfactory completion of 40% of the work and submission of proper documentation, 30% of the contract amount may be released to the contractor with 10% being held as retainer. Upon satisfactory completion of 70% of the work and submission of proper documentation, 60% of the contract amount may be released to the contractor with 10% being held as retainer. Final payment shall be made after satisfactory completion and acceptance of the project. Retainers shall be released with the final payment. 23. A certificate of final inspection by the City of Fayetteville's Building Safety Division must be performed before the release of the final check. 24. Any construction material containing Lead -Based Paint (LBP) shall be removed by workers certified in LBP Interim Controls and with adherence to the current HUD Regulation on LBP Hazards. 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 117 CITY OF ARKA NSAS DEVELOPMENT BLOCK GRANT Residential Permit Application and Plan Review Requirements The following shall be the submittal requirements: • Completion of the Master Permit application and review before any work starts. • "CDBG" will be entered in the Description of Work field. • Specification sheets will be submitted with the application. • CDBG fee waiver sheet for the application process. (Provided by CDBG Staff) • A site plan of the property drawn to scale will be submitted according to permitting procedures. • A floor plan drawn to scale will be submitted indicating where changes to the structure are to occur. This can be done in two parts as before and after with 8 V2 x 11 plans. • The Master permit must be issued before any other permit may be applied for. Highland Home Builder, Inc. Bruce Kerr 479-903-0966 Community Resources Spec writer brucegkerr@netzero.com Community Resources Division �NLA Home Builder, Inc. MODERATE HOUSING REHABILITATION PROJECT Scope of Project: Install new siding, windows, HVAC unit, deck railing, gutters and insulation. Perform repairs to trim and electric system. Replace ceiling tiles in two rooms Owner's Name: Wes & Maggie Mouser Phone: 479-879-2242 Project Location: 1628 N Broadview Drive, Fayetteville, AR 72703 Project # 62123-1410 Administrator: Kyle Belt Phone: 479-575-8240 Fax: 479-444-3445 Contractors Description of Work: Minimum requirements for bidder: Proof of current Arkansas Residential Contractor's license (or Commercial Contractor's license if required by law) which is provided by the State of Arkansas Contractors Licensing Board, Certificate of Liability Insurance, and a statement of Completion of EPA/HUD Approved Lead Safety Training if applicable. GENERAL: The contractor will be responsible for all aspects of the construction, installation, repairs, and cleanup as stated in the Scope of Work and Specifics at the project location stated above. Each bidder will be responsible for a complete inspection of the property at the project location before submitting bid. Give occupant 24 hour notice before inspection. All the distances, measurements, procedures, and listed materials should be verified before submitting your bid to complete the work. The requirements listed here, in the description of work, are general requirements and it will be the responsibility of the winning bidder to assure the City of Fayetteville that the finished project is in compliance with all applicable codes and standards and achieves the goal of raising the efficiency of the building. The contractor's duties and responsibilities include, but are not limited to, the following: 1) Purchasing of all materials. 2) Supervision of all employees and subcontractors. 3) Coordination with the City of Fayetteville CDBG Administrator, the City of Fayetteville Code Compliance Office and owners. 4) Project design. 5) Clean up and restoration of all lawns, planters, walking and driving surfaces to their original condition. 6) Keep job site safe for others and practice safe working practices as required. SPECIFICS: A: ELECTRICAL A - 1 Install a new GFI outlet in the bathroom and repair wiring or replace GFI outlet in the kitchen so it is in working order. A — 2 Make all connections necessary for the new HVAC system, adding any needed breakers and electrical components needed. A —3 Install any missing outlet and switch covers in the home. A — 4 Add any missing smoke detectors to bring the old section of the home up to code. A — 5 Determine what the switch in the laundry room that is missing a cover controls and make repairs. If the switch does not run anything anymore just cap it off and put a blank cover on it. B: SIDING B —1 Install new vinyl siding with vinyl soffits. Build any sub structure to the soffits if needed to install vinyl soffit material. Use metal fascia and cover any exposed wood with aluminum coil as needed. Have colors and profile approved by homeowner. (Soffits have tested positive for lead) B — 2 Build three new crawlspace doors that open and close easily. One of the crawlspace doors may need to be enlarged to allow the new HVAC unit in the crawlspace. Make adjustments as needed to accommodate the new unit. - B — 3 The front porch columns have tested positive for lead. Cover them with coil metal or paint them to match the siding using lead safe practices. C: HVAC C —1 Install a new natural gas 90 plus furnace in the crawlspace of the home. The units should be Energy Star rated with the AC unit with a minimum seer rating of 15. The outdoor AC unit should be installed near the electric meter. C — 2 Install central air vents in the crawlspace. Ensure all ducts are sealed and insulated properly. The unit should have a return air with a filter grill installed for customer to change filters easily. Determine the best way to provide a space for the return air and have it approved by the homeowner. C — 3 Remove the old gas heater in the living room and cap of the gas. D: WINDOWS D —1 Remove old windows. The windows tested positive for lead so remove them using lead safe practices. D — 2 Replace all windows except front left bedroom window that faces front with new single or double hung windows. The left front bedroom window that faces front should be a casement window that meets egress. The windows should be white vinyl windows that are energy star rated with Low-e glass. D — 3 Cover the outside wood around the window trim with metal coil trim bent to fit. D — 4 Seal around all windows to keep out water or air. E: INSULATION E —1 Blow in attic insulation to bring R value to R 38. E — 2 Install a vapor barrier over the dirt in the crawl space of the home. E — 3 Install new R-19 floor insulation between the joists in the crawlspace. F: GUTTERS F —1 Add seamless gutters and downspouts to the home. Have color approved by homeowner. G: CEILING TILES G —1 Replace the ceiling in the laundry room and office off of the kitchen with similar style ceiling tiles. Repair ceiling above tiles as needed so the new ceiling will not sag. Help the customer by moving any furniture or appliances as needed to perform the work. H: DECK RAILING H —1 Install a new handrail on the back porch and stairs that meets code. Use pressure treaded wood. I: TRIM AND PAINT 1-1 Make any needed repairs inside the home around the windows. Add or repair any trim or paint as needed. 