2009, 12-04 Permit App 09003885 Demo Home, GarageSTATE:
Effective October 28, 2007
P:\Community Development\Forms\Building forms\Demolition Permit App.l.doc
Spokane
Valleyk
Community Development Department
Permit 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:
PERMIT FEE:
DEMOLITION PERMIT APPLICATION
PROJECT ADDRESS: 8'3 z Z E 6,I2evadu/�),/
ASSESSORS PARCEL NO.:
BUILDING OWNER NAME: S..)ir�✓s< ,/Se-
3s J
MAILING ADDRESS:
CITY: 5po/CA..)e- 6 9
CONTACT PERSON NAME: 3rgs,on/ i°gjs
PHONE: 9 79 .► 6 6 (7/6
Fax:
83 Z z O ite.t2Q,9ozap/
STATE:
CONTRACTOR NAME: /'%s+/7�/ /��IOt18ZS
ZIP: g 9 Z
CELL:
G>osne-m-er e G
MAILING ADDRESS: a 02„9
Crrv:
PHONE:
FAX:
Wr7 '
5' .6, 3 - 7 7S5'
[7 PZIP: 99/�p r
CELL: 79 - 6 7e
CONTRACTOR LICENSE NO.: -A1Q4W) "1G 935-e id EXPIRES: 3 - to - // CITY BUSINESS LICENSE NO.: „Ave eL.�7`sJ ys.S'OC
PROJECT DESCRIPTION (Please Provide Site Sketch)
Site Plan Provided NI Notice of Intent # d 3 g 7
Spokane County Utilities has approved the disconnection
Describe the scope of work in detail
OE", a t#Dgsz( 9- 7 %D E7 -.4465CS . �c4r�n/'Op�✓ 3 2T/c .
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 submii ed and sequently approved before this application can be processed.
Signature
Method of payment:
Bankcard #:
Cash
0 Check
Date:
❑Visa 0 Mastercard
EXP: VIN#:
Authorized Signature:
/Pe, p /any aveg,oc-
--/p actie-
/g.,1 70Ay.
Page 1 of 1
SPOKANE COUNTY HEALTH DISTRICT
Environmental Health Division
West 1101 College, Spokane, WA 99201 (509) 324-1560
SEWAGE SYSTEM VERIFICATION FORM
Since our office does not have information on file showing the location and size of your
system, please provide the following information in order for us to review your proposal.
Project address: E _ s3 Z 2 r3 roccGCc_.aJG ij
Pro ertY owner: Address:
11 G nn
v r.c. i` c.c (+o i/1 E. (00C3 0 Nu j c cS`fq
Existing property use: 'residential ❑multi -family
If a business, name and nature:
If a business, approximate metered water consumption:
Phone:
z-639/
Type of wastewater fixtures connected to sewage system(s):
toilets ihowers/tub ?<sinks
car wash _sprinkler system hot tub/spa
dishwasher
gallons per
laundry
swimming pool
Year structure built: (?3f Year sewage system installed:
Number of bedrooms: 2-
Has existing sewage system(s) been reconstructed or repaired? ❑Yeslo
If yes, when: Reason:
Location and size of the system: Please make or submit a drawing showing location, dimensions, and
measurements of your lot, stru ture, sewage systemis), water wells, waterline, driveways, direction "north",
etc. IDENTIFY WHAT IDRA N�r�Jeki
I certify that t
Signature o
4/94
is true he t of my knowledge.
cg
the property owner
•
Date
Ilotice of Intent No. g pjy�De
pR - t FOR At•BI: S'I OS YROACTS! DLN101,11IONNOTICE OF INTENT
17are.4mmp Agency Use o»ly
e _
{ Agency flw On(y �—�
_ Refer to the A en 's Renovation, Demolition, and Asbestos Information Sheet as well as Regulation I, Arse a
f Asbestos Removal uemolltlon I ❑ Demolition, No Asbestos Removal
A. Project �1�e� I ®Asbestos Removal 1 ❑ _ -- .
Dos this project involve a fr -damaged structure?- 0 Yes No (ff yes, refer to Sections 9.03.F.3 and 9.08)
Does this ro act involve demolition by fire training?: �.1 ❑ Yes IA No (See Sections 9.02.R, 9.03,F.A- & 9-04-A,6,i.on
D p.. f more than I. structure, refer to S 9.04.A.3)
Bow many contiguous structures does this project involve? (5 max): i �
ph011;1509.924.1715 Fax:
S. Property Owner: Jattiene Rise — ;City:
ty. Spokane l State : WA I Zip: 99212
Iona ,,..
!Cie nAirt
Mailin Address: 8322 B Broadway
C. Site Address:
Contact Person:
8322 B Broadway
Tim. C Phalan
Date survey performed:111/04/2009 }AHERA Bldg. Inspector Name-
® Yes ❑ No [Company: M.arkLidbeetc
Com any
D, ®Asbestos Survey or
D Hater's! Presumed
City: Spokane
State:
WA Zip;
99212
Job Site Phone: 509,315.8532
Was asbestos found?
