HomeMy WebLinkAboutBLD2022-00150_01Demolition Permit 1
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcd@co.jefferson.wa.us
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 # Date:
Related Application #s: Payment #
Demolition of any structure requires the applicant to notify the Olympic Regional Clean Air Agency
(https://www.orcaa.org/asbestos-demolition-programs/demolition-notification/ or 360-338-6419)
prior to obtaining a permit from Jefferson County Dept. of Community Development.
Required Submittal Items
Proof of notification and payment receipt from ORCAA.
Complete Site plan - Please refer to the site plan checklist to ensure all items are on the site plan.
If applicant is different from owner, written authorization from property owner to demolish structure.
Building Information
Site Address:
Assessor Tax Parcel Number(s):
Present Zoning:
Present Use of Property:
Type of Structure to be demolished:
Residence Garage Shed Commercial Other
What existing buildings will remain?
Is there any water on or adjacent to the property?
NO YES Marine Creek Pond/Wetland Lake Other
Sewer disposal method: Onsite septic Public Sewer - Provider
Septic Case #
Wastewater - Sewage Disposal
Is there an existing Septic System on the property? Yes No
Will you be reconnecting to the existing septic system? Yes No
Is there an existing well on the property? Yes No
Do you plan on decommissioning the well? Yes No
RECEIVED BY DCD 3/15/2022
4
4
2901 Oak Bay Rd
921183022
Rural Residential
Home (not currently habitable) / Storage
4
Large metal shop
4 4 4
4
SOM87-00155
4
4
4
4
Demolition Permit 2
Property Owner
Name:
Address:
Phone #: E-mail Address:
Please contact Authorized Agent/Representative with project info.
Property Owner Signature: Date:
Applicant / Contractor: Authorized Agent/Representative
Name:
Phone #: E-mail Address:
License #: Expiration 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 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 to this application and subsequent permit issuance.
Signature: Print Name: Date:
A final inspection must be scheduled once structure is removed to close out case
OFFICE USE ONLY
Building Permit Fees
Demolition Permit Fee $102.00
Environmental Health Review $148.00
Project Scanning Fee $25.50
Technology Fee – 5% $13.77
Total Fees* $289.27
*Additional fees may apply
DCD010
EH038
DCD022
DCD003
RECEIVED BY DCD 3/15/2022
Leslie Fleming / Audrey LaRue
4830 S 170th St, SeaTac, WA 98188
206-300-7459 / 206-364-3316 talondance@gmail.com / audreylarure16@msn.com
3/1/22
Leslie Fleming 3/1/22
NWA
ENVIRONMENTAL
Surveys. Inspections. Sampling
AHERA Building Inspector / Mgmt Planner
EPA Certification AHERA1016201580
97 Fir Circle Port Hadlock WA 98339
chadwitheridge@gmail.com
(360)531-4636
Date: 4/21/2021
Job location:
Owner:
Subject:
2901 Oak Bay Rd Port Hadlock,
WA Leslie Fleming
Insp ection for Demolition
Inspector: Chad Witheridge
EPA AHERA - Building Inspector
#R21-004-AI-O
Expires- 1/13/2022
RECEIVED BY DCD 3/15/2022
Asbestos Bulk Sample Data
NWA ENVIRONMENTAL
Surveys. Inspections. Sampling
AHERA Building Inspector / Mgmt Planner
EPA Certification AHERA1016201580
EPA Certification WAMOA-0042
97 Circle Port Hadlock WA 98339
chadwitheridge@gmail.com
(360)531-4636
Samples were sent to EMLAB P&K
Dates: 4/13/2021
Job location:
Owner:
Subject:
2901 Oak Bay Rd Port Hadlock,
WA Leslie Fleming
Inspection for Demolition
Samples
S1: Vinyl Flooring
S2: Ceiling
S3: Wallboard Material
Inspector: Chad Witheridge
EPA AHERA - Building Inspector
#R21-004-AI-O
Expires- 1/13/2022
RECEIVED BY DCD 3/15/2022
Scope of Work:
1)Good faith inspection for asbestos containing building material (ACBM).
2)Survey, sample and record suspect materials of requested area only.
3)Report to Leslie Fleming with results.
Inspection Report:
Double wide residential mobile home. Composition roof, ACT, vinyl in kitchen and in
bathroom. Drywall and wood paneling throughout the home. Metal and vinyl windows
and exterior wood siding. All materials identified.
