The URL can be used to link to this page

Home My WebLink AboutBLD2009-00002 ItUILDING PERMIT APPLICA•N B Review DO9 00002 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD09-00002 Received Date: 1/5/2009 SITE ADDRESS: 420 APPALOOSA DR BRINNON, 98320 OWNER: JEFFERSON COUNTY PHONE: COURTHOUSE PO BOX 1220 PORT TOWNSEND WA 98368-0920 LAZY C RANCH DIV 1 SUBDIVISION: Block: Lot: 36+ PARCEL NUMBER: 966900035 Section: 34 Township: 26 N Range: 02 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: JEFFERSON CO ENVIRONMENTAL HEAL PHONE: (360) 379-4498 TAMI POKORNY tpokorny@co.jefferson.w 615 SHERIDAN ST — PROJECT DESCRIPTION DEMOLISH EXISTING HOUSE AND GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP DEM VALUATION MAIN: CODE EDITION: 2006 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: �1 `11 D€- Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $0.00 KAS 01/07/09 APPROVED State Building Code $0.00 KAS 01/07/09 Total: $0.00 MAR N 2009 Jefferson County Planning &Building Department is • - - DEMOLITION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD09-00002 Received Date 1/5/2009 SITE ADDRESS: 420 APPALOOSA DR Issue Date 3/18/2009 BRINNON, 98320 APPLICANT: JEFFERSON COUNTY PHONE: COURTHOUSE PO BOX 1220 PORT TOWNSEND WA 98368-0920 36+ SUBDIVISION: LAZY C RANCH DIV 1 Block: Lot: PARCEL NUMBER: 966900035 Section: 34 Township: 26N Range: 02W CONTRACTOR: A PHONE: 360-249-3566 302 WILDER LN MONTESANO WA 98563 Contractor's License CONTRCI955QC Expires 11/3/2009 OWNER, JEFFERSON COUNTY PHONE: if different: COURTHOUSE PO BOX 1220 PORT TOWNSEND WA 98368-0920 PROJECT DESCRIPTION: DEMOLISH EXISTING HOUSE AND GARAGE Directions SEE MAP QUEST MAP AND DIRECTIONS IN FILE To Site: THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 3/18/2010. REQUIRED INSPECTION: FinalApproval: 13 6 BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. SPECIAL CONDITIONS APPLY - SEE REVERSE HOT LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS FOR CASE#BLD09-00002: 1.) SEPTIC SYSTEM NOT VESTED FOR FUTURE USE. SHOULD SEPTIC SYSTEM BE DECOMMISSIONED, DOCUMENTATION AND VERIFICATION BY JEFFERSON COUNTY HEALTH DEPARTMENT IS REQUIRED. I:\F_BLD_Permit_Propane.rpt 10/29/19 • • .,„, v, �eP�NNpl, \E\ BRINNON FIRE DEPARTMENT CHIEF BOB HERBST PO Box 42 272 Schoolhouse Road Brinnon WA,98320 Phone:360-796-4450 Fax:360-796-3999 Cell:360-301-3439 Web Site: www.brinnonfire.org bobh@brinnonfire.org January 2,2009 Ms.Tami Pokorny RECEIVED Jefferson County Water Quality and Environmental Health 615 Sheridan Street JAN 5 Zu Port Townsend,WA 98368 Ph:360.379.4498 irrrr`2tC,n i rr��l�,,;y rip Fax:360.385.9401 Ms Pokorny: This letter is a follow up to our phone conversation on 4 December 2008in regards to the Larson property in the Lazy C Development. As I stated in our conversation there is an annual requirement by NFPA for live fire training for all interior qualified Firefighters.In today's economic environment there is not always enough training dollars to send our volunteers to the WSP Fire Academy at North Bend not to mention providing the back fill coverage while these volunteers are gone for fire&EMS calls. Therefore,I am very much interested in obtaining the above mentioned property to use for not only live fire training but a host of other training events as well.These events will not only benefit our agency but is something that is open to our mutual aid agencies as well.This will also provide an opportunity for those in the Brinnon Community to see some of the capabilities that we have been developing over the last 4 years. There is also a major benefit for Jefferson County as well.Since the property was purchased with