HomeMy WebLinkAboutBLD2013-00123 - Asbestos Survey • •
fr, u' r°o, Accelerated Analytical LLC•
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P.O. Box 309
Littlerock, WA 98556
acceleratedanalytical @comcast.net (360) 239-0354
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Asbestos Survey Report
Located At:
621 South Point Rd.
Ludlow, WA 98365
• •
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
Table of Contents
1.0 INTRODUCTION 3
1.1 Purpose 3
1.2 General 3
1.3 Building Description 3
2.0 SAMPLING 4
2.1 Laboratory Analysis 4
2.2 Sample Analysis 4
3.0 SURVEY RESULTS 4
4.0 LIMITS OF SURVEY 5
APPENDIXES 6
Appendix A: Laboratory Results/ Documentation 7
Appendix B: Site Photographs 8
P.O Box 309 2 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
• •
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
1.0 INTRODUCTION
1.1 Purpose
This good-faith asbestos survey was performed as part of pre-demolition activities to
identify the presence, location and quantity of any asbestos-containing materials
(ACM) within the construction area. The intent of this asbestos survey is to comply
with governing asbestos regulations required by Federal Standards and with the
Washington State guidelines. Currently, the State of Washington requires a "good
faith inspection" for the identification of asbestos-containing materials prior to any
remodeling or demolition work.
1.2 General
On April 03, 2013, Todd L. Venable, AHERA Accredited Building Inspector, of
Accelerated Analytical, conducted an inspection for suspect-ACM at 621 South Point
Rd. in Port Ludlow, Washington. This Asbestos Inspection was performed as part of
pre-demolition, activities.
The site inspection included all accessible areas within the structure.
1.3 Building Description
The Structure was occupied at the time of inspection.
The structure was a Stick Built 3-bay Garage. The structure had a Cement Foundation
System, Aluminum Siding, and a Flat Asphaltic Roof System. The interior was
composed of Wooden Walls and Ceiling System. The floor system was finished
concrete.
P.O Box 309 3 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
• •
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
2.0 SAMPLING
The sampling objective was to determine the quantity and location(s) of asbestos
containing materials. There were two (2) samples collected at the time of inspection.
Sample A was collected from the Asphaltic Roofing materials, Sample B was collected
from the Corrugated Vinyl Roofing Material.
2.1 Laboratory Analysis
The bulk ACM samples are analyzed at Seattle Asbestos Test LLC, 19711 Scriber Lake
Road, Suite 103, Lynnwood, WA 98036 using polarized light microscopy (PLM) with
dispersing staining in accordance with U.S. EPA method 600/R-93-166 as specified in
40 CFR Chapter I (7-1-93 edition) Part 763, Subpart F, Appendix A, pages 499-504.
Polarizing light microscopy quantifies asbestos concentrations at between 100% - 1%
detection levels. Levels below 1% can be stated as "ND".
2.2 Sample Analysis
A Asphaltic Roofing Main Roof Damaged N/A None Detected
B Vinyl Roofing Side Roof Damaged N/A None Detected
3.0 SURVEY RESULTS
Samples A Et B tested Negative for Asbestos Content.
P.O Box 309 4 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
•
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
4.0 LIMITS OF SURVEY
Asbestos surveys are non-comprehensive by nature and subject to many limitations as
described below. Our assessment has considered risks pertaining to asbestos;
however, this survey is limited to only those locations sampled. This survey was not
designated to identify all potential concerns or eliminate all risk associated with
potential asbestos containing materials (PACM5).
Evaluation of other risks, such as toxic and hazardous substances in (or in contact
with) soil and ground water, structural, electrical, mechanical, radon gas, slope
stability, building settlement, moisture, or site-drainage/flooding, have not been
included. No warranty, expressed or implied, is made.
The site visit consisted of a through visual walk-through of the subject area for the
purpose of viewing and sampling PACMs. Advance Environmental Inc. is not
responsible for materials, which require destructive means to access, or materials
that are hidden from sight, those materials hidden behind walls or materials, which
cannot be found with reasonable diligence.
Accelerated Analytical LLC performed this survey in accordance with the generally
accepted standards of care in the sampling profession in Washington State at the time
of this study. This asbestos survey was performed in preparation for a demolition of
the subject structure.