1-2 Install a new 1x4 baseboard in the hallway where it is missing. Paint to match. J: CLEANUP J - 1 All new, used, and excess construction materials that relate to the job or a change order(s) belongs to the contractor and can be removed from the property by the contractor as needed during the project and shall be removed at completion. J - 2 All trash shall be hauled off by contractor and preferably recycled if possible. J - 3 All affected areas shall be left broom clean. J - 4 If lead paint is present, cleanup will be compliant with EPA/HUD Approved Lead Safety standards. K: OTHER K - 1 All work or materials which are not directly noted in the Scope of Work and Specifics, but are necessary for the proper carrying out of the obvious intentions thereof, are to be .understood as implied work and will be provided for by the contractor as if specifically described or drawn. K - 2 All work shall be performed in a workmanlike manner according to common construction practices, according to the specifications set forth in the Community Resources Program's General Specification Manual, and with adherence to city, state, and national codes. K - 3 Any damage to the dwelling or property caused by the contractor, his/her worker(s) or delivery person, and/or their vehicles during the project shall be repaired to like new conditions. K - 4 Where applicable, all plumbing work shall be performed by a Arkansas State licensed plumbing contractor with adherence to the current Arkansas Plumbing Code. K - 5 Where applicable, all electrical work shall be performed by a Arkansas State licensed electrical contractor with adherence to the current National Electrical Code. K - 6 Where applicable, all HVAC work shall be performed under the supervision of a licensed HVAC contractor with adherence to all codes. LEADTE, CHNOL 0 GIE S 1922 Sannyland.Road 31ountain View, Arkansas 72560 May 29, 2014 Mr. Kyle Belt City of Fayetteville 113 West Mountain Street Fayetteville, Arkansas 72701 Dear Mr..Belt: This is a report of the lead -based paint inspection conducted at the :residence of Wes & Maggie Mouser, 1628 BroadviewFayettevillej Arkansas. The inspection was conducted on May 15, 2014. The purpose of the inspection was to determine if lead -based paint was present at or above the Department of Housing and Urban Development's (HUD) regulated level of 1.0 mg/cm2. Lead -based paint was found. on the exterior and interior of the dwelling. One hundred. seventy-four XRF readings were taken with seven of the readings at or above the HUD regulated level. Please refer to the summary report for additional information on specific locations and, lead concentrations. The summary report lists all concentrations that are at or above the HUD regulated level of 1.0 mg/cm2. A sequentialreport lists all XRF readings in. the order they were taken. Both reports provide the structure on which the reading was taken, the location, paint condition, substrate, color and concentration. The wall refers to the side of the,house: (location) that each reading was taken. Example: Exterior wall A is the front entrance side, when looking at the front of the house, then proceed clockwise, wall B being to the lefi of A and go on. Each room after that is oriented the same, with wall A in the living room being the wall facing the front entrance. Paint condition is classified by intact (good), fair and poor conditions. The mode refers to the sampling method selected for conducting the x-ray fluorescence measurements. A diagram with room identifiers and room numbers is included for reference. The inspection was conducted using the RMD LPA-I x-ray fluorescence analyzer (XRF), serial number 3204. The XRF was operated in the quick mode for the quantitative measurement of lead in paint. Frank Terry of Lead Technologies conducted the lead paint inspection. Mr. Terry is a certified lead paint inspector and a certified risk assessor. Lead Technologies is an Arkansas licensed lead paint consultant. According to HUD and EPA regulations a disclosure statement must be provided to the property owner and .any new lessees (tenants) and purchasers of this property prior to becoming obligated under a lease or sales contract. A copy of this report must be .made available to the occupants within 15 days. A lead -based paint disclosure is included with this letter. Please provide the EPA information pamphlet; "Protect Your Family from Lead in Your Home" or "Renovate Right" to the homeowner when you deliver the lead report to them. If you have any questions concerning this survey report or need additional assistance, please feel free to call us. We appreciate you selecting Lead Technologies to conduct your lead paint inspection. Sincerely, Juanita Terry, Vice Presid t Lead. Tecbnologies 7 7 501-3 73-8644 - 8 70-591-6 25 Faw ON logo Mepartinent of Peal* Und TeQuoWgWs Nall . .•.ara l k'.". M .^.013 10, N11A 90t4te of $Uchalv#" 000327 FlImIrTerly ........... Otate of 11rhounno unt a �p mpp.artu 000328 Franh TLrry y.") .... .... 00(0325 Juanita Terry .. . .... . 1-4 ""'d 1 11 . 6— my W "All 000326 Juanita Terry Iveli,KiRAM".., "A copy of this summary must be provided to new lessees (tenants) and purchasers of this property under Federal Law (24 DFR Part 35 and 40 CFR Part 745) before they become obligated under a lease or sales contract. The complete report must also be provided to new purchasers and it must be made available to new tenants. Landlords (lessors) and sellers are also required to distribute an educational pamphlet approved by the U.S. Environmental Protection Agency and ,include standard warning language in their leases or sales contracts to ensure that parents have the information they need to protect their children from lead -based paint hazards." ff mcwtol REPORT NUMBER: S#03204 - 05/15114 10:33 INSPECTION FOR: Mr..Kyle.Richard Belt City of Fayetteville, Comm. Serv. 113 West Mountain Street Fayetteville, Arkansas 72701 PERFORMED AT: 1628. Broadview Fayetteville, Arkansas INSPECTION DATE: 05/15/14 INSTRUMENT TYPE: ACTION LEVEL.: OPERATOR LICENSE: RMID ,MODEL LPA-1 XRF TYPE ANALYZER Serial Number: 03204 1.0 Mgjdlb2 ._ GLmO`142 SIGNED -- Date 1628 Broadview Fayetteville, AR C ...........____..._.._........... Porch . Closet Bedroom Storage Rm5 Rm7 Bath Rm6 Office Laundry Rm4 Rm8 Closet Kitchen Rm9 Bedroom Rm3 D SUMMARY REPORT OF LEAD PAINT INSPECTION FOR: Mr. Kyle Richard Belt Inspection Date: Report Date: Abatement Level Report No. Total Readings: Job Started: Job Finished: 05/15/14 5/17/2014 1.0 S#03204 - 05/15/14 10:33. 174 Actionable: 7 05/15/14 10:33 05/15/14 12:25 Reading No. Wall Structure Location Member 1628 Broadview Fayetteville, Arkansas Paint lead Cond Substrate Color (mg/emz) Mode Exterior Room 001 Exterior 015 A Fascia I Wood Tan 1.5 QM 006A Column Rgt L column I Wood Tan 1.0 QM 004 A PorchCeiling Ctr I wood Tan 1.10 QM. 005 A Porch Supp. Ctr I Wood Tan 1A QM 008 A Rafter End Rgt I Wood Tan 1.0 QM 037 C Window Rgt Sash P Wood white 1.3 QM' Interior Room 001 Living Rm 050 D Window Lft Sash I Wood White 1.4 QM Calibration .Readings ---- End of Readings ---- 1 SEQUENTIAL REPORT OF LEAD PAINT INSPECTION FOR: Mr. Kyle Richard Belt Inspection Date: 05/15/14 1628 Broadview Report Date: 5/17/2014 Fayetteville, Arkansas Abatement Level:. 