the intent of restoring the natural habitat along the Dosewallips River and the necessity of all man made structures having to be removed.By allowing the Brinnon Fire Department to use the structure for this type of training the amount of the grant funding that would be needed to clear the property will be significantly reduced.There by allowing other smaller projects to be completed. I have spoken with a number of the residents that live in the area of the subject structure and they are enthusiastically looking forward to the property being cleared.So much so that a community member has offered to provide full video recording of all the training events and edit a training/recruitment video for the Brinnon Fire Department.I look forward to obtaining the approval of the Board of County Commissioners and moving forward with this project. Firematically, Robert E.HerbstJR. Fire Chief Brinnon,WA !RECEWE 1 r� i� Olympic Region Clean Air Agency N 2[a' 2940-B Limited Lane NW r /� o Olympia, WA 98502 JEFEEj 1 C�►!JFY pE� �l!'� ORCAA ��-,�o (360) 586-1044 or 1-800-422-5623 s94 ,„,,gyp_ ,0.0- Fax: (360) 491-6308 www.ORCAA.org Turco.•00 Notification of Demolition Permit It is unlawful for any person to cause or allow the demolition (or major renovation) of any structure unless all asbestos- containing materials have been removed from the area to be demolished. Work shall not commence on an asbestos project or demolition unless the owner or operator has obtained written approval from ORCAA. A written application for a demolition shall include a certification that there is no known asbestos-containing material remaining in the area of the structure. Project Site Address: 142c ill,D-xv IccSct t1 V e_. County: \1 ' 'rc()f City: 13,r1 viAOcy-y, State: vv4\ Zip: 9 -3tc' Starting Date: .('P rt,X !Vlore h 15 Completion Date: A{troy Arc, *(There is a 10 working day advance notification period from receipt of permit application) Property Owner:,.Teq,e vs.° vl (`;0 y 4.y Telephone: �,4,e)/3 irk —4 Li / Fax:3620/5T S-ei lit o I Mailing Address: 62 ►s- ShC' - da.-v) - City: f rl• I i)f)WAS Lilt d State: VVI'- Zip: . 1 g 366 Demolition Contractor: -jam b State License#: Mailing Address: City: State: Zip: Contact Person: T vyt i Po 1`U r n/ Telephone: s<-eO/ i cj - 4 yc{& Fax: YES NO Demolition by Wrecking or Dismantling? ($25.00 fee)check# nonrefundable ✓ Training Fire Demolition? (If yes, attach fire department request for training fire) Renovation,Alteration, Remodeling, Maintenance, or other Construction? V Asbestos found or suspected* *An ORCAA "Notice of Intent to Remove or Encapsulate Asbestos" form and appropriate fee must be submitted prior to any asbestos removal work. Asbestos removal projects involving demolition must be preformed by a Certified Asbestos Contractor and all friable or potentially friable asbestos must be removed before any demolition begins. Refer to ORCAA Regulation 1 Article 14 for additional requirements that may apply. Asbestos Survey Completed by AHERA Certified Inspector Certification # This approved permit must Enclose$25 Certification of the Asbestos Survey must be available at the job site Processing Fee accompany this form F:\COMMON\Forms\asbestos\DemoPermit.doc Rev.10/22/02 02/17/2009 12: 34 3604171 7 PAGE 01 PEP/17/2009/TUE 08:48 AM ONA FAX No, 360491 8 P. 001 FROM : . FAX NO. :35E0794487 Feb. 13 2009 03:18PM P2 4 �._ Olympic Region Clean Air Ag tcy boy 9' 204O-B Lits u d Lama N W • te n ,TA 085o2 (.omme cial �.- (16O)586.1044•FAX(360)491-63O8 ,}!4 ORCA A p-1.4ngelc5°Lace(360)417.146)6 Asbestos Permit �{`�°P•mnerlw.rn9"0 itaymond OEfite(360)942-2137 -• www.ORCAA.erg .. [x]Cowmesrn:lal Structures [ ) 0W1ler Occupied Residential DtveTling 10 Working Day waft period Prior Notice PROPERTY OWNER ,'� County ."'