2013, 03-07 Permit App: BLD-2013-0369 Demo { Community Development Department (Staff Use Only)
Permit Center (1 «_
SciTYokane 11703 East Sprague Avenue, Suite B-3 PERMIT NUMBER: l7 31 ?
Spokane Valley, WA 99206 . L
Valley Tel: (509) 688 0036 PERMIT FEE:
Fax: (509) 688-0037
permitcenter@spokanevalley.oro
DEMOLITION PERMIT APPLICATION
PROJECT ADDRESS: T_ L \ it-! \ G
765
ASSESSORS PARCEL NO.:
BUILDING OWNER NAME: � &ft/ �jPj-pv—�1 c`-r
MAILING ADDRESS: ki°- •
CITY: -�l.� STATE: kA-JV?_ ZIP: 99
CONTACT PERSON NAME: LC40o
PHONE: ,$ Fax: CELL: 3-,(G os Li if
CONTRACTOR NAME: NGt--yC-
MAILING ADDRESS:
CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR LICENSE No.: EXPIRES: CITY BUSINESS LICENSE NO.:
PROJECT DESCRIPTION (Please Provide Site Sketch)
0 Site Plan Provided ❑ Notice of Intent #
Spokane County Utilities has approved the disconnection
Describe the scope of work in detail
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 required to be submitted and subsequently approved before this application can be processed.
Signature % — Date: �, -O 7- (L
Updated 1-11-11 Page 1 of 1
http://www.spokanevalley.org/filestorage/124/938/210/948/1496/Demolition_Permit_1-11-11.doc
(-,.Mar. 7. 2013 2: 17PM SPOKANE CLEAN AIR No. 2237 P. 1
—From:Mary McDermott
Ifir ,, g.uvg
113 —DO 071 `�iT-- NOTICE OF INTENT oQ lie i€Notice of Intent No. 1Spokane ,:
''�
Regional, FOR AshL'SfOS PROTECTS OTECTS/nr)101 1TrON SPOKANE,REdIONAL
i Agency rrae Only .._,.�r�� tJ.81.rkm..--.--- 1• _; ;etA /,
Review S.okane Re:ional Clean Air•A;enc SRCAA)Re:illation'I,Article IX and Section 10.09 fora.•licable re•u irements...•.
ti Project Type: _ ❑Asbestos Removal ❑ Asbestos Removal&Demolition lgt Demolition,No Asbestos Removal
Does this project involve a fire-damaged structure?: 0 Yes I�fo ;,(If Yes,refer to Sections 9.03.F:3 and 9.08);
Does this project involve demolition by fire training?: ❑Yes I 1 o '(See Sections 9.02.L,9.031.4&9.04.A.6.)....'•
How many contiguous structures does this project involve?: •Maximum of 5 structures per Notice of Intent(NO1)
• Property Owner: PSI k..\ � �y i�14�a\btc3. ne:5z °Et`tL .Fax:
Mailing Address: fg 5 n_if, . ty: ,V.rsi 'State: A Zip:. clq ZO
C. Site Address Contact Person: f►` .tll) 't, ML.A.K1t J bSitaPhone: ' -OgL
Structure#1: If>1 structure,provide details to identi'
#2: _ #3:
#4:: #5:
�•! 17Material MAsbestos Date survey performed: %•-y3 AI ERA Bldg:inspector Name: �k,‘,1 Q 3 C
❑ 'c.Presumed Survey: Was asbestos found? ❑Yes®No Company: tt - ( Cert:No.: T/- \Ia.\ OS c,
E. Asbestos Start Completion For each structure listed in'section C,itemize the.type and
• . • Removal Date: Date: • quantity of asbestos-containing Materials to be removed. ..
f /
Total Linear Feet: Iota I Square Feet: Abatement By(if known):
'Will'ali:asbestos-containing material b- reniov'ed twin the structure s b the asbestos removal corn•letion date? ❑Yes ❑No
P.1 Demolition' Start Date: Demolition By•
Information' (earliest) ' e0 (if known): • OLA-4(1.1.2,
G. Asbestos Project&Demolition Notification Waiting Period and Nan Refundable Pee Categories(additional categories-pg.2)
Your advance notification period will begin when a completed NOT,including required nonrefundable fees,is received by SRCAA:
Check/com•lete all boxes which a•.1 ,.below-
Owner-occupied,single-family residence(see the Renos'aliiin,DClaro,,a: Asbestos into, sheet) 1Vniting I'criori Fee
1.❑ >_10 In ft and/or z 48 s• ft asbestos •roject not •erformed by residing owner ':'. Prior ►otice .• ., $0 :
2. li All Demolition(all asbestos must be properly removed and disposed of prior to demolition Illr.,i 3 Da s'•. ., . r a��
Not owner-occupied,single-family residence Waiting Period lee
3.❑ 10-259 In ft and/or 48-159 s ft asbestos also for<10 In ft or<48 s• ft •er Sect 9.04.A.6.a 3 Da 's!:: • $250 •
4.❑ 260-999 In ft and/or 160-4,999 s ft asbestos .10 Days:: ':$500 . :
5.Q >_1,000 In 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 z 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 sq ft increments beginning at 10,000 sq ft:_ x$250 $ +$1,250 base fee= $
6.❑ All Demolition(this fee waived if.r-o-ect .erformed with .ro'ect cateo 3,4,or 5,above) 10 Days • $250. .
