2009, 06-12 Permit App: 09001721 Demolition GarageSpokane
jValley�
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 NUMBER: 0
PERMIT FEE:
n Commercial
Residential
(1R1
SITE ADDRESS: &Y1 A. LOP,
ASSESSORS PARCEL NO:
$SITZ . 3
Building Owner:
Z
Name: 1 �1N,,i/)b l
Name: �ar►�e
e a uw l
City: I G State: Goa, Zip ZI
Address: 2 714
/) W,/1 �I C1] .i\''
l
City Business Lic
,401. 378 193
City: , 1 �`1,
/'
V'" tate: P �� \ Zip ?
VcrgcYYLL.E
7 /
'/
Phone7�
Fax:
7
C
12
Contac son
Name:
Phone:
tiref ( Cork r l c m
O Oi)" 32c, - 270
Describe the scope of work in detail
Contra r: �,s
1(moi wan113r bit.
Name: 1 �1N,,i/)b l
D1/'(rCl> n
Address:
,&XGOG2
City: I G State: Goa, Zip ZI
Phone `72 CN _ 2.7‘Q Fax:
Contr for c No- ate
EOME� ��lae6 6? -a3- o i,
City Business Lic
,401. 378 193
(f'_Y1AAQ'lo GchPa.
trr A site plan is provided.
K Spokane County Utilities has approved the disconnection.
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 . dinances.
Ownership of -sulti developm
Signature
Method of Pa ment:
❑ Cash Check
Bankcard #:
Authorized Signature:
hts granted by any issued permit inure to the property owner.
Date Oti - 12 — 0 iy
REVISED 2/16/07
❑ MasterCard
Expires:
❑ VISA
VIN#:
Untitled Page
General/Specialty Contractor
A business registered as a construction contractor with L8I to
perform construction work within the scope of its specialty. A
General or Specialty construction Contractor must maintain a
surety bond or assignment of account and carry general liability
insurance.
Business and Licensing Information
Name GEOMETRIC UBI No. 601378193
DESIGNZ
Phone 5093262760 Status ACTIVE
Address PO BOX 6062 License No. GEOMED*9730C
Suite/Apt. License CONSTRUCTION
Type CONTRACTOR
City SPOKANE Effective 9/3/2003
Date
State WA Expiration 9/3/2009
Date
Zip 99217 Suspend
Date
County SPOKANE Specialty 1 GENERAL
Business Individual Specialty 2 UNUSED
Type
Parent
Company
Business Owner Information
Name
Role
Effective Date
Expiration Date
CORKRUM, RUSSELL
OWNER
09/03/2003
Bond
Bond Information
Page 1 of 2
Insurance Information
Insurance
Bond
Bond
Effective
Expiration
Cancel
Impaired
Bond
Received
Bond
Company
Account
Date
Date
Date
Date
Amount
Date
6
Name
Number
12/11/200712/11/2008
$300,000.00
12/13/2007
2
AMERICAN
CONTRACTORS
100038878
12/17/2007
Until
Cancelled
$12,000.0012/24/2007
01/16/2007
4
INDEM CO
INSFB6783
09/02/200609/02/200701
/08/2007
$900,000.00
08/08/2006
1
CBIC
FB6783
09/02/2003
12/17/2007
10/17/2008
$6,000.00
09/03/2003
Insurance Information
Insurance
Company
NameDate
policy Number
Effective
Expiration
Date
Cancel
Date
Impaired
Date
Amount
Received
Date
7
PREFERRED
CONTRACTORS
INSURANC
PCIC5026PCA7924
12/11 /200812/11
/2009
$1,000,000.0012/03/2008
6
PREFERRED
CONTRACTORSPC4929
INS
12/11/200712/11/2008
$300,000.00
12/13/2007
5
ATLANTIC CAS
INS CO
L065006288
12/28/200612/28/2007
$300,000.00
01/16/2007
4
CBIC
INSFB6783
09/02/200609/02/200701
/08/2007
$900,000.00
08/08/2006
t,, -1-•••n• iii ..•11-.......•-• • ,, ,nr; .,r ire,.+,,:1
1'1 ')/'1(1(1(1
Untitled Page
Page 2 of 2
3
CBIC
INSFB6783
09/02/200509/02/2006
Status
Violation
Amount
P37582
$300,000.00
08/25/2005
2
CBIC
INSFCB6783
09/02/200409/02/2005
$300,000.00
08/31/2004
1
CBIC
INSFB6783
09/02/200309/02/2004
$300,000.00
09/03/2003
Infraction / Citation Information
Infration/Citation
Date
RCW Code
Type
Status
Violation
Amount
P37582
8/18/200418.106.020PLUMBER
(5)(b) RCW
INFRACTION
Satisfied
$250.00
i..,,. ,.._,r; n.i.;r ire ..,;i ii nn
* The $250 demolition fee is waived if demolition is performed in conjunction with asbestos project category 2, 3 or 4, above.
