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Home My WebLink AboutBLD2015-00104 - 02 DEMO • DEPARTMENT OF COMMUNITY DEVELOPMENT 'I 621 sh,.rul:u,lnri•i,l 'rt i'nrnr:rnl, TO! 3611119.4•1ill 1 1X: i()1 L16 1 L) f Web:WW W311. "m u;LigIC401 unicgleKd r, IIII (" l t}- 1SW i N DEMOLITION PERMIT APPLICATION Steps in the Permit Process: -Review required submittal items to ensure all information is completed prior to submitting application. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Receipt# i 54305— Date: 3/ 3 V).S` Related Application#5: Payment# y sg t..I Demolition of any structure requires the applicant to receive approval from Olympic Regional Clean ✓ Air Agency(http://www.orcaa.org/services/asbestos-and-demolition or 360-338-6419) prior to obtaining a permit from Jefferson County Dept. of Community Development. Required Submittal Items An approved Demolition permit from ORCAA. ELComplete Site plan - Please refer to the site plan checklist to ensure all items are on the site plan. nIf applicant is different from owner,written authorization from property owner to demolish structure. Building Information Site Address: t 10 t ..lid1 ,1% Tz046,, 8 t,,,yst�4 w A emeaba, 4$320 Assessor Tax Parcel Number(s): "ILA_41100 _ O 2..3 Present Zoning: l,ZQ,, 1 t 5 Present Use of Property: _ : (2„� {-� _ S Lk its. Ii kami , Type of Structure to be demolished: � I_ Residence I Garage Shed n Commercial I Other What existing buildings will remain? Cx4•�,a Is th any water on or adjacen the property? NO YES Marine L Creek L Pond/Wetland — Lake Other Sewer disposal method: Onsite septic Public Sewer-Provider Septic Case ft Wastewater-Sewage Disposal Is there an existing Septic System on the property? Yes No 11__ rn Will you be reconnecting to the existing septic system? Yes i 4y, F Is there an existing well on the property? Yes I' No —' Do you plan on decommissioning the well? Yes :la_Oh Ht1 4E115 u I F_ i CCUNTY ()) n COMMUNITY NVELOPMFP!T • • Property Owner Name: AuK MCA—SU arw't Address: 1V L%(.t1%4 ' ; 47.01 ti-10,Ao1 iut 1a cite!? Phone ##: vr_ 4 moot) E-mail Address: e4„, aet.3nrp.,{p eavt Please contact Auid orized Agent/Re resentative with project info. i Property Owner Signature: Date: 3 4i/<. Applicant/Contractor Authorized Agent/Representative Name: �/-tvw 41)-e - S +`P.�.� .R�4- GQQ+�'�1na Phone#: 3tin_ ,�,- is es E-mail Address: License 4: Expiration Date: QtG tai'. Z�Novtc t Assoc%wtl,twe . 340- 11-1 !-ptv l Sal 5t • i %eve, 04i-cam 3(.0- A11-43V6-1 (6,44) {�w't i�•��t-��, A- 473L Z 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I 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. Applicant may request notice of the County's intent to enter upon the property for visits related a this application and subsequent permit issuance. Signature: f// Print Name: 5 iAL. Date: 3.l ys' A final inspection must be scheduled once structure is removed to close out case OFFICE USE ONLY Building Permit Fees Demolition Permit Fee $78.00 Environmental Health Review $86.00 Project Scanning Fee $19.50' Total Fees* $183.50 *Additional fees may apply MAR 3 1 2015 iJ �r:; '�lltdlY Zp tINITY DK!ORIENT ' I " Kc WA STATE CERTIFIED ASBESTOS CONTRACTOR #1085 PHONE#(360)830-5022 P.O. BOX 220 FAX#(360)830-5020 SEABECK,WA.98380 December 12, 2014 Zenovic &Associates Inc Project: 190 Bee Mill Road 301 E. 6th Street- #1 Brinnon, WA 98320 Port Angeles, WA 98362 CERTIFICATION OF COMPLIANCE AND COMPLETION FOR THE REMOVAL OF ASBESTOS CONTAINING MATERIALS On December 9, 2014 the asbestos containing roofing materials were removed from this double wide manufactured home, while wet and placed in a covered trailer for transport to our facility p o u a to p tY properly package it for shipment to a certified hazardous substance landfill for permanent disposal. The silverseal coating contained 3% Chrysotile. The