It: .Acknowledgement;The Centro!Officer,or duly authorized representative,shall be allowed to access property at reasonable times to inspect projects
specific to the Control;rCeo'vezy,or release of contaminants into the atmosphere,in accordance with SRCAA Regulation I,Article It and RCW.
70.94:200: Per 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 aro scheduled to occur,and times when the Control Officer or duly:
authorized representative areinvestigating air quality complaints fled with the agency and/or have reason to believe that air quality violations have
occuircd or May.be'occurring:No Personhamper shall obstruct, or interfere with any such inspection.I certify that the information contained,in this
notification and;any suppleniental,informa•tion provided is.to the best of my knowledge,accurate and complete. _
Business Name&Address: N/A Pax: . „
Signature:'�, _— --- Print Name:Ta20 _VA:Ca �i• t\ Phone:
Agency Use:Onlyr 0, NO1 Deficient(see page 2):: I NOT(9i-nplete t?na O1l°S r --' Pa e 1 of 2
nate&Initial. Date&Initial g
SIZCAA,3104 E.Augusta Ave.,Spokane,WA 99207/wvvw,spokanc Ie� natr /Ph:(509)477-4727 Fax:(509)477-6828 3/11
-Mar 7. 2013 2 : 17PM SPOKANE CLEAN AIR No. 2237 P. 2
Continued FromPg.1)Asbestos Project and Demolition Notification Waiting Period.and Non.ileefundable Fee Categories
Your advance notification period will begin when a completed NO!,including required notirefundable fees,is received by.SRCAA.• .
Below are additional categories which may apply to the project categories in 1-6,on page 1: •
Check all boxes which apply,below.If applicable,provide all respective information'required.
Iimcrgency Notification Reference Waiting Period Non-Refundable Fcc
7.❑ Emergency Section 9.04.A.6.h Prior Notice :Twice the Regular Fee
Select the reason that best describes your situation:
0 Sudden,unexpected event that resulted in a public health or safety hazard.
['The project must proceed immediately to protect equipment,ensure continuous vital utilities,or minimize property damage_
[]Asbestos-containing materials were encountered that were not identified during the asbestos survey.
❑The •ro'ect must•roceed to avoid im.osin_an unreasonable financial burden.
Anlcndinenl RifeC(o NOl Aniendinent form(Section 9.11433)
Annual Notification Refer to Annual NOL form (Section 9.04.A.6.j)
Alternate.Asbestos Project Work Practices Reference Waiting Period Nun-Refundable Icc
8.❑ Alternate Asbestos Project Work Practices Section 9.08.A 10 days Twice the Regular Fee
Exception for 1.1a7ardous Conditions Reference Waiting 1'criocl Non-Refundable Fee
9.❑ Exception for Hazardous Conditions Section 9.08.0 10 days Regular Fee
Name of.erson that area ared the Alternate Work Plan:
Company,he/she represents:
His/her certified AHERA Proeat Desi: er No:;
His/her Certified Industrial Hygienist(Ca)number or
Professional Engineer(PE)license number;;
Demolition with Non friable Asbestos Roofing Reference Wailing Period Non-Refundable Fee
10.0 Demolition with Nonfiiable Asbestos Roofing Section 9.08.13 10 days Twice the Regular Pee,
Name of person that determined that nonfriable asbestos
roofing material could be left in place per Sect.9.08.13:
Company he/she represents:
His/her certified AHERA Project Designer No.:
.1. Optional:List additional parties you would like copies of this Noland address):
Agency Use Only. Receipt. 6819
02/20/2013
Acct 4. 2056 COPY
Reason(s)NOT Deficient: SpokaneEaneRegionalust9Clean5384 Air Agency
3104Aug. WA 9207 a Ave
Spok
Todd Browning
Valley WA 99203
PO Box 8760
Spokane ---- - -----
--- -------- -
Treasurer's Receipts
Memo Noi 413-0008 For 6114 E. 10th A:09..00
NOL 1f 13-0008 For 6114 E.
30.00
Non Taxed Aint: --_.- -
30.00
30.00
------------
30.00
Ttl Tendered: 0.00
Change:
Issued By; Mary
02/20/2013 12:06:30
Page 2 of 2
SRCAA,3104 E. Augusta Ave.,Spokane,WA 99207/www.spokanecleanair.org/Ph:(509)477-4727 Fax:(509)477-6828 .3/11
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