Accelerated Analytical LLC
Todd L. Venable AHERA
Accelerated Analytical LLC
P.O Box 309 5 Phone:360-239-0354
Litderock,Washington 98556 Email:acceleratedanalytical @comcast.net
• •
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
APPENDIXES
P.O Box 309 6 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
• •
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
Appendix A: Laboratory Results/ Documentation
P.O Box 309 7 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
•
•
Accelerated Analytical Asbestos Survey Report
621 South Point Rd.; Port Ludlow, WA
Appendix B: Site Photographs
P.O Box 309 8 Phone:360-239-0354
Littlerock,Washington 98556 Email:acceleratedanalytical @comcast.net
. S
Accelerated Analytical Asbestos Survey Report
621 South Point
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Port Ludlow WA
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Asphaltic Roo ing A Interior walls and ceiling
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Corrugated Roofing B
P.O Box 309 9 me:a6239-9
Ltde mck,Washington 98556 Email:acc eler aanaly R&qm
4
1.9CON eed JEFFERSTY
too ` ' DEPARTMEON NT OF COUN COMMUNITY DEVELOPMENT
40. 1
621 Sheridan Street• Port Townsend •Washington 98368
a . 360/379-4450 • 360/379-4451 Fax
q� � www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
MoV Er IF4ST)N C} Covvca AiLlo CL&TFOCT f(C M IENT CaAr izd44, 7 5-1UPi
Tax Parcel Number. Tr“POCX) 2 CP Property Size: (acres/square feet)
Site Address and/or Directions to Property:
C.Pe C :co-rf-f °6 NT 12aAU )eT lJ ctov`1) L JA �ce 5
Property Owner(s)of Record: 'T ✓� ^)J$� VI i'¢CA t if4 /�t (H Ain
Telephone: Fax: email: �
Mailing Address: C� )t C�.,l'Mfpras .DiK '31J LS O/�rt•k� WJ �gjOZ,1
Applicant/Agent(if different from owner): Cceofeae. (.3.)I` Z.L.K.
Telephone: 3(ag".)— 7 —t h Fax: ..C)—be?7-54L ) email:neO( 4,51y1"t . U
Mailing Address:
What kind of Permit?(Check each box that applies
1,.ilding ❑Critical Areas Stewardship Plan
Demolition Permit ❑Variance(Minor,Major or Reasonable Economic Use)
❑Single Family *Garage Attached/Detached ❑Conditional Use[C(a),C(d),or C]*”
❑ Manufactured Home ❑ Modular ❑Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)*"
❑ Change of Use ❑Boundary Line Adjustment
❑ Address ❑Road Approach ❑Short Plat"
❑Home Business ❑Cottage Industry ❑Binding Site Plan"
❑Propane ❑Long Plat**
❑Sign ❑Planned Rural Residential Development(PRRD)/Amendments*"
❑Allowed"Yes"Use Consistency Analysis ❑Plat Vacation/Alteration**
❑Storrnwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
O Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development"
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference ❑Tree Vegetation Request
**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 V'S.LO(. to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE )e Date:x
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 its 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. Staff's 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.
Signature: Date:
The action or actions Applicant will undertake as a result of the Issuance of this pemtlt may negatively Impact upon one or more threatened or
endangered species and could lead to a potential lake'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 complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date:
G:\PeanitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
• •
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.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
T -iW ( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: ' EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
O New ,`F Q,Wood Existing: _ ❑ Sewer
❑ Addition 0 Steel Proposed: Bank ❑ Community System
O Alteration/Remodel ❑ Concrete Total: Height: Xlndividual System
❑ Repair ❑ Masonry SEP Permit#
eK Demolition ❑ Other: Bedrooms: `1 Water Supply:
Existing: N A Setback: `A.Pr•vate well 0 Two Party
Type of Heat: Proposed: 0 Public
Total: Name of System:
If this is a Commercial Project you must answer the following: ,` tt tt
Number of Parking Spaces: Current N A Proposed: OA Number of ADA Parking Spaces: 1•/ tc
Number of occupants Sn�dudes owners,tenants,employees,etc) Current 7.1 A Proposed iir,
IBC Occupancy:h IBC Type of construction: Ye) Will you have Food Service? Y-s IIIZ
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 1 Hot Water Tank 1 Pellet Stove 1 Other
Is this appliance being installed in a Manufactured I 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.
4,T d r.i .T. 9 ;" x x i t t r u t S•uare Foote!e Current Pro••Sect r �_ ao..L _):*-' Ali,i ,,,, ., „-e:E_A I1if., , tt „r t:1 ,_:r
Main Floor Heated `• . App
2"°Floor Heated Consistency Review:
Other Heated :: 00
T
Unheated Basement x State Surcharge fee:
:'fin ` ,
Other i 1t - Pot Water Review fee:
Garage/Carport ', 3 vxfa
� � SUBTOTAL do(o'
• it 911/Rd Approach fee:
• TOTAL: $ b
bi ° Receipt Number: /q0 a iiS
.a Cash/Check Number: a A .
