2003, 02-27 Permit App: 03001191 Demolitioncif,J.7 — V t—i '-J WN -
Agency Case No.
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03 —0CLJ
Agency Use Only
SPOKANE COUNTY AIR POLLUTION CONTROL AUTHORITY
1101 West College Suite 403. Spokane, WA 99201
NOTICE OF INTENT
TO PERFORM:
"D3teR- .i
FES 2 7
Agency Use Only
eT
2003
UN(pYmAyI
A. Project Type:
1. ❑ Asbestos Removal
2. U Asbestos Removal & Demolition 13.�DemolitiO tl-Np As��,elsf
nU l
U
B. Property p
Owner: C. 'i . Cetioie
Phone: �) t'9,3 22-113
Property Owner's C �y,'''
Mailing Address: 1108 6, 3/' /9t)t
`
City -lo ne U0..l1.
II'
State: 1J &
Zip9.92
ttY
C. Asbestos nMnEea.NTCLntnr. nlnala ae mm.BTn.N,NINNQ,.REL
Contractor:
Contractor
Owner/CEO:
Mailing Address:
Phone: ( )
Contract
Job No.:
City:
State:
Zip: _
Fax: ( )
D. Site
Address: 7°207 e 7 `-(/
City k2.nC f2il4„
state:WA__
Zp:992c
Project Manager or p \
Contact Person: C -!K , kedOlc (-caj ) - r 3`� `�
J
hone: (83 )Z2-54 3
\
E.
'�
❑
Asbestos Survey or
Mat'I Presumed:
No. of
Structures: /
Date Survey was / /
Conducted: Z ZO 03
rr,
Was Asbestos Found? hA Y
❑ If No, Attach Survey
AHERA Building leslSURVEY"EQUIRD)JUOa"LC Daly '1la. eROJerIsawl. AS
Inspector Name: E G r, 00 [is
rRonoev"CI 32/Jrsaa
Certification No.: 02-V Z9S
Expiration
Date: l2/'f/0:
F. Demolition
No. of
Structures: /
Start
Date: 3/8 I0 3
U Training Fire (List Fire Dept. as demolition contractor beimInfonnatioa:
0 Ordered Demolition (attach copy of Order)
Demolition PRINTNM@ HERE INTER *WLJNGG ACOR<MIN BOY J ON BACK IF TRAINING BURN ENTER ARE DEPT. HERE
Contractor: /'Jy` y'
Phone: ( )
%
C. Asbestos Project
No. of Structures
Start., In /
Completion
Wk. Days: 4 T -��,% b;e.: .1
Information:
(see back if> 1) /
Date: 016 O 3
Date: 3//i�o 3
Hours: - p.,,. ra,...
�oo�%
Total Quantity to be Removed: �inear Ft. 3 & 6 quare Ft.
Will all asbestos material be � Yr
removed by project completion? 0 N
Thenal System Insulation: I U BoilWFurnace Ins. U Duct Ins. LI Pipe Ins.
Other.
Surfacing Mat'l: 0 Fireproofing 0 Paints 0 Plaster 0 Textured Coatings
Other:
Misc. Mani:
I U Cement Bd. ❑ Cement Pipe 0 Flooring Mat'I ,"Roofing MaVI
Other: n1e4.-, +t-4g.4D ate,
EL Asbestos/Demolition Project Categories:
u
1. ACI Owner -Occupied Residential Asbestos Removal & Demolition Project
0 Owner -Occupied Residential Demolition Project, No Asbestos Removal
Notification
Project Fee
Waiting Period
NON-REFUNDABLE
525
`iriolblotice
2. 0 All Other Demolitions With No Asbestos Removal Project
10 Days
$150
3. U 10 - 259 linear feet or 48 - 159 square feet (see back of form for options)
3 Days
$150
4. U 260 - 999 linear feet or -I60 - 4,999 square feet
10 Days
5300
5. ❑ 1,000 - 9,999 linear feet or 5,000 - 49,999 square feet
10 Days
5750
6. ❑ > 10,000 linear feet or> 50,000 square feet
10 Days
51,500
7. 0 Emergency Asbestos Project or ❑ Emergency Demolition Project
Prior Notice
Twice Project Fee
8. ❑ Altemate Means of Compliance for friable materials or ❑ Demolitions
10 -Day Review Period
Twice Project Fee
9. U Altemate Means of Compliance for nonfriable asbestos materials
Concurrent with Project
Twice Project Fee
r Id
o hcmby unify that Ne mformatlon contained in this notification, and supplemental data described herein, is to the best of my
knowledge accurate and complete. 1 shall not cause or allow any asbestos project or demolition activities to begin until the
appropriate waiting period has elapsed.
C t4 thea khd 7 '7-mar/ago
Signature prerentin
Date
Completeness Review
Performed By:
Notice of Intent (66-160B8)1/98, 11/99
Agency
,