1.0 Report No. S#03204 - 05/15/14 10`33 Total Readings: 174 Job Started: 05/15/14 10:33 Job Finished: 05/15/14 12:25 Read No. Rm Room No. Name Paint Wall Structure Location Member Cond Substrate Color Lead (mg/cm2) Mode 1 CALIBRATION 0.9 TC 2 CALIBRATION 1.0 TC 3 CALIBRATION 0.9 TC 4 001 Exterior A PorchCeiling Ctr I Wood Tan 1.0 QM 5 001 Exterior A Porch Supp. Ctr I Wood Tan 1.0 QM 6 001 Exterior A Column Rgt L column I Wood Tan 1.0 QM 7 001 Exterior A. Soffit I Wood Tan 0.6 QM 8 001 Exterior A Rafter End Rgt I Wood Tan 1.0 QM 9 001 Exterior A Door Ctr Lft casing I Wood Tan 0.0 QM 10 001 Exterior A Door Ctr Rgt jamb I Wood White 0.1 QM 11 001 Exterior A Door Ctr U Lft I Wood Natural -0.1 QM 12 001 Exterior A Wall U Rgt I Wood flan -0.2 QM 13 001 Exterior A Wall L Lft I Wood Tan -0.3 QM 14 001 Exterior A Corner board Lft I Wood Tan 0.0 QM 15 001 Exterior A Fascia I Wood Tan 1.5 QM 16 001 Exterior B Fascia I Wood Tan 0.0 QM 17 001 Exterior B Soffit I Wood Tan -0.1 QM 18 001 Exterior B Rafter End Lft I Wood Tan 0,5 QM .19 001 Exterior B Wall U Ctr I Wood Tan -0.2 QM 20 001 Exterior B Corner board Rgt I Wood Tan -0.1 QM 21 001 Exterior B Door Lft Rgt casing I Wood Tan 0.0 QM 22 001 Exterior B Door Lft Lft jamb I Wood White 0.0 QM 23 001 Exterior B Door Lft U Ctr I Wood Natural -0.2 QM 24 001 Exterior C Door Lft U Rgt I Wood Natural -0.1 QM 25 001 Exterior C Door Lft Rgt jamb I'Wood White -0.1- QM 26 001 Exterior C Door Lft Lft casing I Wood Tan -0.1 QM 27 001 Exterior C Railing Lft Railing I Wood Tan 0.2 QM 28 001 Exterior C Column Rgt U column I Wood Tan 0.0 QM 29 001 Exterior C Porch Floor Lft P Wood Tan -0.2 QNt 30 001 Exterior C PorchCelling Lft I Wood Tan -0.1 QM 31 001 Exterior C Porch Supp. Lft I Wood Tan 0.2 QM 32 001.Exteri_or C Soffit I Wood Tan -0.1 QM 33 001 Exterior C Rafter End Lft I Wood Tan -0.1 QM 34 001 Exterior C Fascia I Wood Tan 0.0 QM 35 0.01 Exterior C Corner board Rgt I Wood Tan -0.1 QM 36 001. Exterior C Wall L Ctr I Wood Tan -0.3 QM 37 001 Exterior C Window Rgt Sash P Wood White 1.3 QM 38 001 Exterior D Wall L Lft I Wood Tan -0.3 QM 39 001 Exterior D Conner board Lft I Wood Tan -0.1 QM SEQUENTIAL REPORT OF LEAD PAINT INSPECTION FOR; Mr. Kyle Richard Belt Read Rm Room Paint Lead No. No. Name Wall Structure Location Member Cond Substrate Color (mg/cm') Mode 40 001 Exterior D Crawlspace Lft P Wood Tan -0.3 QM 41 001 Exterior D Soffit I Wood Tan -0.1 QM 42 001 Exterior D Fascia I Wood Tan 0.0 QM 43 001 Exterior D Rafter End Rgt I Wood Tan 0.0 QM 44 001 Exterior D Vent Pipe Ctr I Metal Tan 0-1 QM 45 001 Living Rm A Wall L Lft I Drywall Tan -0.1 QM, 46 001 Living Rm B Wall U Ctr I Drywall Tan -0.1 QM 47 001 Living Rm C Wall L Lft I Drywall Tan 0.1 QM 48 001 Living Rm D Wall U Rgt I Drywall Tan 0.1 QM 49 001 Living Rm D Window Lft Well P Wood White 0.5 QM 50 001 Living Rm D Window Lft Sash I Wood White 1.4 QM 51 001 Living Rm A Baseboard Lft I Wood White 0.0 QM 52 001 Living Rm A Crown Mlag Oft I Wood White 0.1 QM 53 001 Living Rm A Door Rgt Header I Wood White 0.0 QM 54 001 Living Rm: A Door Rgt Lft jamb I Wood Natural 0.2 QM 55 001 Living Rm A. Door Rgt L Lft I Wood Natural 0.1 QM. 56 002 Bedroom. C Door Rgt Lft casing I Wood White 0.2 QM 57 002 Bedroom C Door Rgt Rgt jamb I Wood White 0.0 QM 58 002 Bedroom C Door Rgt L Ctr I wood white -0.1 QM 59 002 Bedroom B Window Ctr Sill I Wood White -0.5 QM 60 002 Bedroom B 'Window Ctr Lft jamb I Wood White -0.1 QM 61 002 Bedroom D Baseboard Lft I Wood White 0.0 QM 62 002 Bedroom B Closet Rgt Door I Wood White -0•.2 QM 63 002 Bedroom B Closet Rgt Door Casing I Wood White 0.1 QM 64 002 Bedroom B Closet Rgt Door Jamb I Wood White 0.1 QM 65 002 Bedroom B Closet Rgt Shelf I Wood, White 0.1 QM 66 002 Bedroom B Closet Rgt Shelf Sup. I Wood White 0.0 QM 67 002 Bedroom B Closet Rgt Wall I:Drywall. White -0.2 QM 68 002 Bedroom B Ceiling I Drywall White -0.1 QM 69 002 Bedroom A Wall. L Rgt I Drywall White. 0.0 QM. 70 0.02 Bedroom B Wall U Lft I Drywall White -0.1 QM 71 002 Bedroom C Wall, L Ctr I Drywall White -0.1 QM 72 -- 002 Bedroom D Wall. U Lft I 'Drywall White -0.1 QM 73 003 Bathroom A Wall U Ctr I Drywall Green -0- 1 QM 74 003 Bathroom B Wall L Ctr I Drywall Green -0.3 QM" 75 003 Bathroom C Wall U Rgt I Drywall Green -0.3 QM 76 003 Bathroom D Wall L Lft I Drywall Green 0.0 QM 77 003 Bathroom C Ceiling I Drywall White -0.3 QM 78 003 Bathroom B Window Ctr Sill I:Wood White -0.2 QM 79 003 Bathroom B Window Ctr Apron I Wood White -0.1 QM 80 003 Bathroom A Cabinet Rgt I Wood. White -0.3 QM 81 003 Bathroom A Vanity Lft I Wood White -0.1 QM 82 003 Bathroom D Door Rgt Rgt casing I Wood White -0.2 QM 83 003 Bathroom D Door Rgt Lft jamb I Wood White -0- 1 QM 84 003 Bathroom D Door Rgt L Rgt I Wood White -0.2 QM 85 003 Bathroom D Closet Lft Door Casing I Wood White 0.0 QM 86 003 Bathroom D Closet Lft Door Jamb I Wood White 0.0 QM SEQUENTIAL REPORT OF LEAD PAINT INSPECTION FOR: Mr. Kyle Richard Belt Read Rm Room Paint Lead No. No. Name Wall Structure Location Member Cond Substrate Color (mglcm2) Mode 87 003 Bathroom B Baseboard Rgt I Wood White -0.1 QM 88 003 Bathroom A Attic Entry Ctr I Wood White 0.1 QM 89 004 Office A Wall U Lft I Wood Natural -0.1 QM 90 004 Office B Wall U Rgt I Wood Natural -0.1 QM 91 004 Office C Wall L Ctr I Wood Natural 0.0 QM 92 004 Office D Wall U Rgt I Wood Natural 0.0 QM 93 004 Office C Baseboard Lft I Wood Natural 0.0 QM 94 004 Office B Floor I Wood Natural -0.3 QM 95 004 Office B Window Lft Lft casing I Wood Natural -0.2 QM 96 004 Office B Window Lft Well I Wood White 0.3 QM 97 00.4 Office C Door Lft Rgt casing I Wood Natural 0.1 QM 98 604 office C Door Lft Lft jamb I Wood Natural -0.4 QM 99 004 Office C Door Lft U Lft I Wood Natural 0.0 QM 100 004 O€€ice A Closet Rgt Door I Wood Natural 0.0 QM. 101 004 Office A Closet Rgt Door Jamb I Wood Natural 0.1 QM 102 004 Office A Closet Rgt Shelf I Wood Natural 0.1 QM 103 004 Office A. Closet Rgt Shelf Sup_ I Wood Natural -0.1 QM' 104 004 Office A Closet Rgt Wall I Wood Natural 0.2 QM 105 005 Bedroom A .Door Ctr U Ctr I Wood Natural 0.0 QM 106 005 Bedroom A Door Ctr Lft jamb I Wood Natural 0.0 QM 107' 005 Bedroom A Door Ctr Header I Wood Brown 0.1 QM 108 005 Bedroom C Baseboard Lft I Wood Brown -0.1 QM. 10'9 005 Bedroom B Window Lft Rgt casing I Wood Brown 0.1 QM. 110 005 Bedroom B Window Lft Lft casing I Wood Brown -0.1 QM Ill 005 Bedroom B Crown Mldg Ctr I Wood Brown -0.1 QM. 112 005 Bedroom A 'Wall L Ctr I Wood Natural 0.1 QM 1.13 005 Bedroom B Wall U Rgt I Wood Natural 0.0 QM 114 005 Bedroom C Wall L Lft I Wood Natural 0.0 QM 115 005 Bedroom D Wall U Rgt I Wood Natural -0.1 QM 116 006 Bathroom A Vanity Ctr I Wood Natural 0.0 QM 117 006 Bathroom A Cabinet Lft I Wood Natural. -0.1 QM. 118 006 Bathroom. B Door Lft U Rgt I Wood Natural -0.2 QM 119 006.Bathroom B 'Door Lft Lft casing I Wood Brown -0.1 QM 120 006 Bathroom B Door Lft Rgt jamb I Wood Brown -0.1 QM 121 006 Bathroom D Baseboard Rgt I Wood Brown -0.2 QM 122 006 Bathroom C Closet Lft Door i Wood Brown -0.3 QM 123 006 Bathroom C Closet Lft Door Casing I Wood Brown 0.0 QM 124 00.6 Bathroom C Closet Lft Door Jamb i Wood Brown 0.0. QM 125 006 Bathroom C Closet Lft Shelf I Wood Brown 0.0 QM 126 006 Bathroom C Closet Lft Shelf Sup. I Wood Brown 0.0 QM 127 006 Bathroom C Closet Lft Wall I Wood Broom 0.0 QM 128 006 Bathroom D Heater Rgt I Metal Brown 0.0 QM 129 007 Storage A Wall U Rgt I Wood Brown -0.2 QM 130 007 Storage B Wall L Lft I Wood Brown 