3
•rsvx'RJs!.�'
ESTIMATED COST(REQUIRED) Date:
.Fair market value of all labor and materials foundation to finish I fiS I I 3
Initials: /
G:\Permit Center\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
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oEpAwT�ewTopcO� DEVELOPMENT
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621 Shrridan Street 'Port Townsend 'VYmehingtong830V
350/379'4*50' 360/379-4451 Fax
x"m°roj*Monol.wa.usicnmmdnvemp'nent
Master Permit Application MLA: __ - -
1 Prolect Description(include separate sheets as necessary) i
4'-'��
1 Site Address and/or Directions to Property: 1
•
.! What kind of PerTnit?(Check each box that applies
''. Alyilding 173 Critical Areas Stewardship Plan
'-: -srii.Demolition Permit Li Variance(Minor,Major or Reasonable Economic Use)
1 10 Single Family :A,Garage Attached. !Detached D Conditional Use(C(a),CO),or Cl"
1 1,...i Manufactured Horne 0 Modular 0 Discretionary'LT or Unnamed Use Classification
! 0 Commerdal" '111 Special Use(Essential Public Facilities)**
`: fl Address_________ill Road Approach 0 Short Plat**
1.=.1 Home Business 0 Cottage Inclustiy HI Binding Site Nan"
Li Propane 0 Long Plat**
0 Sign 0 Planned Rural Residential Development(PRRD)/Amendments''''
LIAllowed'Yes"Use Consistency Analysis 0 Plat Vacation/Atteration-
H Slorrnwater Management L.-/Shoreline Master Program Exemption/Permit Revisions*'
0 Site Plan Approval Advance Determination tSPAAD)* El Shoreline Management Substantial Development** ,
Temporary _Shoreline Management
Wireless'I- Plan/UDC/Land Use District Map Amendment
2;Forest Practices Act/ReleaSe of Six-year Moratorium Li Jefferson County Shoreline Master Program Amendment ,
•May require°Pre-Application Conference 0 Tree Vegetation Request ,
Please identify any other local,state or federal permits required for this proposal,if known:
I hereby designme_c,.. _d{?;Lig,,,ie„,te,-...:.1_ ',..mr,r,.., to act as my agent in matters relating to this application for permit(s), :
By signing this application form.the owneriageot attests that the informabon provided herein,and in any enactments.is true correct to the best ot i
m, ,w'mmk"w°moge Any material falsehood«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 attorneys fees and
expenses which may in any wa accrue against Jefferson County as a result of or in consequence of the granting of this permit
, i Im*m�xn°mmp,��.o�*,^and nvh'o/ewn'vJene�mcvumv and^^omnm*�m,�vw,^m�~v,v'�eo�xvm°wwwon^em�p/^a*o° \
review and any required later inspections. Stun access and and nqhi of entry wixueammmeav^lem'oouwymont informs the County.v writing"t/^*
Signature -____ Deny_ t111 _'
'___--____—_ ____-___-___�-______'—_______--___-__ -__-___-- ---_Y
The action or actions Applicant will undertake of negatively~w�*"��vopm"mm�mmumv�v,
" ^ may �=°'
ecoangered species and could lead to a potential lalce of an endangered species as those terms are defined in the federal law known ac the
Endangered Species Act or ESA"Jefferson County makes no assurances to the applicant that the actions that will he undertaken because this
I permit has been issued will not viotat the ESA Any indivi'eual,group or agency can file a lawsuit on behalf of an endangered species regarding yaur
action(s)even if you are in n Applicant"c*ov~mdg^mth-*he,she n,x holds individual
and n^w mv The Applicant has read this disclaimer and n^aw,mw°abelow
s.o"m.= Date: ��/z�^ | __.
---------- '-- /-- ( ----
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^ .r,..ir,ii,i'Txi,..^°°x"^xym'*"x`xn,^x^owi,2,.perr""^nx+,.~5-29 OS+"
III I
BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the pa,cel refetenced herein,that they are not licensed contractors and tr,:,t
they wit he assuming the its o.rrblty of the General Gontractor for the proposed prole;
...------ ,,,, _______
Signature --... Date
..,-------- -------tir
GE NEPAL CONTRACTOR OR MANUFACTURED HOME INSTALLER* Ptiorti.: FAY. i
MAILING-ACADRE.!:,S. Ewa:
CutriTeActoft'sliceNsc WAINS
NUMBER: NUMBER
_......