RECEIVED BY DCD 3/15/2022
NWA
ENVIRONMENTAL
Surveys. Inspections. Sampling
AHERA Building Inspector / Mgmt Planner
EPA Certification AHERA1016201580
EPA Certification WAMOA-0042
97 Fir Circle Port Hadlock WA 98339
chadwitheridge@gmail.com
(360)531-4636
Date: 4/21/2021
Job location:
Owner:
Subject:
2901 Oak Bay Rd Port Hadlock,
WA Leslie Fleming
Inspection for Demolition
Inspector: Chad Witheridge
EPA AHERA - Building Inspector
#R21-004-AI-O
Expires- 1/13/2022
Summary: ND= No Asbestos Detected
S1: Vinyl Flooring ND
S2: Ceiling ND
S3: Wallboard Material ND
All asbestos containing building materials with a reading greater than 1% is considered a
hazardous material if disturbed.
If removed the owner or certified abatement contractor must follow the rules of the EPA
and governed by Olympic Region Clean Air Agency.
During renovation it is possible that additional suspect ACBM may be found. Should
such suspect material be discovered an AHERA certified inspector will have to sample
and test the material to prove it is of non asbestos.
NWA Environmental is not responsible for identification of hidden materials that are not
identifiable with reasonable diligence.
Thank you, Chad Witheridge Building Inspector EPA Certification #R21-004-AI-O
RECEIVED BY DCD 3/15/2022
Demolition
Notification
Olympic Region Clean Air Agency
2940 Limited Lane NW
Olympia, WA 98502
(360) 539-7610 - FAX (360) 491-6308
South Bend Office (360) 942-2137
Port Townsend Office (360) 338-6419
www.ORCAA.org
Name: Leslie Fleming
Site Address:2901 Oak Bay Rd City:Port Hadlock Zip:98335
Date Received
6/8/2021 Receive date:6/8/2021
Start Date:6/25/2021
#ASB
Mailing Address: PO BOX 251 City:Seabeck Zip:98380State:WA
Phone:Email:
Total Fee:$39.00
# of structures being demolished:1
PROPERTY OWNER
DEMOLITION CONTRACTOR
County:Jefferson
Contractor Name:GB Construction General Contracting LLC Phone:(360) 271-9107 Email:Gradybashore@yahoo.c
DEMOLITION INFORMATION
Asbestos present?Survey attached?Yes No Yes No
Agency Use Only Agency Use Only Agency Use Only
Payment Info.Asbestos Permit:
Demolition Permit:
OVER
I do certify that I am the owner, authorized agent of the owner, or authorized contractor for the property subject to this ORCAA Notification. I authorize
ORCAA staff to enter the property listed in this Notification 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.
Emergency - must be accompanied by letter explaining emergency circumstance
#21DEM006126
Electronically submitted by: mary.f.bashore@gmail.com
Site Contact Person:Grady Bashore Phone:3602719107
All identified asbestos was removed under
Asbestos Permit #N/A
DEMOLITION PROJECT CATEGORY
Complete Demolition
Training Fire Fire Agency, Contact, Phone:
Other Structures - 10 day wait period - Nonrefundable
Single-family Residence - 10 day wait period - Nonrefundable
Year Structure Constructed:1980 Is this a:mobile home modular home
build on-site
RECEIVED BY DCD 3/15/2022
Demolition
Notification
Olympic Region Clean Air Agency
2940 Limited Lane NW
Olympia, WA 98502
(360) 539-7610 - FAX (360) 491-6308
South Bend Office (360) 942-2137
Port Townsend Office (360) 338-6419
www.ORCAA.org
OVER
Demolition projects (larger than 120 sq. ft.) within Clallam, Grays Harbor, Jefferson, Mason, Pacific, and Thurston
counties REQUIRE A NOTIFICATION and require that the following conditions be met prior to the demolition.
Olympic Region Clean Air Agency (ORCAA) regulations define a demolition project as the wrecking, razing,
dismantling, or burning (by a fire protection agency for training), or removal of any load supporting structural
member of a structure, including any related handling operations, making all or part of the structure permanently
uninhabitable or unusable.
The following information is merely a reference guide and not a substitute for agency regulations.
1. Notifications are required for all demolition projects with a footprint of 120 square feet or larger.
2. An asbestos survey is required for all demolition projects. The survey must be conducted by a certified Asbestos
Hazardous Emergency Response Act (AHERA) building inspector. Qualified inspectors may be found in your local
Yellow Pages, through the internet, or on ORCAA’s website.
3. Asbestos samples must be sent to a NVLAP Laboratory (National Voluntary Laboratory Accreditation Program) per
40 CFR 763.87. A list of labs can be found on ORCAA’s website.
4. The start date on demolition projects must be at least 14 days from the submission date of the complete application
and payment.