Olympic Region Clean Air Agency Notification to Remove Asbestos Permit was obtained and funded by our company. However, ORCAA does not allow the abatement contractor to obtain the Demolition Peiniit,that must be secured by your firm or the owner. There is a 10 working day wait Required by ORCAA after you obtain their permit before you can commence demolition activities. This is non-friable, miscellaneous materials that can safely be handled without becoming airborne due to the heavy mastic materials used in their manufacture. The demolition debris that will be delivered to an approved transfer station will not contain any asbestos materials, as the materials identified in the AHERA Report, have been removed. Jeanie Taylor, Coordinator, KCB, Washington State Certified bestos Contr ct #1085 WA STATE LICENSED GENERAL CONTRACTOR #KCB****922J5 ;L;701: "5iwce 196y' Ii1 - i r_ i MAR 3 1241 ` ' ------ c rr ,I Ir IP(DE+rI OPPcF'!T I € ![1 K Environments/ Services PHONE#(360)830-5022 P.O. BOX 220 FAX#(360)830-5020 SEABECK,WA 1 JTAY.0R4Y HOO.cOM 98380 December 12, 2014 Zenovic & Associates Inc 301 E. 6th Street— Ste 41 Port Angles, WA 98362 Attention: Scott Headrick, PE Attention: Transfer Station attendant or Reclamation Contractor CERTIFICATE OF COMPLIANCE in disposing omiscellaneous demolition materials 190 Bee Mill Road Brinnon,WA 98320 Structure: Double-wide manufactured Certifying that the materials that are being disposed of is construction debris from the site listed above and does not include any asbestos containing materials. Being transported by t Skyler Taylor, US EPA Certified AHERA Building Inspector #BI'- •I-0108*14-02 a 3 015 a, Li JEFrERSO COUNTY -,T OF COMMUNITY DEVELOPMENT • • • 2940-B Limited Lane NW Olympia,WA 98502 : 1 - 1-800-422-5623 • (360) 539-7610 A A / „ Fax: (360)491-6308 ORCAA Permit Application Status Permit Status E Approved El Disapproved Notes APPROVED 3/17/2015 3/16/15 Asbestos Permit 14ASB004639 Hold--survey not complete. 3/17/2015 Complete Survey. 3/17/2015 PFM Review Date Reviewed by 15DEM004022 Expiration Date Permit# Application Received 03/12/15 $60.00 03/12/15 Amount Due 0 Cash CI Check Cl Credit card Additional notes or permit conditions . nr M Port Angeles Field Office: 116W. 8th St, Suite 113, Port Angeles,WA 980 A,119 360) 1 -1 3 1 2015 466 Rii\mond Field Office: 301 Ocean Ave., Raymond,WA 98577: (3 94,F, -'137 i '2,r CEIOFMEIRVISUCNITYCCDFIVITEYLOPMENT Olympic'Region Clean Air Agency(OIA) • 2940 Limited Lane NW ,,,, Olympia, WA 98502 360-539-7610 I FAX 360-491-6308 ' , Port Townsend 36ice 42-21 360-338-6491 Raymond Office 360 942 2137 • ORCAA www.orcaa.org DEMOLITION PERMIT APPLICATION Demolition and renovation projects within Clallam,Grays Harbor,Jefferson, Mason, Pacific and Thurston counties REQUIRE A PERMIT and require that the following permit conditions be met prior to demolition or renovation. Olympic Region Clean Air Agency(ORCAA) regulations define a demolition project as the wrecking, razing, leveling, dismantling or burning (by a fire department for training purposes)of a structure making the structure permanently uninhabitable or unusable. Renovations include the removing of load bearing structural members, but not to the extent to make the structure uninhabitable. The following information is merely a reference guide and not a substitute for agency regulations. 1.A good faith asbestos survey must be conducted by a certified Asbestos Hazardous Emergency Response Act(AHERA) building inspector. Qualified contractors and inspectors may be found in your local Yellow Pages,through the Washington State Department of Labor and Industries, or on ORCAA's website. 2.Asbestos samples must be sent to an NVLAP laboratory (National Voluntary Laboratory Accreditation Program) per 40 CFR 763.87. A list of labs can be found on ORCAA's website. 