AR—HITECT/ENUNEEi4 PHONE ( ) FAX:( )
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MAILING ADDRESS: &mot
Project Type: Pr-me Type:
Bathrooms: , Shoreline: I Type of Sewage Disposal:
New .'",‹ Wood Existing- 1(...w.c.
, , Sewer
Addition Steel Proposed : Bank Community System
Afteration/Remoder Concrete Total ---- Height t a' i'd uaI System
• epair : Masonry . _. SEP Permit#
,$)(-:Demolition Other. Bedrooms• ' Water Supply:
Existing '''"4 A Setback ."/ Private well 1 wo Party
-- - - ,
P :
f ype of Heat _. roposed Public
Name of System:
If this is a ommercial Pro'ec ou must answer the topilowinsed.;: Number 0, __ _a,, g_paces:
Number of Parking Spaces. Current: _ir ____......„ roPo N& 11,16 I Proposed Psecirktn.. .,,,,:*
Number of occuparitcIncludes owners,tenants.employees,et,,_,C._u:nfot_ __. P
—
Will you have Food Service? le."..itiQ,
IBC°C'kAiPancY: . --'61---- IBC Type of'AInstrucl:°r- rnark-ailiterns below that apply:
If this is a P pane Tank and/or Applia e installation permit.
I Underground Tank ; Above ground Tank Size of Propane Tank:
,.
Heat Stove Cook Stove Woodstove 1 Fireplace Insert Hot Water 1 Pellet Stove 1 Other
Is this appliance being instaljed in a Manufactured!Mobile Home? Yes I
When applying fora permit to install a propane tank must also submit a site plan showing all of the buildings,a"property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components.
including the reserve area.
. - ,77.71
. ,.r.--....u4n.vf.nik ',.-..%.. ';-. ..:-,..-. ' ,.i,'-'3,4:,..-:-„ik.,-;;.„
hurrent Proposed 7. .„-- ,- A,-- ,,,. ,4, : ...-., ..,..:,,,-...., . Amatot ,,,,t,, , ,
Square Footage _ ed -r....,..Gate,' -'' ' q '•-,"- ' - •
Main Floor Heated i ;-:..-.:,,.r-r.- '- EH Bid App Review:
I
..
1
.1,--Z4-FI-Oef—Fteated i — --14,St?..,,,.,-.1 ., Consistency Review:
1 Other Heated
A
:; ''''''' -''' Base fee:
' .i:.,'" l. ,-
, Mezzanine I 1..4--:inf.-i''':"•‘:' Additional Section:
; I '
r---
------t—a'
Heated Basement : ' :','.,,-.'-... Plan Check fee:
■
-4 . .
UnhaatedWasement
;::,:si'..:.''' State Surcharge fee: 1
Other Unheated 4-
.' ,.. .. ..,-
i--- ----
1 r' '"' "' Pot Water Review fee:
t
Garage/Carport :
i i ' ' * - SUBTOTAL
: • :4;.',...i.,::..,;.-.
, , ..,.. .. _
, .. . .
Decks 1 1-- •-.----r4...---t4:-- 911/Rd Approach fee: I
,-,,,,,,,,,,
' - ---
Other TOTAL: $ '
- — i,- - --;
i 4'.`;"ttiii,,;„:.,-.: Receipt Number: ;
-',, '','',;-• ''-' Cash/Check Number: 1 i
i .
rESTIkiiitED COST(REQUIRED) Date;
1 :
; .
1 +Fair market vatue of ell labor and materials foundatton to finish 1 , , ,
initials: -I :
------ ,
p„..r.„0.-(1,,,,,ktf il...-0)Rt..,1Slittf\DILI.Ft.)RM::,',N11.“,:,Print s Applic.)144)5 24 1 ,1,.,,
• •
SEATTLE ASBESTOS TEST, LLC nvLAP Accredited,29016g4
CHAIN OF CUSTODY
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Client Name - 4-r-C-0 A^Vti-Yr r-C-A 1, LL.c
Address City i-r-r-rt-E-rtac-le ST Uu A 7XP 185f
Phone: (?6°)2- —4)3 5 Fax: — Email:
Project Location: ( 2-t So v To?c-s-,01 i-c-r3v),;;N ' Project Manager: R-ki i--;"'
Turn Around Time a4‘,.-.Number of Samples A Client Job# 1 5/3 -A
IMMO WENT SAMPLE# IIIIIIMaae.aagtaat-alIllM LAB ID A/R
1 1) R c C-=4.1 (7.