5. 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 or renovated.
6. Any and all structures on the same parcel of property that are not proposed to be demolished must be identified as
such.
7. A copy of the asbestos survey and the Demolition Notification must be kept on site and be available for review by
Agency inspection personnel.
ADDITIONAL REQUIREMENTS:
In addition to Agency requirements, most building departments require a demolition permit (separate from ORCAA’s
Notification). The Washington State Department of Labor Industries may also require notification.
“Single-Family Residence” means any structure containing space for use such as living, sleeping, food preparation and
eating. This term includes houses, mobile homes, detached garages, houseboats, and houses with a “mother-in-law
apartment” or “guest room”. This term does not include multiple-family units (i.e. apartment, duplex, condominium, etc.),
nor does this term include any mixed-use building, structure, or installation that contains a residential unit.
Emergency Project: A project that was not planned but results in a public health or safety hazard; the project must proceed
immediately to protect equipment, ensure continuous vital utilities or minimize property damage; ACM was encountered
that was not identified during the survey or the project must proceed to avoid imposing an unreasonable burden.
RECEIVED BY DCD 3/15/2022
Approved by:
Approved Signatory
Amber Rutter
Report for:
Chad Witheridge
NW Asbestos
97 fir circle
Port Hadlock, WA 98339
Regarding:Project: 2901 Oak Bay Rd
EML ID: 2618113
All samples were received in acceptable condition unless noted in the Report Comments portion in the body of the report. The
results relate only to the samples as received and tested. The results include an inherent uncertainty of measurement associated
with estimating percentages by polarized light microscopy. Measurement uncertainty data for sample results with >1% asbestos
concentration can be provided when requested.
Eurofins EMLab P&K ("the Company") shall have no liability to the client or the client's customer with respect to decisions or
recommendations made, actions taken or courses of conduct implemented by either the client or the client's customer as a result
of or based upon the Test Results. In no event shall the Company be liable to the client with respect to the Test Results except for
the Company's own willful misconduct or gross negligence nor shall the Company be liable for incidental or consequential
damages or lost profits or revenues to the fullest extent such liability may be disclaimed by law, even if the Company has been
advised of the possibility of such damages, lost profits or lost revenues. In no event shall the Company's liability with respect to the
Test Results exceed the amount paid to the Company by the client therefor.
Dates of Analysis:
Asbestos PLM: 04-14-2021
Service SOPs: Asbestos PLM (EPA 40CFR App E to Sub E of Part 763 & EPA METHOD 600/R-93-116, SOP EM-AS-S-1267)
NVLAP Lab Code 500053-0
EMLab ID: 2618113, Page 1 of 2Eurofins EPK Built Environment Testing, LLC
RECEIVED BY DCD 3/15/2022
Eurofins EMLab P&K
4955 Yarrow Street , Arvada, CO 80002
(800) 651-4802 Fax (623) 780-7695 www.emlab.com
Date of Receipt: 04-13-2021
Date of Report: 04-15-2021
Client: NW Asbestos
C/O: Chad Witheridge
Re: 2901 Oak Bay Rd
ASBESTOS PLM REPORT
Total Samples Submitted:3
Total Samples Analyzed:3
Total Samples with Layer Asbestos Content > 1%:0
Location: 1, Vinyl flooring Lab ID-Version‡: 12497953-1
Sample Layers Asbestos Content
Beige Sheet Flooring with Fibrous Backing ND
Yellow Mastic ND
Composite Non-Asbestos Content: 20% Cellulose
Sample Composite Homogeneity: Moderate
Location: 2, Ceiling Lab ID-Version‡: 12497954-1
Sample Layers Asbestos Content
White Drywall with Brown Paper ND
White Compound with Paint ND
Composite Non-Asbestos Content: 10% Cellulose
Sample Composite Homogeneity: Moderate
Location: 3, Wallboard material Lab ID-Version‡: 12497955-1
Sample Layers Asbestos Content
White Drywall with Brown Paper ND
Multicolored Wallpaper ND
Composite Non-Asbestos Content: 20% Cellulose
Sample Composite Homogeneity: Moderate
EMLab ID: 2618113, Page 2 of 2Eurofins EPK Built Environment Testing, LLC
The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to
claim product certification, approval, or endorsement by any agency of the federal government. Eurofins EMLab P&K reserves the right to
dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified.
Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When
detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large
amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection
limit and to aid in asbestos identification.
‡ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is
reflected by the value of "x".
RECEIVED BY DCD 3/15/2022