0.1 QM 131 007 Storage C Wall U Ctr I Wood Brown -0.2 QM 132 007 Storage D Wall U Lft I Wood Brown -0.2 QM 133 007 storage D Window Rgt Rgt casing I Wood Brown -0-.1 QM SEQUENTIAL REPORT OF LEAD PAINT INSPECTION FOR: Mr. Kyle Richard Belt Read Rm Room Paint Lead No. No. Name Wall Structure Location Member Cond Substrate Color (mg/cm') Mode 134 007 Storage D Window Rgt Sill I"Wood Brown 0.1 QM 135 007 Storage A Closet Ctr Door Casing I Wood Brown 0.0 QM 136 007 Storage A Closet Ctr Door Jamb I Wood Brown 0.0 QM 137 007 Storage A Closet Ctr Shelf Sup_ L Wood Brown 0.2 QM 138 007 Storage B Baseboard Lft I Wood Brown 0.1 QM 139 007 Storage B Crown Mldg Lft I Wood Brown -0.1 QM 140 0:07 Storage A Door Rgt Rgt casing I Wood Brown 0.1 QM 141 007 Storage A Door Rgt Lft jamb I Wood Natural -0.1 QM 142 007 Storage A Door Rgt U Rgt I Wood Natural 0.0 QM 143 008 Laundry A Wall U Ctr I Wood Natural -0.1 QM 14.4 008 Laundry B Wall L Lft I Wood Natural -0.1 QM 145 008 Laundry C Wall L Ctr I Wood Natural 0.1 QM 146 008 Laundry D Wall U Rgt I Wood Natural -0.2 QM 14.7 608 Laundry D Window Ctr Apron I Wood Natural -0.1 QM 148 008 Laundry D Window Ctr Sash I Wood Natural 0.1 QM 149 00.8 Laundry B Baseboard Lft I Wood Natural -0.1 QM 150 008 Laundry A Door Rgt Header I Wood Natural -0.1 QM 151 008 Laundry A Door Rgt Rgt jamb. I Wood Natural 0.0 QM 152 008 Laundry A Door Rgt-L Rgt i"Wood Natural 0.0 QM 153 008 Laundry C Closet Ctr Door I Wood Natural -0_2 QM 154 008 Laundry C Closet Ctr Door Casing I Wood Natural -0.1 QM 155 008 Laundry C Closet Ctr Wall I Wood Natural -0.2 QM 156' 008 Laundry C Closet Ctr Wall I Wood Brown -0.1 QM 157 008 Laundry C Floor P Concrete Grey 0.0 QM 158 009 Kitchen A Cabinet Lft 1 Wood White o.0 QM 159 G09 Kitchen D Window Ctr .Sill I Wood White -0.1 QM 160 009 Kitchen C Door Rgt U Rgt I Wood Natural -0.2 QM 161 009 Kitchen C Door Rgt Header I Wood Grey -0.4 QM 162 009 Kitchen C Door Rgt Lft jamb I Wood Grey -0.1 QM 163 009: Kitchen C Baseboard Lft I Wood Grey 0.0 QM 164 009 Kitchen C Chair rail Lft I Wood Grey -0.1 QM 165, 009 Kitchen A Wall L Ctr I Wood Grey -0.1 QM 166 009 Kitchen B Wall L Rgt I Wood Grey 0.0 QM 167 009 Kitchen C Wall L Lft T Werad- Grey -0.1 QM 16.8 009 Kitchen D Wall L Ctr I Wood Grey -0.1 QM 169' 009 Kitchen A Wall U Lft I Drywall Grey -0.1 QM 170 009 Kitchen B Wall U Ctr 1 Drywall Grey -0.3 QM 171 069 Kitchen C Wall U Ctr i Drywall. Grey -0.1 QM 172 CALIBRATION 0.8 TC 173 CALIBRATION 0.8 TC 174 CALIBRATION 0.8 TC ---- End of Readings ---- Risk Assessment Summary Part l: Identifying Information: A lead -based paint inspection and a risk assessment were conducted at the residence of Wes & Maggie Mouser, 1628 Broadview, Fayetteville; Arkansas. Frank & Juanita Terry, certified inspectors and risk assessors, Arkansas certification numbers 000327 & 000328 and 000325 & 000326, conductedthe inspection and risk assessment on May 15, 2014. Lead Technologies is an Arkansas lead -based paint consulting firm; license number 000606. Part 2: Results: List of Locations and Type of Identified Lead Hazards: The exterior was covered with wood clad. The overall condition. of the exterior and interior of the house was intact except for some of the windows which were in poor condition. Deteriorated lead -based, paint was found on the exterior of the house on the window components. Non -deteriorated lead based paint was found on the fascia, the front porch column s and the front porch ceiling and porch supports, and on the rafter ends.. Environmental dust wipe samples were collected throughout the house to evaluate the lead. in dust concentrations. The lead in dust was .above the HUD standard for the windowsills. The HUD standards are 40 ug/ft2 for the floors; the windowsills. are at 250 ug/ft2 and the window troughs are set at 400 ug/ft2. Using these criteria, the lead in dust is considered a hazard. One soil sample was collected at the perimeter of the house on sides A, B, C and D; the soil was mostly covered. The soil lead level was less than 49 (ug/g) for the perimeter sample. That level is below the EPA Guidance'Ievel: for soil. The .current EPA Guidance level for soil is 1,200 ug/g for bare soil at building perimeters and yard areas and 400 ug/g for bare soil play areas. Using these criteria; the covered soil is not considered a.lead hazard. Part 3: Lead hazard Control and Estimated Costs; A licensed lead -abatement contractor or an E.PA RRP certified contracting film, using certified renovators, as directed in 745.89 shall conduct the lead work. The Contractor shall comply with EPA 40 CFR Part 745 orHUD Lead Safe Housing rule, June 2004. a. The Contractor shall post signs clearly defining the work area and warning occupants or other persons not involved in the renovation to remain outside the work areas. The occupants are not permitted to enter the worksite during hazard reduction activities, until after hazard reduction work has been completed and clearance is achieved. b. Before beginning the renovation, the firm must isolate the work area so that no dust or debris leaves the work area while the renovation is being performed. In addition, the firm must maintain the integrity of the containment by ensuring that any plastic or other impermeable materials are not torn or displaced. During all exterior work that will disturb lead -based paint, the windows, doors, ventilation intakes and other openings in or near the worksite (within 20 feet of the renovation) shall be sealed. during the hazard control work. For interior work close all windows and doors in the work area, cover with plastic sheeting to confine dust and debris. Cover the ducts opening with plastic sheeting. The firm must ensure that the containment does not interfere with the occupantand. worker egress in an emergency. c. Ensure that doors within the work areas that will be used while the job is performed are: covered with plastic that allows workers to pass through while confining the dust and debris. d. Cover the ground or area with. plastic or other disposable .impermeable material extending 10 feet beyond the work or a sufficient distance to collect falling debris. If the property line is within 10 feet of the property line, a vertical containment roust be erected.: to prevent the migration of contamination (dust and debris). e. The work practices listed below are prohibited during renovation: l.) Open flame burning or torching of painted surfaces. 