2011, 07-18 Permit App: 11002126 DemolitionSpokane
Valley%
sommunity Development Department
ermit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcenter(&spokanevallev.orq
(Staff Use Only)
PERMIT NUMBER: t( P.92
PERMIT FEE:
5-0
DEMOLITION PERMIT APPLICATION
PROJECT ADDRESS: 10q/ 0
ASSESSORS PARCEL NO.: ')So '13 04 3 /
BUILDING OWNER NAME: Qp'6ji '&77-te) /!4//� "2
MAILING ADDRESS:
A) .33 0,3 Gv 1 //f » .s A -L
CITY: 51)494' gam" 1/4lf STATE:
CONTACT PERSON NAME: �di�I pi 0;92_
ZIP:
PHONE: 52J ! —') f d (3 ` 7 FAX:
CONTRACTOR NAME:
CELL:54 r 2i /3??
MAILING ADDRESS:
CITY: STATE:
ZIP:
PHONE: FAX:
CELL:
CONTRACTOR LICENSE No.:
a�
EXPIRES: CITY BUSINESS LICENSE NO.:
P JECT DESCRIPTION (Please Provide Site Sketch)
Site Plan Provided 0Notice of Intent #
0 Spokane County Utilities has approved the disconnection
Describe the scope of work in detail
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DISCLAIMER
The permitted verifies, acknowledges and agrees by their signature that: 1) if this permit is for construction or on a dwelling, the dwelling is/will
be served by potable water. 2) Ownership of this City of Spokane Valley permit inure to.the property owner. 3) The signatory is the property
owner or has permission to represent the property owner in this transaction. 4) All construction is to be done in full compliance with the City of
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) The City of
Spokane Valley permit is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additional
Information may be r uired to be submitted
edd and subsequently a..r. ed before this application can be processed.
Signature Gdt7f(% � Date: /
Updated 1-11-11 Page 1 of 1
http://www. spokaneva l ley.org/filestorage/ 124/938/210/948/ 1496/Demolition_Permit_1-11-11.doc
Notice of Intent No. Spokane
• Regional .-�(i
1 Agency Use Only 1 Ctean Ai
NOTICE OF INTENT
FOR ASBESTOS PROJECTS / DEMOLITION
YrA
Date Stam
•
-A
en Use Onl
Review Spokane Regional Clean Air Agency (SRCAA) Regulation I, Article IX and Section 10.09 for applicable requirements.
A. Project Type:
❑ Asbestos Removal
❑ Asbestos Removal Demolition
ix Demolition, No Asbestos Removal
Does this project involve a fire -damaged structure?:
■ Yes [A No
(If yes, refer to Sections 9.03.F.3 and 9.08)
Does this project involve demolition by fire training?:
■ Yes a No
(See Sections 9.02.L, 9.03.F.4 & 9.04.A.6.f)
How many contiguous structures does this project involve?:
1
Maximum of 5 structures per Notice of Intent (NOI)
B. Property Owner:
gob Q41 tJ- /11 VC Uei
Phone:
,Sof- 7/0- /Jy13a.x:
Mailing Address:
j 0 A,t, by, Cc iet,n ( R d
City:
5,Ma .I C Citi
tate:
GJ
Zip:
i q ..zo.
C. Site Address
Contact Person:
AA) Er 4kj, /l1 tJeLlc,,
Job Site Phone:
/1/Pit/
Structure #1:
- s-pdic-
/s99 /0 0= /MJQ; e , ph/6 _ #0,,,,,,,__-N6,
If >1 structure, provide details to identify,
#2:
C
#3:
' U/rt,l,1 t/ WA" nj C Z v (o
#4:
•
#5:
D. ❑ Material
Presumed
[Asbestos
Survey:
Date survey performed:
14242-01
AHERA Bldg. Inspector Name:
P h; 1 13 2 f 6 -
Was asbestos found?
❑ Yes No
Company:
f} A-
Cert. No.:
&IQ -- 10-09 (p
E. Asbestos
Removal
Start
Date:
Complet'
Date:
For each structure listed in section C, itemize the type and
quantity of asbestos -containing materials to be removed.
Total Linear Feet:
TotaJSquare Feet
Abatement By (if known):
Will all asbestos -containing matei al be removed from the structure(s) by the asbestos removal completion date?
❑ Yes ❑ No
F. Demolition
Information
Start Date:
(earliest)
6 V i'
liiimolition By,_
if known):
Q f J p. .4.. 1
G. Asbestos Project & Demolition Notification aiting Period and Non -Refundable Fee Categories (additional categories - pg. 2)
Your advance notification period will begin when a completed NOI, including required nonrefundable fees, is received by SRCAA.
Check / complete all boxes which a..1 , below. .
