2003, 09-18 Permit App: BLD-03-02509 Fire Restoration1
1
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e
galley
PERMIT APPLICATION WORK SHEET
SPOKANE VALLEYCOMMUN/TY DEVELOPMENT
BUILDING DIVISION
11707 East Sprague Ave Ste 106 ,
Spokane Valley, WA 99206.
Phone: (509)688-0036 Fax: (509)688-0037
REQUIRED SITE INFORMATtON
STREET ADDRESS:. ,lit 2 c" 4/*(711 d, _
ASSESSOR'S TAX PARCEL NUMBER(S):
LEGAL DISCRIPTION:
PERMIT DESCRIPTION:
ITIi DING.PERMTT . • 0 CHANGE EN USE
QRELOCATION Q -SIGN
O GRADING
UTENANT
fOTHER-
OWNER / APPLICANT INFORMATION
OWNER:
PHONE: 9zs- /3/-/3&
ADDRESS: C�� ,
nom( C�. /11 N4, /•ii T(„STAr ,ZIP
CONTRACTOR: �yG���
PHONE: 31/ -S 0 A FAX: TO --577i6
CITY,. STATE, ZIP
ADDRESS:6 /S G
Q
APPLICANT:
PHONE:
FAX:
ADDRESS:
CITY, STATE, ZIP
ARCHITECT:
PHONE:
ADDRESS:
FAX:
CITY, STATE, ZIP
WA ST CONTRACTOR LICENSE # CONTACT:
PERMIT/BUILDING INFORMATION
COST OF PROJECT:
BUILDING HEIGHT TO PEAK:
BUILDING DIMENSIONS:
'NUMBER OF STORIES:
NUMBER of BEDROOMS:
FLANKING SETBACK:
FRONT SETBACK:
REAR SETBACK:
LEFT SETBACK:
30% SLOPES ON PROPERTY:
OCCUPANCY GROUP.
CONSTRUCTION TYPE:
STRUCTURES ON PROPERTY:
CRITICAL AREAS:
CURRENT PROPERTY SIZE:
CURRENT PROPERTY USE:
CURRENT SEPTIC USE:
CURRENT WELL USE:
RIGHT SETBACK: IMPERVIOUS SURFACE AREA:
MAIN FLOOR SQ FT:
2ND FLOOR SQ FT:
UNFIN BASEMENT:
FINISHED BASEMENT:
GARAGE:
COVERED DECK:
DECK:
Sep 18 03 03:08p derrick j Pincher
Labor and Industries
Industrial Hygiene Compliance
(Regional addresses and phone
numbers on page 2)
508-483-5126
P.3
NOTICE OF
ASBESTOS ABATEMENT
PROJECT
THIS NOTICE MUST BE RECEIVED NO LATER THAN 10 CALENDAR DAYS PRIOR TO THE START DATE
COMPLETE ALL APPLICABLE BOXES — INCOMPLETE OR ILLEGIBLE NOTICES WILL NOT BE ACCEPTED
MAIL OR FAX TO THE REGIONAL OFFICE — CIRCLE CHANGES ON AMENDED NOTICES
Notice date: 7 /a 1 / 13 3
Initial
■
Amended$ Site Work Hours Su Mo Tu We Tb Fr Sa
Start date: -1 /(/ Q3
On Hold
■
Off Hold
■
1MUO am
■ Duct paper
/
V
/
7-
�/
T
C Completion: % / 5 /O 3Y Emergency []
pin
y'.3 () m pm
Project Dates and Work Hours must be Exact
• Roofing
CONTRACTOR
PROPERTY OWNER
Company Name
3cCU\,r-o oc- (\L) Spc,ltiC ne.
Name
C\ OEc\rm kri\,n
Contractor Certification Number
131q
Owner's Ageot
f \ t -C-CA belc+n Cn\W ccP
Signature �.,!'..
Company
❑ Mag. pipe insulation
0 Cement asbestos pipe
Printed Name
Ot ccAc.k ' trmC t er
Address
‘33()% E.1'6\s nk,31\ ckel‘c,
PhoneNumber. ' rLC
Sal- (0
City State ZIP-I4
Spoti_Cx_r-Ve--
job Site C.A.S.
Tech C_J-‘c\ex
Phone number
«oca a1(0-7387
JOB SITE
FACILITY
t,,j
Address 3aO(o Sot A*An 46oL,C\,S� 1
/
-\
T f��tccn v\'C.L1
Building NajPe •Room
KeStCie f1\CA. \
Age � . Size t y � � 1 -a
T
City
3 �OV. CA ne_ Spokrkne WA
Remodel
II
Demolition
ZIP + 4 CtCOUCO County
® Repair
■
Maintenance
QUANTITY OF ASBESTOS TO BE:
® REMOVED
❑ ENCAPSULATED
Quantity t0O's square feet
® Indoors 0 Outdoors
CONTROL MEASURES
■ Fireproofing
1 Boiler insulation
® Popcorn ceiling
® Ncg. pres. enclosure
• Wrap & cut
■ Duct paper
0 VAT
F Wet methods
• CAB
■ Glove bag
❑ Sheet vinyl '
• Mini enclosure
El HEPA vacuum
• Roofing
❑ Other
el Critical barriers
Et Manual methods
• Asbestos paper
Quantity linear feet
■ Other
1 Other
❑ Mag. pipe insulation
0 Cement asbestos pipe
RESPIRATORY PROTECTION
• Mudded pipe ins.
a '/A mask APR
■ Type C continuous flow
• Air cell pipe insulation
■ Full face APR
® Type C pressure demand
■ Ducting/duct insulation
■ Duct tape
0 Other
■ Giber
IN Other
• PAPR
F413-025-000 notice of asbestos abatement project 9-02
SEP 15 2003 16:04
For clean copies go to http://www.hv.wa.gov/forms/
509 483 5126 PPGE.03