3.The start date on other structure demolition must be at least 10 working days from the submission date of the complete application and payment. 4. It is the responsibility of the property owner and/or demolition contractor to ensure there is no asbestos-containing material present in the structure to be demolished. 5.Any and all structures on the same parcel of property that are not proposed to be demolished must be identified as such. 6.A copy of the asbestos survey and approved Demolition Permit, as well as any subsequent amendments, must be kept on site and available for review by Agency inspection personnel. 7.The original demolition permit will expire on the Completion Date. Under no circumstances will a project be extended beyond 1 year from original start date. ADDITIONAL REQUIREMENTS In addition to Agency requirements, most building departments require a demolition permit(separate from ORCAA's Demolition Permit).The Washington State Department of Labor&Industries may also require notification for asbestos removal projects. "Owner Occupied Residential Dwelling" means any single family housing unit which is permanently or seasonally occupied by the owner of the unit. This term includes houses, mobile homes,trailers, houseboats, and houses with'mother-in-law apartment'or a'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 use as a rental, or for commercial purposes. PROPERTY OWNER ��Q 3 1 1015 I Li Cr CO'��lliNITY DEVELOPMENT • • Name Mailing address Ann Matsunami 1650 Liliha Street, Suite 201 City ZIP State Honolulu 96817 HI Site address City ZIP 190 Bee Mill Road Brinnon 98320 FAX Phone number Other contact number Email 808-595-6600 DEMOLITION CONTRACTOR ❑ check the box if same as property owner information Business/Contractor Name On-site contact RJ Services Vern Peters E-mail Mailing address City ZIP lumbervern mail.com PO Box 2461 Port Angeles 98362 p @9 9 Phone number Other contact number 360-477-1053 DEMOLITION PROJECT INFORMATION Number of structures being demolished 1 Start date Completion date Is asbestos present? 03/30/15 04/02/15 No Attach your asbestos survey below 20150312113707.pdf Has all identified asbestos been removed Yes DEMOLITION PROJECT CATEGORY ® Complete demolition ❑ Training fire-(complete fields below) 4 —� ❑ Renovation, alternation, remodeling, maintenance or other construction I i n If training fire, provide fire protection agency name, point of contact and telephone number MAR 3 1 2015 r�(?b.C.LINTY ❑ Owner occupied residential dwelling- Permit fee: $35.00-Prior Notice- Nonrefundable Or COMMUNITY DEVELOPMENT ® Other Structures- Permit fee: $60.00- 10 working day wait period- Nonrefundable ❑ Emergency Fee$50.00-must be accompanied by Government Ordered Declaration (other structures only) Attach declaration below PLEASE MAKE A NOTE OF YOUR FEE. • • Applicant name Date Vern Peters 03/12/15 I do certify that I am the owner, authorized agent of the owner, or authorized contractor for the property subject to this ORCAA application/permit. I authorize ORCAA staff to enter the property listed in this application at reasonable times for purposes of inspecting the work that is the subject of this application/permit and to ensure compliance with permit conditions, applicable laws and regulations. I understand that granting of this permit by ORCAA does not authorize anyone to violate federal, state, or local laws or regulation pertaining to activities associated with this permit. I have read and will abide by the conditions set forth in this permit and any addendum thereto. I do certify under penalty of perjury under the laws of the state of Washington that the information in this application and supplemental data is,to the best of my knowledge true, accurate and complete. I agree A==-} LEI (1M MAR 3 1 2015 ( / JNIY COMMUNITY DEVELOPMENT