2) The use of machines through high speed operations such as sanding, grinding, power planning, needle gun, abrasive blasting, or sandblasting unless equipped with HEPA vacuum attachments to collect dust and debris at the point of generation. The machines must be operated so that no visible dust or release of air occurs outside the shroud or containment system. a) Opexating;a heat gum or painted surfaces is permitted only at temperatures below 1,100 degrees Fahrenheit.. f. All waste must the contained to prevent the release of dust and debris. g. A. thorough clean ng:shall be conducted on the exterior and interior of the property. Interiors must .be wet wiped -and. HEPA vacuumed to remove dust, debris and residue.. h. Clearance testing must be conducted at the completion of all rehabilitation work to ensure that any existing lead contamination is removed. If the rehabilitation cost exceeds $25,000, then a licensed lead -abatement contractor will be required to conduct all the lead work. Hazard f: Deteriorated Paint — Deteriorated lead -based paint was found on the exterior of the house on the window components. a. Place visqueen below/around the exterior work areas to contain the paint chips. Seal the interior window area with visqueen to limit dust migration to the inside. Remove and replace the windows with new windows. Conduct a thorough cleanup of the interior using the HEPA vacuum/wet wash methods. Clean up any paint chips on the ground. $5,500.00 Hazard 2: Elevated Lead Dust Concentrations - The lead in dust concentration was above the HUD standards for the window troughs. a. Conduct a thorough cleaning of all the windows, floors and/or horizontal surfaces throughout the house and porch. Cleaning shall be conductedutilizing the HEPA vacuum, wet wash, HEPA vacuum sequence or other method of equivalent efficacy. $1,800.00 Part 4 Summary and Ongoing Monitoring Recommendations: A lead -based paint inspection and risk assessment was conducted on May 15, 2014. Deteriorated lead -based paint was found to be a hazard and the lead in dust concentrations exceeded the standard for the window troughs. HUD recommends ongoing monitoring of dwellings by reevaluations and visual examinations of all properties containing lead -based paint or lead -based paint hazards. A reevaluation is a risk assessment that includes more limited soil and dust sampling and a detailed visual examination of paint films and any existing lead hazard controls (such as enclosures). According to the finding of this survey, a. reevaluation should be conducted in one year. The reevaluation should be conducted by a certified risk assessor and should include both a visualexamination and. environmental sampling for lead contaminated dust. A visual survey (by the owner or owner's representative) should be conducted annually and whenever information indicates a possible problem. According to the HUD regulations; notification of the results of this lead -based paint risk assessment must be provided to the occupants within 1.5 days of receipt of this report. J to Terry, Certified re!'000326 sessor Arkansas certification n Chapter 5: Risk Assessment Form 50 Resident Questionnaire (To be completed by risk assessor via interview with resident.) Children/Children's Habits l . (a) Do you have any children that live in your tome? No (If no children, skip to Question 5) (b) If yes, how many? NIA (c) Record blood lead levels, if }mown. (d) Are there women of childbearing age preseit? No I nrarinn nfthP rnnms/areas where each child sleeps_ eats_ and olays. Name of child Location of Bedroom. Location ofall rooms where child eats Primary location where child plays indoors Primary location. where child plays outdoors 3. Where are toys stored/kept? 4. is there any visible evidence of chewedor peeling paint on the woodwork furniture, or toys. Family Use Patterns 5. r Which entrances are used most frequently? 6. Which windows are opened most frequently? 7. Do you use window air conditioners? If yes, where? (Condensation often causes paint deterioration) 8. (a) Do any household members. garden? (b) Location of garden. (c) Are you planning any landscaping: activities that will. remove grass or ground covering? 9. (a) How often is the household cleaned? (b) What cleaning methods do you use? 10. (a) Did you recently complete any building renovations? (b) If yes, where? (c) Was building debris stored in. the yard? If yes, where? l l . Are you planning any building renovations? if yes, where? 12. (a) Do any household members work in a lead -related industry? (b) If yes, where are dirty work clothes placed and cleaned? N/A NIA Front All Yes, Back bedroom MO_ N/A Yes Weekly Sweet). mot). vacuum, dust No N/A No Yes. City of Fayetteville No. N/A Chapter 5: Risk Assessment Form 5.1 Building Condition Form Condition Yes No Roof missing parts of surfaces (tiles, boards, shakes, etc.) X Roof has Boles or large cracks x Gutters or down spouts broken NIA Chimney masonry cracked, bricks .loose or inissing, obviously out of plumb NIA Exterior or interior walls have obvious large cracks or holes, requiring more than routine pointing (if masonry) or painting X Exterior siding has missing boards or shingles X Water stains on interior walls or ceilings X Plaster, walls or ceilings deteriorated X Two or more windows or doors broken, missing; or boarded rap X Porch or steps have major elements broken, missing, or boarded up Y. Foundation has major cracks, missing material, structure leans, or visiblyunsound X x Total number Z 7 s: If the Yes column has two or more checks, the dwelling is usually considered to be -in poor conditionfor the purposes of a risk assessment. However specific conditions and. extenuating circumstances should be considered before determining the final condition of the dwelling and the appropriateness of a lead hazard screen. Notes: Some of the windows had been, replace and some were old wooden windows. The living room had ceiling damage. There were water stains in the kitchen, laundry room, storage room and the back bedroom. According to the Homeowner, the roof had been repaired and there were no active water leaks. There .had been significant water damage to the front bedroom due to water intrusion from the outside. Chapter 5': Risk Assessment Form 5.2 Paint Conditions on Selected Surfaces (Single -Family, Owner -Occupied) Building component Location Notes Paint condition (intact, fair, poor, or not present) to be completed by risk assessor Deterioration due to friction or impact? Deterioration due to moisture? Location of painted component with visible bite marks Building siding INTACT NO NO NO Exterior trim Fascia FAIR NO YES NO Exterior windows POOR YES YES NO Exterior doors SfaSii FAIR YES YES NO Railhogs: FAIR YES YES NO Porch floors Back porch POOR YES YES NO Other porch surfaces- INTACT NO NO NO *Interior doors FAIR YES NO NO Ceilings FAIR NO YES: NO Walls FAIR YES YES NO Interior windows POOR YES YES NO interior floors . Laundry room POOR YES NO NO Interior trim FAIR YES NO NO Stairways NIA Radiator NIA Kitchen cabinets INTACT NO NO NO Bathroom cabinets. Stain INTACT NO NO NO Other surfaces If the: overall condition of a component is similar throughout a dwelling, that condition should be recorded. If a component in a couple of locations is to poor condition, but the overall condition is good or fair, the specific sites. of the badly deteriorated paint should be noted. The specificlocations of any component with:bite rnarks.should he recorded. Chapter 5: Risk Assessment Form 5.3 Field Sampling Form for Dust (Single -Surface Sampling) Name of risk assessor: Juanita Terry Name of property owner: Wes & Maggie Mouser Properly address: 1628 Broadview, Fayetteville, Arkansas Dwelling selection protocol: x All dwellings Targeted Worst case Random Target dwelling criteria (check all that apply) Code violations x. Judged to be,:in poor condition Presence of two or more children between ages of 6 months and 6 years Serves as day-care facility Recentlyprepared for re -occupancy Sample number Room (record name of room used by the owner orresident) Surface type (circle the type) Wood Is surface smooth and cleanable? Dimensions of sample area (inches x inches) Area aa) Result of lab analysis (jig(W) 5/152014 Wl.. office Floor Yes 12x12 1.00 <1.0.0 W2 'Living room. Window trough Yes 39.5x4.25 L17 2,058.4 W3 Kitchen Floor Yes 12x12 1.,00 <10.0 W4 Kitchen Window sill Yes 28x3.25 0.63 <15.9 W5 Laundry room .Floor Yes 12x12 1.:00 24.6 W6 Office - - Window trough Yes 28x4.25 0,83 451.2 W7 Bathroom Floor I Yes 12x12 1.00I <10.0 1ti18** I Bathroom Window sill I Yes 28x4.25 9.83 1 <1.2.0 "*Blind plank ' Measure to the nearest .1/8 inch, HUD standards: 40 µglitl(floors), 250 µg/ft'- (interior windowsills), 400 l:tg/ft' (window troughs) Total number of samples on this page 8 Page 4 of 5 Date of sample collection: 5/15/2014 Date shipped to lab: 5/19/2014 Shipped by: Juanita Terry Received by: See laboratory chain of custody .form Chapter 5':.Risk Assessment Form 5.4 Field Sampling Form for Soil (Composite Sampling Only) Name of risk assessor:_ Name of property ourner Wes & Maggie Mouser Property, address:. 