.'hone: (300 )379-44ge ,in road: .0kd11yataa atierson.wa.us Name:Jefferson Pi e rSQ n`V k=9?: (3S0 )379 44$� Mobile; MailieL .AadreR`615 Sheridan Street ''`''Port Townsend sm '_W_A 9/3168 S�ile Contact Peroon; ;'boxse: (oeo )379 4498 Ernait; k trers00.wa.uai _Tam! Pokorny FAx_ (ssv )379.4487 . ,Mertoilc: 3130 315.9870 -SitGMdresa:420 Appaloosa Drive r'''`y-Brinnon fittm'WA ' ASBESTOS CONrrRAcToR - Contracts r/Bnsioras Name: f( Phone (380 )830-6022 Email:jtayiori(cn gyehoo.eor KC id i n C. F.A�X: (380 )830-6020 Mr bilc: {360 )731..1414 M*fl g Mcid65s4;PO Box 220 '�k'-Seabed, stcitc:WA ono PRO CT INFORMATION "' Soli:1)11w: Completion Dam: rein*Stilt Daym work 5bi{tliourx MarchJ, 20D9 March is,2008 ,47 x 1NX TA _„•Ba P ,5u_ I 9AM•5:3UPM #Structures to be abait:d: Total Quantity to be :iquate heat: JJJ---.Linear Feet 1 temoved Dis osa1 Site:Olympic View Transfer St-to Colorriliis Rid Will this structure be demolished efts r cwb.utos Will WI identified asbestos be removed fenr0 removal Yeas X No -- structure Yes X No ' _ Circle Material being removed: H_ atltr/Pomace ,,,..._L7uet Insulation _____Pipe Insulation _Fireproofing i.'aintx Blaster M Cuocent Board Cancot Pipe X Flooring Roofing Textured Coating „-_Ocher _ ASBESTOS PROJECT CATEGORY NONFUNDABLE FEE . 1-[ ]10-259 linear or 11-1.59 square feet - 81S0 2-[X)260-999,lincar or 140-4,999 squats feet $325 —_ ...-. 3- [ J 3000-9,999 Linea?or 5,000-44,999 al feet -- $650 4-,[ ]10,000+linear oc 50,000 argtnire fret M $1,300 E gene` $50 --- [ 1 Annual-limit of 26o linear feet o 160 gore feet 8500 7 boa read and Will abide by Oa rondirioss solo b la rbit pewit an a;sy addendum tbcrrto. I do Hereby tent r Oat the lnfarttomtoa in Obit apptll.Nn,e,mod,r plcruret.l dasr e - i„ re the bait sf ary k owfcdge, accsrara aoaer ocarOlete. Jefferson Count)! 0212 09 Applicant Name Lute Mats- a 1' lxaymeat info, ry ( Approved ...... t\Sbet os P t 'y ` �� L ) cash I7iarapprovcd Peach# CDASB00'`'emu l t4 [ j[ ] Cheri r ar{1 RE:vitw date;J/i77 0/ Demolition Beam# Yarm�rM W FHB r� zoos Po 04f -p-11 � /� r Receive data;: /_ / -at:vlamed by:i e.C ira I/- survey: f 1 Yen [)[No T. AAonlif Um Only Alsios0 Uri On • . nr Ulo Only 10/2 /0 m OVER �'—O.Prf�' 11 . , �� 0r, JEFFERSOSUUNTY � . . E. g,� '�.3., DEPARTMENT OF COMMUNITY DEVELOPMENT .1 \�. CEI V D ~' ' 621 Sheridan Street• Port Townsend •Washington 98368 4 .7 > 360/379-4450 • 360/379-4451 Fax M1� �S NO�p www.co.jefferson.wa.us/commdevelopment J N 0 5 2CCr Master Permit Application MLA:r' ' V Ql'n Project Description(include separate sheets as necessary): i)(J. (ram1, XtSfirn PLC,t,I.Se !&id Tax Parcel Property Asscssa r : 3 it/ i SS" *+z Number: 110 to cite a 3-5 Size:Ati,i-.vla (; fe f �6 I ft z- (acres/square feet) Site Address and/or Directions to Property: 42i"' fop A LtwsCx b; iv' (mot�y C� Property Owner(s)of Record: :re a I irc c y K:P u il it Telephone: A-C'/31e1 - LI LI' 0 Fax: email: ±r o k vY n y t'�C'�'je- t,. . Mailing Address: /: i r 51-,e-'rr c e( W a 0 Si- p r,� A- '1;C-3(e g / Wel t LI,.S Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit? (Check each box that applies ❑Building ❑Variance(Minor,Major or Reasonable Economic Use) Q Demolition Permit 0 Conditional Use[C(a),C(d),or CJ** ❑Single Family ❑ Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home 0 Modular ❑ Special Use(Essential Public Facilities)** ❑ Commercial* 0 Boundary Line Adjustment ❑ Change of Use ❑ Short Plat** ❑ Address 0 Road Approach ❑ Binding Site Plan** ❑ Home Business 0 Cottagelndustry ❑ Long Plat** ❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑Sign ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management 0 Shoreline Management Substantial Development** ❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* El Jefferson County Shoreline Master Program Amendment ❑Forest Practices Act/Release of Six-Year Moratorium ❑Tree Vegetaion Request *May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she wants prior notice./ LS 2 t_ 0•--A-q Signature: l�/�/�r ��l«'� �QA Date: ?