2000, 12-11 Permit App: 00011112 Demolition Garage00 ---- i 11 I t;)
1 I PROJECT APPLICATION WORK SHEET
SPOKANE COUNTY DIVISION OF BUILDING & CODE ENFORCEMENT
1026 WEST BROADWAY AVENUE
A-4 SPOKANE, WA 99260
spomif COUNTY 509-477-3675
SPECIFIC SITE INFORMATION
Street Address: C)J
Assessor's Tax Parcel Number(s):
Legal Description:
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Project Description: [f%r %��,' f�1 �'Y�— ' (� % .0 ✓l z ��
O Building Permit O Change in Use O Grading O Manufactured Home Permit
O Relocation O Sign O Tenant (New/Change) Other
OWNER/APPLICANT INFORMATION
Gil /ndir„ty —hn ch—hl by —w—td rvoardino this nrnivrt
Owner.
w On
Me INN
Phone:
D {t—)9/
❑ Applicant. Phone:
a,, --(a t��
Fax:
Dimensions
Fax:
Mailing AdJd/ress:,
Finished basement sq. ft.
Occupancy group
Construction type
Mailing Address:
Deck sq. ft.
Cost of project
Heat source (electric, gas, etc.)
City, State, Zip
City, State, Zip
Con ractor
Phone
r� 3 — ��y y q
❑ Architect/Engineer Phone
Ji
J J
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Fax
Mailing address
P 0. /✓%1
Lf LJ ���
Mailing address
City, State Zip
City, State Zip
WA State Contractor license p
Contact name:
Sv ;
PROIFCT INFORMATION
w On
Me INN
Building height to peak
H of stories
Main floor sq. ft.
Unfinished basement sq. ft.
Dimensions
Total habitable space
2' floor sq. ft.
Finished basement sq. ft.
Occupancy group
Construction type
Garage sq. ft.
Deck sq. ft.
Cost of project
Heat source (electric, gas, etc.)
i
r.
Width: Length: What is the square footage of the sign How high is the sign?
face?
Year: Make: k of signs Area of existing signs
ADDITIONAL SITE INFORMATION
Are there structures on the property? D Yes X No
What is the current property size?Q
I yes, identify on site plan
(square feet or acres f
Is any part of the property within 250 feet of a shore1, e?
What is the current use of this property?
I yes, identify on site plan O Yes o
Is your property in a designated wildlife habitat area?
Will the site be served by a septic system? Yes O No
O Don't know O Yes KNO
Is any part of the property within a 100 yr flood plain?
Are or will there be wells located on the property?
If yes, identify on site plan
If yes, identify on the site plan O Yes 'XNo
O Maybe O Don't know D Yes No
Are there any wetlands, streams or ponds within 200 feet of the
Is there evidence of fill or excavation on the property?
property?
O Yes '>2( No
I es, identijy on site plan O Yes PKNO
rise in 100 ft)
Are there slopes greater than 30% on the propertyr3�rNo
Are critical or hazardous materials used or stored on sit .
O Yes
O Yes X No
DEPARTMENT USE ONLY
Date Received: Staff Representative:
METHOD OF PAYMENT
V/S4
❑ CASH ❑ CHECK ❑ ❑ ❑
FAXED PERMITS WILL ONLY BE ACEPTED WITH PAYMENT OF A MAJOR CREDIT CARD
DATE: EXPIRES:
BANKCARD NUMBER:
SUBTOTAL
AUTHORIZED SIGNATURE: F Cf5tJN1 YPRt1 C ENCR�I}
33366 Fed Grant F�
33403 State Grant ❑ 33831 Local Assessment
0
CHCASH ECK El
MONEY ORDER ❑
ACTION DATE
REVENUE CODE
RECEIPT NO.
AMOUNT RECEIVED
RECEIVED FROM
L({Gf:: r✓ (i±�nw
El
32191 Operating F-1
34317 SEPA Fees F-1 Other
33366 Fed Grant F�
33403 State Grant ❑ 33831 Local Assessment
0
32291 Grass Fees
34395 NOC Review F� 34396 Registration
El
34397 hsbestos 0
32292 Ag Burn Fees n 34398 Wood Stove Exemp.
35900 Penalties F�
36990 Misc Income r-1 34318 Oxy Fuel Program
El
32191 Operating F-1
34317 SEPA Fees F-1 Other
El
Permit
SPOKANE COUNTY
AIR POLLUTION CONTROL AUTHORITY
1101 W. College Ave, Suite 403, Spokane WA 99?91 /I
RECEIPT NO. 10712
r fiw .J �iw.