H.
hs
NOTICE OF INTENT
�,
JUN 12 2009 i�
Completeness
Review
�OI complete
❑ NOI deficient -
ee /Attacheddy
�//off, / ' 9 ,t7J
Notice of Intent No.,
Spokane ' �'v� FOR PROJECTS / DEMOLITION
t l;
Sr AkkivL riculUNAL
CLEAN AIR AGENCY
lPrint Name: 1 . . ' 1
�� '
Agency Use Only
Regional , .ASBESTOS
Clean Air, Date Stam, -A_ Use On
Agency Use Only
Refer to the A_enc 's Renovation, Demolitio irtc d Asbestos Information Sheet as,,,,i, ,as Regulation I, Article IX
A. Project Type:
l ❑ Asbestos Removal
I U' • estos Removal & Demolition �� .. olition, No Asbestos Removal.
ik
Does this project involve a fire -damaged structure?: ■ Yes (If yes, refer to S• ' 9.03.F.3 and 9.08)
►�o
Does this project involve demolition by fire training?: ■ Yes o (See Sections 9.02.R, 9.03.F.4 & 9.04.A.6.f)
How many structures does this project involve?: 1 (If more than 1 structure, refer to Section 9.04.A.3)
B. Property Owner: l
Phone^ f) 523-8 41 2
Fax:
Mailing Address: 2 1.4 .ic- \
City: e p
State: (jjk
Zip: ?9„9/2
C. Site Address:
City: rNe !$ll?�
State: f�
Zip: ��j
Person: ll�q p� f �-� r�Ya1'.f yh
��Contact
Job Site Phone d 26— 2T.
D.
Asbestos Survey or Date survey performed:VI' ')8
ARRA
Bldg Inspector Name:
0.€3y1 cs '1.-
Material Presumed) Was asbestos found? ❑\es No
`
Company:
vizo-r-
Cert. No.:
i�
, Q — 0 vL
E. Asbestos Removal
Information:
Start
Date:DC 22-
-
Completion
Date: () -22—
Abatement By`
(ifknown): ' 11(r)'u't/,( /1D4 eorJiQdp c 0€814.,
List individual type and
�l % on �,J r
�� rJ -Find {/
quantity of materials to be
removed. If>1 structure, list
materials for each structure
CJ
Total Square Feet:
Total Linear eet:
by address / location.
Will all asbestos material be remove from the structure(s) by project completion? Yes ❑ No
F. Demolition
Information:
Start Date:
(earliest) 66.-22- �) 6,
Demolition B
(if known): y� {
/f I 7
t rte Y, j,�:�ARA, 7 ;I '
l j/'
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. ❑ 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
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. ,0 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 roofing, 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 . s ledge accurate . d co H plete.
�/'�'�
Business Name: ��' i ' -1L I. I " ' i:. ax( P(n 2 y`(P(.Phone Z% 2
Completeness
Review
�OI complete
❑ NOI deficient -
ee /Attacheddy
�//off, / ' 9 ,t7J
,
Mailing Ad. s: ,
- .1_
P (� .:.i %
Signature: A ., _,
lPrint Name: 1 . . ' 1
�� '
.J
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
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