2009, 06-12 Permit App: 09001803 DemolitionSpokane
Valley
Community Development
Permit Center
11703 E Sprague Ave, Suite B-3
Spokane Valley, WA 99206
(509)688-0036 FAX: (509)688-0037
www.spokanevalley.org
Demolition
Permit Application
PERMIT NUMBE
R:>tc?(-5
PERMIT FEE:
n Commercial
Residential
SITE ADDRESS: I 0 6 `3 iTEv)ire_,
ASSESSORS PARCEL NO: 1:5 ( gri
wfl 2Yz06
mlding Owner
Name: (/any/ ‘543e
Address: /0,6 Z 3 4 1'
nr i re.. •
City•` kc!1
State: L,
e�
Phone: 53 !) 7 Z �0 f J Fax:
Zip: 99206
Cell z/6 o Si V -
Contact Person`;'
Na e: Clo /1,1 fih c, r� 54 _,L,
Pho :lt../lo -0SG t}
1escribe the scope of work in detail
i1G Gcrn, /74 id la oiwvo
ontracto
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contractor Lic No: Exp Date:
City Business Lic. No:
o A site plan is provided.
o Spokane County Utilities has' approved the disconnection.
o Notice of Intent #
The permittee verifies, acknowledges and agrees by their signature that: 1) Ownership of this City of Spokane Valley
Permit inure to the property owner. 2) The signatory is the property owner or has permission to represent the property
owner in this transaction. 3) All construction is to be done in full compliance with the City of Spokane Valley
Development Code. 4) This City of Spokane Valley Permit is not a permit or approval for any violation of federal, state or
local laws, codes or ordinances.
Ownership of resulting development rights granted by any issued permit inure to the property owner.
Signature
Method of Payment:
❑ Cash
Bankcard #:
Authorized Signature:
REVISED 2/16/07
❑ Check
Date 6,-- 1 0
❑ MasterCard
❑ VISA
Expires: VIN#:
V
* The $250 demolition fee is waived if demolition is performed in conjunction with asbestos project category 2, 3 or 4, above.
H.
J UN
JUN 1 7 2009
I.
Notice of Intent No. Spokane Regional� ;�� _ NOTICE R ASBESTOS ROFTINTS / E No s nt u 009
i
Agency Use Only 1 Clean Airy„ ��, ?, [�
i , , (�VOnl
Refer to the Agency's Renovation, Demolition, and Asbestos Information Sheet as well as Re. ulation I, Article IX
A. Project Type:
❑ Asbestos Removal
❑ Asbestos Removal & Demolition
!Demolition, No Asbestos Removal
Does this project involve a fire -damaged structure?: • Yes ►! o (If yes, refer to Sections 9.03.F.3 and 9.08)
Does this project involve demolition by fire training?: • Yes 4E1 No (See Sections 9.02.R, 9.03.F.4 & 9.04.A.6.f)
How many structures does this project involve?: / (If more than 1 structure, refer to Section 9.04.A.3)
B. Property Owner: kark I4.Sts i r
Phone: 9z -z--1.0 I,/
Fax:
Mailing Address: / 0C2 C -r r„p,'re j
City:.% . ,
/O j•1,,, ,
State: wit
Zip: k (J k
C. Site Address: /0 6-z -$. £ ,.,., f),,,-,. ,
LAY: ()Pc. ,
State:Ilk
Zip: 99 z_,0 i
Contact Person: An c &'c r-
Job Site Phone:2/6--0_51,4
D. N;] Asbestos Survey or
❑ Material Presumed
Date survey performed: b•- i 5 - 0 2'
AHERA Bldg. Inspector Name:
PkEL_ %3. r C
Was asbestos found? ❑ Yes Z No
Company:
AdthJ�•� 4sk,s¢
,pert. No.:
350 9\0 1 3 37 • Cli
E. Asbestos Removal
Information:
Start
Date:
Completion
Date:
Abatement By �j
(if known):
List individual type and
quantity of materials to be
removed. If >1 structure, list
materials for each structure
by address / location.
Total Square Feet:
Total Linear Feet:
Will all asbestos material be removed from the structure(s) by project completion? ❑ Yes ❑ No
F. Demolition
Information:
Start Date: ,n
(earliest) L� --�G— 0 9
By
(if known): CM) 49- , ,
G. Asbestos Project and Demolition Notification Waiting Period and Non -Refundable Fee Categories
Owner -occupied, single-family residence (see the Renovation, Demo., & Asbestos info. sheet)
Waiting Period
Fee
1. N All Demolition (all asbestos must be properly removed and disposed of prior to demolition)
Not owner -occupied, single-family residence
3 Days
Waiting Period
( $30
Fee
2. ❑ 10-259 In ft and/or 48-159 sq ft asbestos
3 Days
$250
3. ❑ 260-999 In ft and/or 160-4,999 sq ft asbestos
10 Days
$500
4. ❑ >_ 1,000 In ft and/or >_ 5,000 sq ft asbestos
10 Days
$1,250
5. ❑ All Demolition
10 Days
$250*
Additional categories
❑ I have completed and attached the Supplemental Notice of Intent (NOI) for emergency, alternate asbestos project work practices,
demolition with nonfriable asbestos roofmg, or exception for hazardous conditions.
* The $250 demolition fee is waived if demolition is performed in conjunction with asbestos project category 2, 3 or 4, above.
H.
Optional: List additional parties you would like copies of this NOI and/or related notices sent to (list name & fax number and/or mailing address):
I.
I certify that the information contained in this notification and any supplemental information provided is, to
the best of my knowledge, accurate and complete.
4_G --
lintlifecs Name: '0C Fax: Phone:1 Z/(,O}sbf
Completeness
eview
OI complete
0 N I deficient -
+ ached
J
Mailing Address: J✓V2i 3 C .,,-r...,
4j(?�i 99LC
Signature: ���AA›......c.1
Print Name: IJGs5c Ahem Q
�r
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Agency Use Only
Spokane Clean Air, 3104 E. Augusta Ave., Spokane, WA 99207-5384 / www.spokanecleanair.org / Ph.: (509) 477-4727 Fax: (509) 477-6828
Your advance notification period will begin when a completed NOI, including required nonrefundable fees, is received by SRCAA. NO1 11/08