1628 Broadview. Fayetteville Arkansas Sample number Location Bare or covered Lab result (µg/g) 5/15/14/St Building perimeter sides A,B,C,D: Mostly Covered 49 HUD interim. standard for play area 400 HUD interim standard for perimeter 1,200 Collect only the top 1/2 inch of soil. Total, number of samples on this page I '.Page 5 of 5 Date of sample collection: 5/15/1:4. Date shipped to lab: 5/19/14 Shipped by: Juanita Te►y _ Received by: See lab chain of custody form. SCHNEIDER LABORATORIES GLOBAL INCORPORATED 2512 W. Cary Street • Richmond, Virginia • 23220-5117 804-353-6778. 800-785-LABS (5227) (FAX) 804-359-1475 Over 25 Years of Excellence in Service and Technology LABORATORY ANALYSIS REPORT Lead Analysis based on EPA 7000B Method Using Preparation Method EPA 3050E ACCOUNT #: 647-14-3341 CUSTOMER: LEAD TECHNOLOGIES DATE RECEIVED: 5/21/2014 ADDRESS: 1922 Sunnyland Road DATE ANALYZED: 5/21/2014 Mountain View, AR 72560 DATE REPORTED: 5/21/2014 PROJECT NAME: City Of Fayetteville JOB LOCATION: 1628 Broadview PROJECT NO.: PO NO.: Sample Type: WIPE SLI Customer Collection Sample Sample Total Lead Sample Sample Date Description Area Lead Conc No. No- (ft2) (pg) (Ilg/fie) 32217737 5-15-14 W 1 5/15/2014 10:00 AM Office Floor i.00 < 10.0 < 10.0 322/7738 5-15-14 W 2 5/15/2014 10:00 AM Living Rm W Trough 1.17 2,408.3 2,058.4 32217739 5-15-14 W 3 5/15/2014 10:00 AM Kitchen Floor 1.00 < 10:0 < 10.0 32217740 5-15-14 W 4 5/15/2014 10:00 AM Kitchen W Sill 0.63 < 10.0 < 15.9 32217741 5-15-14 W 5 5/15/2014 10:00 AM Laundry Floor 1.00 24.6 24.6 32217742 5-15.14 W 6 5/15/2014 10:00 AM Office Window well 0.83 374.5 451.2 32217743 5-15-14 W 7 5/15/2014 10:00 AM Bath Floor __. 1.00 < 10.0 < 10.0 .32217744 5-15-14 W 8 5/15/2014 10:00 AM Bath W Sill 0.83 < 10.0 < 12.0 Analysis Run ID: 53431 Analyst: MARTI H. BAIRD Total Number of Pages in Report: 1 Reviewed By Mohammed Eltilib, Metals Team Leader Results relate only to samples as received by the laboratory. Visit www.siabinc.com for current certifications. Final concentration calculations are based on client supplied information. Accrediting bodies: AIHA-LAP, LLC 100527, NVLAP 101150-0, VELAP/NELAC 460135 - Call laboratory for current national and state certifications. Minimum Reporting Limit: 10.0 jig. EPA Lead Hazard Std. 40 ug/it2 floors (please check lead wipe EPA HUD limit in your state) and 250 ug/ft2 interior window sills, based on weighted avg of all samples taken. EPA Clearance Std. 40 Pg/ft2 floors, 250 ug/ft2 interior window sills, 400 ug/ft2 window troughs. MDLs and resulting reporting limits are based on ASTM E 1792 compliant media. `Data precision justifies 2 sig figures. All internal OC parameters were met. Unusual sample conditions, if any, are.described. M [ t SCHNEIDER EASORATORIES GLOBAL,I WorkOrdje{]rjK,e jj ppll(� I (11 1�� 11±it 251 l+Vt �t Cary St►eet Ricf mo •d,°Virginia 211'20 511� 11 Q 11 il� j� 111 � tt 804-351.6778 • 8,30-785 ABS (522 7)•• Fax 804-:359-1475 1 1 1 tl 8 t� - _ icom CO. LVAD"ftGUMOL'odfas. ^S01-373-8644 ra ectt�iarttt: _ rr> es i Location: ! ' 5 eciatstntr tianx iiiCltfe racrsls r"c+r r,c1a. rrz orYi t w stJif ; acra es Ffi — — �: ,_..._ ----.. �.._ 3txta CUiCattaction _.... r --• Lt Nwrii:ar _ ._..�._..� � `turn Around Tfir� F�s�fiiK f �aiei ue. fS�iy%t DIP ' rants f a rat�^��,is "A E that a ' i � _ �•�_� �_ Q z t,auts' fomr�YroltS!?baf4A3E AsSostes AiF f fff2ttPCUfYtiC5��14YbNStaS 133U1k1 A 3b 1D t�lrsamptes an 4 raNfx tEve. Usa ack 'fauna! %rrors a6vd d - - �[� ,___ 'iHF tcF6•rn�,,' s:m,�. _^� -- `t_l (� Satre day` OPCM (NIOSH 7400) FLtA (t PA 60 ),t !zo!116) Leba 0 1 is mess day' r� rAir 0 sts!If �OTEM (Atd2:' A) rjPue. 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A --area S--blank P=parson E=oxCetextan_.. �Begitux?ng/End of 5ampte.Pariod 3tTump GBttbr tton to Liters 'Voluma in Liters (t[me In min* itaw in Umtn] ampiad elmquistied to lain h..a..t•' D FX n- tip" lAhA13 1Fi§hE. r 24 • -` Li ctp tGNilrtil --' _ ti;NArufk ("j cse ATEr .,,AE ATFITiME � � WB. j h .otCustad do�.=2-nr:i , m Team comJCoASl33oez, Sam le returns U ste& .Ambienttamp173 Ice _' -M pt4 CIS S X< CITY of 7ayN 711c ARKANSAS STANDARD BID PROPOSAL FORM PROJECT NUMBER: 62123-1410 DATE ISSUED: 07-21-2014 DATE AND TIME OF OPENING: Monday, 4:00 pm, August 4, 2014 OWNER'S NAME: City of Fayetteville -PROJECT ADDRESS: 1628 N. Broadview Dr., Fayetteville, AR 72703 ATTENTION The City has the right to select which of the items listed below will be completed based on the amount of funds available. *In blanks below please quote price for each item and the total for project at the bottom. A) Electrical: B) Siding: C) HVAC: D) Windows: E) Insulation: F) Gutters: G) Ceiling Tiles: H) Deck Railing: I) Trim & Paint: J) Cleanup: K) Other: Mailing Address: 113 W. Mountain Street Fayetteville, AR 72701 COMMUNITY RESOURCES ~0ayettevi lle-ar.gov MY TOTAL BID PRICE FOR THIS PROJECT IS $ Upon signing this Bid, the bidder certifies that they have viewed the property, read and agree to the requirements set forth in this bid proposal, including specifications, terms and standard conditions, and pertinent information regarding the articles being bid on, and agree to furnish these articles at the prices stated. Complete Business Address: Name of Firm: Phone # Residential Contractor's License number Street address or P.O. Box City / State/ Zip Code Printed Name: Signature: Title: CITY OF Ta—Ile ARKANSAS COMMUNITY DEVELOPMENT BU REHABILITATION CONTRACT THIS CONTRACT, executed this 18th day of September, 2014 BETWEEN Wesley & Margaret Mouser 1628 N. Broadview Dr. Fayetteville, AR 72703 Hereinafter referred to as the "Owner" whom resides at the stated property and Evans Construction and Remodeling LLC 1123 Crutcher St. Springdale, AR 72764 Hereinafter referred to as the "Contractor" whom warrants themselves to be licensed and qualified to perform the work specified herein and APPROVED BY the City of Fayetteville, hereinafter referred to as the "City," IN CONSIDERATION OF THEIR MUTUAL COVENANTS, THE PARTIES AGREE AS FOLLOWS: 1. EFFECTIVE DATE: This document shall have no force or effect unless and until executed by the Owner and Contractor, and approved by the City of Fayetteville. A properly executed and approved copy shall be mailed to the Contractor at the address shown above. The date on which the copy is mailed shall be referred to as the "Effective Date." If a properly executed and approved copy of this Contract is not mailed on or before thirty (30) consecutive calendar days from the date of execution, the Contractor is not bound by the terms of this Contract. If however, a properly executed and approved copy of this Contract is mailed after that date, and the Contractor subsequently performs work on or delivers materials to the Property, the Contractor shall be bound by this Contract. The Contractor shall not be compensated under this Contract for work commenced or materials delivered to the Property before the Effective Date. 