Agency Uie
.�rvM.�i+a..vv��. . �.� rVLLV ■.V.�K.VI�■.AVL Av.uv.�a ■ . I � � �.j��r�.r,.r `- ,
1101 West College, Suite'403, Spokane, WA 99201
NOTICE OF INTENT i ;i E, f)u
TO PERFORM: Agency use Only
A. Project Type: 1. Asbestos Removal 2. U Asbestos Removal do Demolition 3. Demblitiba N2 Mb tom; Removal
B Ownerty
: Ms. Dorothy Hale Phone: 09 489-5181
Property Owner's
Mailing Address: 924 E. Nina Circle T:7 Spokane State: WA Zi :99206
C. Asbestos .erasrracvrCX"Ur "arntarnxaae AWA&ULM L"M
Contractor
Contractor:
Owner/CEO:
Information:
Structures: 1
Contractor
Mailing Address: N
Phone:
Job No.:
city:
State:
Zip:
Fax:
Surfacing Mat'l: Fireproofing U Paints
D. Site
Address: 924 E. Nina circle Ci State: W A Zip: 99206
Project Manager or
Contact Pcnun. Jeff Larson Phone: ( 509) 535-7944
!~ U Asbestos Surveyor No. of Date Survey was Was Asbestos Found? U Yes
E311-03-2000 Mat'I Presumed: Structures: Conducted: If No, Attach Survey
AHERA Building AN ANEUstNVEr aafQWAWSUMEdUDL4RlflrQV IAaZc7SLWDTAS I ra0►mmarKV321:1J*w Expiration
Inspector Name: Samuel W. Bailey Certification No.:3509-00-C04-01 Date: 1/25/2001
F. Demolition
No. of
Stan
U Training Fire (List Fire Dept. as demolition contractor below)
Information:
Structures: 1
Date: 12/11/2000
1 ❑ Ordered Demolition (attach copy of Order)
Demolition
laWrM AMMAZEENfUA6$MAGADOM3SAWAU'JQMarr[ s1X4aarcauowavrn #=nVr.N=
Thermal .System Insulation PoacAFurnacc Ins
Contractor:
Larson's Demolition, Inc.
Phone: 509 1 535-7944
G. Asbestos Project
Information:
No. of Suucdtres:
see back if> l) -Ti
tart
ate:
2.
Completion
Date:
10 Days
Wk Days: M T W Th F Sa Su
Horns:
Total Quantity to be Removed: Linear Ft.
Snuare Ft.
Will all asbestos material be U Yes
removed by Proiect completion? ❑ NO
Thermal .System Insulation PoacAFurnacc Ins
U Duct InsPipe
Ins 01bcr:
10 Das
Surfacing Mat'l: Fireproofing U Paints
U Plaster
Textured Coatings tither.
I
10 Da
Misc. Mat' 1: 1 U Cement Bd. U Cement Pipe U
Flooring Mat'I
Roofing Mat'I Other.
10 Dat
H. Asbestos/Demolition Project Categories:
I. ❑ Owner -Occupied Residential. Asbestos Removal & Demolition Project
Owner -Occupied Residential Demolition Project. No Asbestos Removal
Notification
Waitin¢ Period
Prior Notice
Proiect Fee
NON-REFUNDABLE
$25
2.
All Other Demolitions With No Asbestos Removal Project
10 Days
5150
3.
U 10 - 259 linear feet or 48 - 159 square feet see back of form for ions
3 Days
S150
4260
- 999 linear feet or 160 - 4,999 square feet
10 Das
5.100
5.
1 000 - 9,999 linear feet or 5,000 - 49,999 square feet
10 Da
$750
6.
U > 10.000 linear feet_ or > 50,000 square feet
10 Dat
$1,500
7.
U Emergency Asbestos Project or rl Emergency Demolition Project
I Prim Notice
Twice Project Fee
8.-U
Alternate Means of Compliance for friable materials or Demolitions
I O -Day Review Period
Twice Project Fee
9.
Alternate Means of Compliance for nonfriable asbestos materials
Concurrent with Pro
Twice Project Fee
1. I do hereby certify that the infonlWion contained in this no ifica km and supplemental data desaibed herein, is to the best of my Coarpkarmm Review
knowledge accurate and complete. I shall not sane or allow testy asbestos project or demolition activities lo begin mail the Pedb—d By:
apwomm w -ting Penod has -
Larson Is Demolition, Inc. 12/08/2000
&S;ianrs Repnraasr r Durk
Arewcv Ure On&
Vaicr of intrnr (66-16068) 2198