�`_� f `_ The action or actions Applicant will undertaker as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable responsibility for adhering to and co plying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: ://j I(4, S ee, 0.A'{-c.C,h t.,0 Date: /.5/dc 7 Set a / t e4/ G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc 7 BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. a Signature: Date: ± '.., Eli v GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: i, EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New ❑ Wood Existing: ❑ Sewer ❑ Addition 0 Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair 0 Masonry SEP Permit# `El Demolition 0 Other: Bedrooms: Water Supply: / Existing: Setback: ❑ Private well 0 Two Party Type of Heat: Proposed: ❑ Public Total: Name of System: _ If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: I Underground Tank i Above ground Tank Size of Propane Tank: i Heat Stove i Cook Stove i Woodstove I Fireplace Insert i Hot Water Tank I Pellet Stove I Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage Current Proposed ,fir cep ser_n y i s ",,.:.._ •. .„IIALO.0 Main Floor Heated x ;Z'- L4 EH Bld App Review: 2n°Floor Heated : Consistency Review: Other Heated ` `4"' Base fee: Mezzanine Additional Section: Heated Basement t-TP*Ctttag Plan Check fee: fftt r r State Surcharge fee: Unheated Basement 'sa 9 b L( SZ; Other Unheated u "; t r Pot Water Review fee: 1`. • ; V. Garage/Carport "> > t� SUBTOTAL v o � � : i3a.,sz.. Decks ��+ Ott 911/Rd Approach fee: Other 1 '$ '` TOTAL: $ i 3a , cr.) r;:, - e:t4',ei5,41,..::,,-', priVgrAN Recei tNumber: 43 Cash/Check Number: ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish Initials: G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc 1 RECE]1V1-1,' D • • Date: Initial Y Date Application Received Amended: ❑ ,��e`` '' 2940 B Limited Lane NW - , �� 'c' Olympia, WA 98502 1' til, Completion: ❑ ( t Phone: (360) 586-1044 .� ORCAA j Fax: (360) 491-6308 Annual: ❑ $500 \t°`-",� ,,. ."` www.ORCAA.orq Agency Use Only / Permit Application for an Asbestos Project A. Project Type: 1.1a Asbestos Removal 2. ❑ Renovation 3. ❑ Maintenance 4. ❑ Encapsulation 5. ❑ Demolition 6. ❑ Emergency 7. U Other: B. Property�y Owner: ,TG Et'esr5o in noon 41 Phone:(3(?o)371 - L1497 Property Owner's Mailing Address: 6215 1 erl cl&n f City:TirF-IOwnseta State: W/. Zip:67g3k8' C. Asbestos Contractor: Contractor Owner/CEO: Kee, �VIG a I.. Je11 'e- 7-o•ylor- Mailing Address: f 0. Box Zd Phone: (3(4°) &'30^ 6-02-2-- gg3TO City:$sue liee-le--- State: WA Zip: Fax: (34/0) $30 — 602-6 D. Site Address: gig37 0 14L0 irea'L0o5cc LY'i Ve, City: grinvta 0/ WA State: Zip: Project Manager or Contact Person: 'Fa vn(' Po korrl y Phone:B(ap)379'-q t-9 8 E. I Asbestos Survey or No.of Structures: Date Asbestos Survey Conducted: W Asbestos Found? ❑ Mat'l Presumed: Ns 1 q f 31/D 1 ❑ If No,Attach Survey AHERA Building AN AHERA SURVEY IS REQUIRED BEFORE ALL DEMOLITION Certification No.: Expiration Date: Inspector Name: PROJECTS OQL ).- C3oG 1/vt-Hi .