Owner -occupied, single-family residence (see the Renovation, Demo., & Asbestos info. sheet) Waiting Period Fee
1. ❑ >_ 101n ft and/or >_ 48 sq ft asbestos project not performed by residing owner
Prior Notice
$0
2. ❑ All Demolition (all asbestos must be properly removed and disposed of prior to demolition)
3 Days
. _ $30
Not owner -occupied, single-family residence
. Waiting Period Fee
3. ❑ 10-259 In ft and/or 48-159 sq ft asbestos (also for <10 In ft or <48 sq ft per Sect 9.04.A.6.a)
3 Days
$250
4. ❑ 260-999 In ft and/or 160-4,999 sq ft asbestos
10 Days
$500
5. ❑ >_ 1,0001n ft and/or >_ 5,000 sq ft asbestos (see below if >_ 2,000 In ft or >_ 10,000 sq ft)
10 Days
$1,250
If >_ 2,000 In ft or >_ 10,000 sq ft, the additional incremental fee added to the $1,250 base fee is calculated as the greater of:
Number of 1,000 In ft increments beginning at 2,000 In ft:
x $250 =
$
+ $1,250 base fee =
`
$ �
Number of 10,000 In ft increments beginning at 10,000 In ft:
x $250 =
$
+ $1,250 base fee =
$ Q
6. IN All Demolition (this fee waived if project performed with project category 3, 4, or 5, above)
1 10 Days
c1,24)
H. Acknowledgement. The Control Officer, or duly authorized representative, shall be allowed to access property at reasonable times to int projects
specific to the control, recovery, or release of contaminants into the atmosphere, in accordance with SRCAA Regulation I, Article II and RCW
70.94.200. For the purposes of renovation, demolition, and asbestos projects, reasonable times include, but are not limited to, any of the following:
when renovation, demolition, or asbestos removal appear to be occurring or are scheduled to occur, and times when the Control Officer or duly
authorized representative are investigating air quality complaints filed with the agency and/or have reason to believe that air quality violations have
occurred or may be occurring. No person shall obstruct, hamper or interfere with any such inspection. I certify that the information contained in this
notification�anod any sup emental information provided is, to the best of my knowledge, accurate and complete.
fI , t
Busi iessName^e r ess: Rte b-� V' + IN J. U Q. i ( Q V Fax?-�;1
Signature: /%ifi* Print Name: -e. ct-t G»-,QPhone`�D 4'► v — 13q
Agency Use Only:
❑ NOI Deficient (see page 2)
❑ NOI Complete
Page 1 of 2
g
ate & Initial
Date & Initial
SRCAA, 3104 E. Augusta Ave., Spokane, WA 99207 / www.spokanecleanair.org / Ph:(509)477-4727 Fax: (509) 477-6828
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I.
(Continued From Pg. 1) Asbestos Project and Demolition Notification Waiting Period and Non -Refundable Fee Categories
Your advance notification period will begin when a completed NOI, including required nonrefundable fees, is received by SRCAA.
Below are additional categories which may apply to the project categories
Check all boxes which apply, below. If applicable, provide all respective
Emergency Notification
7. ❑ Emergency
in 1-6, on page 1.
information required.
Reference Waiting Period Non -Refundable Fee
Section 9.04.A.6.h Prior Notice Twice the Regular Fee
Select the reason that best describes your situation:
❑ Sudden, unexpected event that resulted in a public health
❑ The project must proceed immediately to protect equipment,
❑ Asbestos -containing materials were encountered that were
❑ The .ro'ect must iroceed to avoid im.osin_ an unreasonable
Amendment
Annual Notification
- ' 1 ..j' W
or safety hazard.
ensure continuous vital utilities, or minimize property damage.
not identified during the asbestos survey.
financial burden.
Refer to NOI Amendment form (Section 9.04.B)
Refer to Annual NOI form (Section 9.04.A.6.j)
' e e 1 ce W • iti 1 Peri d N -Ref dable Fee
8. ❑ Alternate Asbestos Project Work Practices
Section 9.08.A 10 days Twice the Regular Fee
Exception for Hazardous Conditions
9. ❑ Exception for Hazardous Conditions
Reference Waiting Period Non -Refundable Fee
Section 9.08.0 10 days Regular Fee
Name of person that prepared the Alternate Work Plan:
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Company he/she represents:
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His/her certified AHERA Project Designer No.:
at( C
His/her Certified Industrial Hygienist (CIH) number or
Professional Engineer (PE) license number:
Demolition with Nonfriable Asbestos_Roofmg _ _..,. '_ _..
10. ❑ Demolition with Nonfriable Asbestos Roofing
__Reference ..,_ __ :,Waiting_ Period_-_ __Non -Refundable- Fee
Section 9.08.B 10 days Twice the Regular Fee
Name of person that determined that nonfriable asbestos
roofing material could be left in place per Sect. 9.08.B:
Company he/she represents:
His/her certified AHERA Project Designer No.:
,
J.
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):
Agency Use Only. 1L
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SRCAA, 3104 E. Augusta Ave., Spokane, WA 99207 / www.spokanecleanair.org / Ph:(509)477-4727 Fax: (509) 477-6828
Page 2 of 2
3/11