E. Asbestos Removal Start
information:, Date-
List individual p and
quantity of material8 to be
removed. If>1 structure, list
materials for each structure
by address 1 location.
11/20/09
Completion
Date;
160 SF VAT
Mark Lidbeck
Cert. No.:
OIL Ft (G
1122/09 I Abatement By
(if known);
768 SF Sheetrock Skimcoat
Day Northwest Environmental
Total Linear Feet:
Will all asbestos material be removed from the structure(s) by project completion? El Yea n No
Total Square Peet, 1, 928
F. Demolition Start Date:
_ Demolition �y
Information: (ear {lest) (if known):C.
Asbestos Project and Demolition Notification Walling Period and Non -Refundable Fee Categories
Your advance notification period will begin when a completed NOT, including required nonrefundable fees, is received by SRCAA.
Owner -occupied, single -fancily residence (see the Renovation, Demo., & Asbestos info. sheet) Waiting Period
Prior Notice
1. ® l 10 in ft and/or � 48 sq ft asbestos project not performed by residing owner
2. 0 All Demolition (all asbestos must be properly removed, and disposed of prior to demolition)
Not nurser -occupied, singIt-family residence
3. ❑ 10-259 In ft and/or 48-159 sq ft asbestos
3 Days
Fee
$0
$30
Waitinu, Period Fee
3 Days
$250
4, l] 260-999 in ft and/or 160.4,999 sq ft asbestos
S, Q 1,0001u ft and/or>_ 5,000 sq ft asbestos
6. ❑ All Demolition
e The $250 demolition fee is waived if demolition is performed in conjunction with asbestos project oategory 3, 4 or S, above.
Additional Categories Which May Apply to the Project Categories in 1-6, Above
10 Days
$500
10 Days
$1,250
%nne agency MitIfiCatiau
7. ❑ Emergency
Alternate ASbCSTOS Project Work Practices
8. ❑ Alternate Asbestos Project Work Practices Section 9.08.A 10 days
Spokane Clean Air, 3104 B. Augusta Ave-, Spokane, WA 99207 / www, pokanecleanair.org / Ph: (509)477-4727 Fax: (509) 477-6828 9,
Received Time Nov,18 2009 5:39PM No.2130 ; a
1 'd 1ti€6.°N REV 1031D 3NVYOdS 10017:8 600Z ti :;o
10 Days
$250*
Reference J' r{r,cl Non -Ref ndnIde FAN!
Section 9,04.A.6.h
Prior NotIce
Twice the Regular Fee
Select tho reason that best describes your situation:
❑ Sudden, unexpected event that resulted in a public health or safety hanrd. pp eny damage
❑ The project must proceed immediately to protect equipment, ensure continuous vital utilities, or minimize
❑ Asbestos -containing materials were encountered that were not identified during the asbestos survey.
❑ Theyroject must mooed to avoid imposing an unreasonable financial burden.
Reference Waiting,Period Nun -Refundable Fee
Twice the Regular Fee
Exception for Hazardbut Conti itions
9. ❑ Exception for Hazardous Conditions
Reference Waiting Period Non -Refundable ._et -
Section 9.08.0
10 days
Regular Foe
Name ofpeison that prepared the Alternate Work Plan:
Company he/she I esents:
His/her certified AHERA Project Designer No.:
His/her Certified Industrial Hygienist (CIB) number or
Professional Engineer (PE) license number:
Demolition %%lib Non friable Asbestos Roofing. Reference
10.0 Demolition with Non$lable Asbestos Roofing
Section 9.08.E
waiting Pt, Clod Non-i2efundtthle Fqe
10 days
Twice the Regular Fee
Name of person that determined that nonfr-iable asbestos
main material could be left in lace er Sect. 9.08.B;
Cort_pat LWahe represents:
His/her certified ARRA Project Designer
II. 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);
Acknowledgement
The Control Officer, or duly authorized representative, shall be allowed to access property at reasonable times to inspect projects
specific to the control, recovery, or release of contaminants into the atmosphere, in accordance with SRCAA Regulation I, Article II
and RCW /0.94.200. For the purposes of renovation, demolition, and asbestos protects, reasonable times include, but arc 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 Offleor or duly authorized representative are investigating air quality complaints filed with agency and/or have reason
to believe that at quality violation 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 and any supplemental information provided is, to the best of my knowledge,
accurate and complete.
Business Name: Day Northwest Environmental ram M2.11.11621 non.; 509.315.8532
Mailing Address: p4 BOX 2862 Spokane, WA, 99220
Signature:
,l. ,agency Use only,
❑ NOI Deficient:
Print Name: Tim C Ph aloe
_MMIk
-75 NOI Complete air tk u (6 °1
Date &Initial
rage.6 v, 2
,.,___ 3,�,,r? 8. e c t1P W4 W07! r1w.sFaPecll erg/Ph:(509)477-47271<ax:(509)477-6828 09/09
SlReceived Time N°v. 1$.g���' S:��M No.21�30
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