--rtdile wArvtoA- Ic4.?oloo I I0/27/07 F. Demolition No.of Structures: ' Start ❑ Training Fire(List Fire Dept.as demolition contractor below) Information: Date: ❑ Ordered Demolition(attach copy of Order) Demolition Print name here:enter mailing address in boxJ on back ofform. If framing burn,enter name offire department here Contractor: Phone:( ) G. Asbestos No.of Structures:(see Start Date: Completion Wk.Days: M T W Th F Sa Su Project back if> 1) r Date: Hours: Information: I Will all asbestos material be removed by Total Quantity to be Removed: Square Feet Linear Feet project completion?❑ Yes ❑ No Thermal System Insulation: Li Boiler/Furnace Ins. ❑Duct Ins. ❑Pipe Ins. Other: Surfacing Mat'l: ❑Fireproofing [❑Paints Plaster U Textured Coatings Other: Misc.Mat'l: U Cement Bd. U Cement Pipe Flooring Mat'l U Roofing Mat'l Other: H. Asbestos/Demolition Project Categories: Notification Waiting Period NONREFUNDABLE FEE 1. TResidential Dwelling Asbestos Removal Project Prior Notice $25 2. UDemolition 10 Working Days $25 3. Uless than 10 linear feet or less than 11 square feet Prior Notice $25 4. U1It-259 linear feet or 11 - 159 square feet 10 Working Days $100 5. (14260-999 linear feet or 160-4,999 square feet 10 Working Days $250 6. U 1,000-9,999 linear feet or 5,000-49,999 square feet 10 Working Days $500 7. ❑10,000+linear feet or 50,000+square feet 10 Working Days $1,000 8. VAnnual Permit Aimited removal,additional permits,contact ORCAA) Prior to start of New Year $500 9. UEmergency Project Prior Notice $50 10. UAmendments(no fee for 1st and 2nd amendment) Prior Notice $25 I. 1 do hereby certify that the information contained in this notification,and supplemental data Payment received date: described herein,is to the best of my knowledge accurate and complete. I shall not cause or allow Reviewed date: any asbestos project or demolition activities to begin until the appropriate waiting period has Reviewed by: elapsed. Permit Number: �� Date: Date taxed/mailed notification to applicant: Signa For Compliance With Regulation 1,Section 14-Asbestos Print NameTjq pVt I P�L� � Representingj � LO U✓l+r Agency Use Only Rev.07/07/04 • • The Olympic Region Clean Air Agency is the local air pollution authority for Clallam,Grays Harbor,Jefferson,Mason,Pacific, and Thurston Counties. The Olympic Region Clean Air Agency's Regulation 1, Article 14, requires advance notification be submitted to the Agency, on Agency-provided forms, for any asbestos project and for any demolition project, regardless of asbestos content, involving any structures. Notices of Intent should be mailed or hand delivered to the Agency (address on reverse side) with the appropriate project fee. An Agency representative will review the notification, and if it is completed correctly a copy will be returned by mail or fax within 3 to 5 days to information provided in box C and box J. The returned copy will be your valid notification.You must have an approved permit prior to job commencement. J. Demolition Contractor: Owner/CEO: Mailing Address: Phone:( City: State: Zip: Fax: ( GUIDELINES FOR SUBMITTING AN APPLICATION TO PERFORM AN ASBESTOS PROJECT Enter all applicable information accurately and completely. Incomplete Notices of Intent will be returned. Box A.Check all appropriate project type. Box B. Enter the legal property owner information. Box C. Enter the asbestos contractor information, or "not applicable" (N/A) for demolition projects when no asbestos- containing materials are present. For a Residential Dwelling asbestos removal project, list the property owner doing the asbestos removal(include property owner's mailing address). Box D. Enter the asbestos removal or demolition site address. For a Residential Dwelling asbestos removal project where the property owner's mailing address