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF r Teele ARKAN5A5 NITY DEVELOPMENT BLOCK GRANT PROGRAM 2. THE CONTRACT: This Contract consists only of this Part I (Specific Terms), Part II (Standard Terms), and the following attachments: A. Description of Work Specifications — (dated 7-17-2014 ) B. Community Resources, Housing Rehabilitation General Specifications C. Payment Schedule 3. TIME FOR COMMENCEMENT AND COMPLETION: The Contractor agrees to commence, or cause to be commenced, the actual work described in the Description of Work, on start date per Notice to proceed. The Contractor agrees to complete, free of liens or rights of liens of contractors, mechanics, material men or laborers, all work listed in the Description of Work within Thirty (30) days from the start date per the Notice to Proceed If work has not been completed by such date, subject to extensions approved by the Owner and the City for the period of any excusable delays (e.g. strikes, acts of nature or other reasons beyond the control of the Owner or Contractor) the Contractor shall be assessed liquidated damages in favor of the City in the amount of Twenty-five Dollars ($25.00) per day for each calendar day proceeding the effective date, as stated above. If, for any cause, the Contractor fails to fulfill in a timely and proper manner the obligations under this contract, the City shall have the right to terminate this contract by giving a written notice to the Contractor of such termination and specifying the effective date of such termination. Upon termination of a contract, the work accomplished in the specified manner under this contract shall be compensated for in a manner based upon the itemized bid submitted by the Contractor prior to the initiation of this contract. If work has not been started by said date, this contract may be considered null and void, all housing assistance contracts of the Contractor, approved but for which Notices to Proceed have not been issued, may be considered null and void, and the "City" will have the right to consider the Contractor ineligible to bid future projects. 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF T. Neville ARKANSAS 4. CONTRACT PRICE: The Contractor agrees to accomplish work as described in the Description of Work in accordance with each and every term and condition of this Contract, for a total contract price of Thirty-two thousand & sixty-five dollars ($32,065.00) The price of specific items of work is stated in the Description of Work and/or the Bid Proposal Form. 5. PROGRESS PAYMENTS: The Contractor agrees that the total contract price shall be paid in one payment 100% completion, two payments 50% progress and 100% completion, or three payments 40% progress, 70% progress, and 100% completion, based upon the value of the work completed at the time the progress payment is requested. Such progress payments shall be disbursed at the time and in the amounts specified in the Payment Schedule (attachment C), after inspection and approval of the work by the Owner and the City, less a retainage of ten percent (10%) of the price of the work completed. The retainage shall be retained until final payment in order to protect the Owner from any default by the Contractor. 6. CONTRACTOR: In the event the Contractor defaults, the retainage shall be disbursed in accordance with Part II, paragraph 10 of this Contract. Final payment shall be due upon satisfactory completion and acceptance of the work as in compliance with this Contract by the Owner and the City, permit sign -off, submission of satisfactory wavier(s) of liens satisfactory to the Owner and the City indemnifying the Owner against any lien, and submission of all warranties and guarantees. The Owner shall not withhold payment to the Contractor except for noncompliance with the terms of this Contract, and shall not request the Contractor to perform work outside the scope of this Contract as a condition of receiving payment. Retainages will be held until all inspections required by the City have been performed and passed. The Contractor acknowledges that it is a material breach of this Contract to request or accept a progress or final payment which is in excess of the price of the work completed at the time such payment is requested, less the required retainage. 7. WARRANTY: The Contractor warrants that all improvements, hardware and fixtures of whatever kind or nature to be installed or constructed on the Property by the Contractor or Contractor's subcontractors will be of good quality, 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF ellevit ARKANSi Y DEVELOPMENT suitable for their purpose and free from defects in workmanship or materials, or other deficiencies. The Contractor agrees that before final payment is made on a completed and approved project, the Contractor will furnish the Owner and City, (1) manufacture's warranties and/or guarantees on all warrantable products and materials installed in the project, including but not limited to: asphalt shingles, water heaters, and furnaces and other heating equipment and (2) Contractor's warranty which is valid for one (1) year from the date of final inspection. The Contractor agree to remedy any defects in the Contractor's work and materials and any damage resulting there from which may appear within a period of one (1) year from the date of final acceptance of the work which is the date upon which final inspection was performed. 8. PARTIES TO CONTRACT: The Owner and Contractor agree that they are the sole parties to this Contract and are solely responsible for its performance. The parties agree that the neither the City nor the United States Department of Housing and Urban Development assumes any liability or responsibility whatsoever for the performance of any term of this Contract. The owner(s) WILL NOT perform or hire another contractor to perform any type of construction related repairs, improvements, or modifications to his/her/their home as of the date of this contract through the final inspection phase which will be performed by the City or The Community Resources Division. Failure to comply with this section will cause this project to be placed on hold until the unauthorized repairs, improvements, or modifications have been completed. The Owner agrees that only the items listed in the Contract and Description of Work are to be accomplished by the rehabilitation project. The owner agrees that he or she will provide notice of defects in workmanship or materials installed in the project within a reasonable period of time (30 calendar days). The Contractor will not be responsible for defects caused by acts of the occupants, by occupant's abuse, neglect or inadequate maintenance, or by Acts of God. It is recognized by the parties that the City shall make a grant and/or loan to the Owner which shall be used to pay in whole or in part the cost of the contract, subject to additions and deductions in written and signed change orders, as provided in the Description of Work and Housing Specs of the contract. The Contractor agrees that the CDBG Programs Administrator shall 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF Tay �Vlle ARKANSAS have the right to act for the owners in taking all actions necessary to insure the full and complete performance of the obligations of the Contractor under this contract, and the Contractor agrees to hold the City harmless from and indemnify and the City against any and all claims from the owner or any third persons arising from the action of the Contractor with reference to this contract. 