2 13 11111111111121111"MI 111111
3 INIIIIIIIIIIIIIII 111111111
4 1111111111111111111 MIME
5 IIIIIIIIIIIIIIIIM MIN
6 111111111111111111111111
INEIIMIIIIIIIIIIIIINIII 11111111111111111
8 IIIIIIIIIIIIIIIIII MIMI
9 IIIIIIIIIIINIIIIIII
10 111MNIIIIIIIIIIM 111111111
111111111111111111111 11111111111111111111111111111
1121 aIIIIIIIII"IHIIIIMIIIIIIIIIIIIIIIIIIIMIIIIIMIMIIIIIMM
IIIIBIIIUIIIIIIIIIIIIIIIIIIIIIIMIIINIIIIIIIIIIIIIIIIII 111111
sinifill
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16 111111
18 11111111111111111111111
19
20 MB
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Print Name Company Name Date Time
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1-.,c3.4:i V E-0-a-rs,....e. /010 A Elt. i-1/37i7
ELIPM g`i L-P"' -5p,'4-C4L- IIIIIIM=1 A .A• 4-14310
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Seattle Asbestos Test warrants the test results to be of a precision normal for the type and methodo ogy employed for each sample
submitted and disclaims any other warrants,expressed or implied,including warranty of fitness for a particular purpose and warranty
of merchantability.Seattle Asbestos Test accepts no legal responsibility for the purpotm for which the client uses the test results.
By giving on this form the clients agree to relieve Sande Asbestos Test of any liability that may arise from the test results.
S
SEATTL.E ASBESTOS TEST
Lynnwood Laboratory:19701 Scriber Lake Road,Suite 103, Bellevue Laboratory 12727 Northup Way,Suite 1,Bellevue, Seattle Laboratory 4500 9th Ave.NE,Suite 300,Seattle,WA 98105,
Lynnwood,WA 98036,Tel:425.673.9850,Fax:425.673.9810 WA 98005,Tat 425.861.1111,Fax:425.861.1118 Tel:206.633.1111,Fax:206.633.4747
ANALYTICAL LABORATORY REPORT
RIM by Method EPA/600/R-83/116
Attn.: Mr.Rylan Baker Client Accelerated Analytical,LLC Address: P.O.Box 309,Little Rock,WA 98556
Jolgt: 1313-A Betch#: 201310488 Date Received: 4/4/2013
Samples Reed: 2 Data Analyzed: 4/5/2013 Samples Analyzed: 2
Project Loc.: 621 Southpoint Rd,Port Ledlow,
WA
Analyzed by: Christina Buce Reviewed by: Steve(Fanyao)Zhang,President
Lab ID I Client Sample ID Layer Description % Asbestos Fibers Non-fibrous Components % Non-asbestos Fibers
Black asphaltic None Cellulose
1 A 1 material with Asphalt/binder 14 ,
detected Synthetic fibers
fibrous material
Beige brittle None
2 B 1 material with
detected Filler, Binder 23 Glass fibers
fibrous material
1
-------
Jefferson Co Dept of Comm IOWA- Online Payments • Page 1 of 1
,, ' Jefferson County
Step 1:Select Payments Step 2:Review and Submit Step 3:Confirmation and Receipt
Step 3: Confirmation and Receipt
Result: Payment Authorized
Confirmation Number: 10223168
Your payment has been authorized successfully and payment will be processed.
Jefferson County Department of Community Development thanks you for your payment.For questions about your account,please call 360-379-4452 Thank you for using
our bill payment services.
Please save or print a copy of this receipt for record keeping purposes.
My Bills
Description Amount Due
Building Renewal Fee payment of$76.00 on Permit Number 996600026 $76.00
Subtotal: $76.00
Customer Information Convenience Fee: $2.50
First Name: George Total Payment: $78.50
Last Name: Wittier
Address Line 1: 17791 Fjord Dr Ne
Address Line 2: Ste N140
City: Poulsbo
State: Washington
Zip Code: 98370
Phone Number: 3607796699
Email Address: jadams@co.jefferson.wa.us
Payment Information
Card Number: ************9000
Expiration Date: **f**
Print
https://client.pointandpay.net/web/JeffersonCoDeptofCommDevWA 4/15/2013