differs from the site address listed in Box D, a letter must accompany the Notice of Intent verifying that the structure located at the site address is currently being used as the property owner's domicile. Multiple asbestos/demolition projects involving more than one structure must be submitted in accordance with the ORCAA Regulation 1,Section 14.05(a)(8). *Residential dwelling (ORCAA Article 14, Section 14.03 Definitions) means any non-multiple unit building containing space for uses such as living, sleeping preparation of food, and eating that is owned, used, occupied, or intended or designed to be occupied by one family as their domicile.This term includes houses,mobile homes,trailers, houseboats, and houses with a"mother-in-law apartment" or"guest room." This term does not include structures that are demolished or renovated as part of a commercial or public project. Nor does this term include any mixed-use building, structure, or installation that contains a residential unit, or any building that is leased or used as a rental. Box E. Enter the asbestos survey information or check material presumed(for asbestos projects only). An AHERA building inspector must conduct an asbestos survey prior to any demolition project (i.e., the wrecking, razing, leveling, dismantling or burning of a structure, making the structure permanently uninhabitable or unusable). A copy of the survey results shall accompany the application. Box F. Enter the demolition project information. If the structure is to be used in a training fire, list the fire department responsible for conducting the burn as the demolition contractor in Box J. If the property owner has been ordered to perform a demolition by a government official,submit a copy of the order from the appropriate official. Box G. Enter all asbestos project information or enter"N/A" for demolition projects with no asbestos removal required. All multiple structure asbestos projects must be submitted with a work plan, map of the structures,complete site address, type and amount of asbestos material to be removed from each structure,AHERA asbestos survey,and work schedule. Box H. Check appropriate project categories in boxes 1 through 8. Asbestos project fee does not include demolition project. An additional $25.00 is required for a demolition project. Emergency notifications must be submitted with a letter from the property owner explaining the necessity for the emergency. Emergency demolition notifications must be submitted with a letter from an authorized government official or a licensed structural engineer documenting that the structure is in imminent danger of collapse. Box I. Sign the notification certifying the accuracy and completeness of the information provided on the form. Box J. Enter demolition contractor mailing information(on back). Mandatory amendments are required for changes that increase the project type, job size categorp the types of asbestos materials to be removed and work schedule changes. A $25.00 processjpg f r ci�iiTed\for,all tamendments* (1' and 2nd amendments have no fee requirement). Ji For technical assistance, or inquiries concerning notification and amendment status contact ORCAA at(360)586-1044 Rev.07/07/04 r` X 9 2 m v, C) ( . -I S 3 . • rn c.— . ors 'CI • 02 s11 11 ® 17 •" Cs 73 c, m Q CZ CM i -i rn v v o rn TT 0 0 l y r Ri • z u�i q r 0 d D z r. TIA > g tit 0 A J - 2. r m o N > c-, rn G\ `� CO til �I -o r I O n 3 ° D ),\ "A ' . A \ 1 i z . )zr NI ,-- C)- -O . 7 , Y '- 7m - , �—�'G----r-11 o _ r, a\ xD o p W t °cn 1 C 9° d Z. .v, T I. m e —(:: , xi ?,, c‘-.. t Tc -Ps _ ksi,. HJ, xv m -- > F -71 v • ^ pxi n _____. _ v4. o 00 , , SO i. a 0