9. CONTRACT LIMITS: This Contract shall be deemed to be the entire Contract and no other work shall be done or monies paid for such work unless advance notice thereof is given to the City of Fayetteville Community Resources Division and the specific procedures set forth in the General conditions for Rehabilitation are followed. IO.STATEMENT OF WORK: The Contractor does hereby agree that, according to this Contract and for the price set forth hereinabove, he/she will furnish supervision, technical, personnel, labor, materials, tools, equipment, fixtures and services including transportation services, and perform and complete all work required in an efficient and workmanlike manner for the Rehabilitation of Property listed above. The Contractor shall not assign this Rehabilitation Contract without prior written consent of the Owner and said request for assignment of the Contract shall be submitted to the City of Fayetteville Community Resources Division. I LLEAD-BASED CLEARANCE TEST RESPONSIBILITES: The City will provide funding for no more than two clearance tests, where applicable. It is the sole responsibility of the Contractor to provide funding for any clearance tests needed after the first and second clearance tests provided by the City. EQUAL OPPORTUNITY PROVISIONS 1. CIVIL RIGHTS ACT OF 1964 COMPLIANCE During the performance of this contract, the contractor agrees to comply with the following requirement: Under Title VI of the Civil Rights Act of 1964, no person shall, on the grounds of race, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF 0 le Tay 1 ARKANSAS 2. SECTION 503 HANDICAPPED COMPLIANCE (IF $2,500 OR OVER) During the performance of this contract, the contractor agrees to comply with the following requirements: AFFIRMATIVE ACTION FOR HANDICAPPED WORKERS a) The contractor will not discriminate against any employee or applicant for employment because of physical or mental handicap in regard to any position for which the employee or applicant for employment is qualified. b) The contractor agrees to take affirmative action to employ, advance in employment and otherwise treat qualified handicapped individuals without discrimination based upon their physical or mental handicap in all employment practices such as the following: Employment, upgrading, demotion or transfer, recruitment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship. c) The contractor agrees to comply with the rules, regulations and relevant orders of the Secretary of Labor issued pursuant to the Act. d) In the event of the CONTRACTOR'S noncompliance with the requirements of this clause, actions for noncompliance may be taken in accordance with the rules, regulations and relevant orders of the Secretary of Labor issued pursuant to the Act. e) The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices in a form to be prescribed by the Director, provided by or through the Contracting Officer. Such notices shall state the contractor's obligation under the law to take affirmative action to employ and advance in employment qualified handicapped employees and applicants for employment, and the rights of applicants and employees. f) The contractor will notify each labor union or representative of workers with which it has a collective bargaining agreement or other contract understanding, that the contractor is bound by the terms of Section 503 of the Rehabilitation Act of 1973, and is committed to take affirmative action to employ and advance in employment of physically and mentally handicapped individuals. g) The contractor will include the provisions of this clause in every subcontract or purchase order of $2,500 or more unless exempted by rules, regulations, or orders of the Secretary issued pursuant to Section 503 of the Act, so that such provisions will be binding upon each subcontractor or vendor. The contractor will take such action with respect to any subcontract or purchase order as the 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF • aye ; e ARKANSAS PROGRAM Director of the Office of Federal Contractor Compliance Programs may direct to enforce such provisions, including action for noncompliance. 3. SECTION 109 OF THE HOUSING AND COMMUNITY DEVELOPMENT ACT OF 1974 COMPLIANCE During the performance of this contract, the contractor agrees to comply with the following requirements: No person in the United States shall on the ground of race, color, national origin, or sex be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity funded in whole or in part with funds made available under this title. a) Whenever the Secretary determines that a State or unit of general local government which is a recipient of assistance under this title has failed to comply with subsection (a) or an applicable regulation, he shall notify the Governor of such State or the Chief Executive Officer of such unit of local government of the noncompliance and shall request the Governor or the Chief Executive Officer to secure compliance. If within a reasonable period of time, not to exceed sixty (60) days, the Governor or the Chief Executive Officer fails or refuses to secure compliance, the Secretary is authorized to (1) refer the matter to the Attorney General with a recommendation that appropriate civil action be instituted; (2) exercise the powers and functions provided by Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000 d); (3) exercise the powers and functions provided for in Section III (A) of this Act; or (4) take such other action as may be provided by law. b) When a matter is referred to the attorney General pursuant to subsection (b), or whenever he has reason to believe that a State Government or unit of general local government is engaged in a pattern or practice in violation of the provisions of this Section, the Attorney General may bring a civil action in any appropriate United States District Court for such relief as may be appropriate, including injunctive relief. EXECUTION/SIGNATORIES TO AGREEMENT PROVIDED ON SUCCEEDING PAGE 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125 CITY OF J •7.1 ray Reville ARKANSAS COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM IN WITNESS WHEREOF, we have hereunto set our hands on the date first written above. Wesley Mous r, Owner f r Margaret ouser, Owner Randy Evans, Evans Construction and Remodeling LLC, Contractor Approved b3 By Yolanda Community 113 W MOUNTAIN ST I FAYETTEVILLE AR 72701 1 PHONE 479.575.8260 1 FAX 479.444.3445 Form CR 125