05-103673 City of Federal Way Demolition Permit #: 05 - 103673 - 00 - DE
Community Development Services
P.O.Box 9718
Federal Way,WA 98063-9718 1
Ph:(253)835-7000 Fax:(253)835-2609 Inspection request line: (253) 835-305C
Project Name: LAUSIER-BALDWIN
Project Address: 2718 S STAR LAKE Parcel Number: 516000 0010
Project Description: Demolition of existing mobile home
Owner Applicant Contractor
CATHY BALDWIN QUALITY CONSTRUCTION&FIX-IT QUALITY CONSTRUCTION&FIX-IT
28081 24TH PLS 28517 47TH PLS 28517 47TH PL S
FEDERAL WAY WA 98003 AUBURN WA 98001 AUBURN WA 98001
(253)859-4421
PERMIT EXPIRES July 26,2007.
Permit issued on July 26,2005
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and the u • • be in . •.ce with the laws,rules and regulations of the State of Washington and
the City of Federal •ay.
410
Owner or agent: II Date:
7//°4
THIS CARD IS TO •MAIN ON-SITE
CITY OF ommunity Development Inspection Record
Federal Way IVR INSPECTION REQUEST PHONE # (253) 835-3050
PERMIT #: 05-103673-00-DE
Owner: CATHY BALDWIN
Address: 2718 S STAR LAKE RD
FEDERAL WAY, WA 98003-6920
This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD.
Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not
be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence. On-going inspections
are logged on the back of this card.
❑ Final-Building(4050)
Approved
By i' yr Date 001--
• THIS CARD IS TIVEMAIN ON-SITE
CITY OF :17 ``-� Community Development Inspection Record
Federal Way IVR INSPECTI REQUEST PHONE # (253) 835-3050
PERMIT #: 05-103673-00-DE
Owner: CATHY BALDWIN
Address: 2718 S STAR LAKE RD
FEDERAL WAY, WA 98003-6920
This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD.
Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not
be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence. On-going inspections
are logged on the back of this card.
0 Final-Building(4050)
Approved
By Date S/2 /0_5-.lA
•
5 /
Lki) OY k__ LA (. (9-1,410 (_,(L-/ , -
CiC." AP-6'
4 A i
67/4/J.*
( 7-6
s______
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City of Federal Way Demolition Permit #: 05 - 103673 - 00 - DE
Community Development Services
P.O.Box 9718
Federal Way,WA 98063-9718
Ph:(253)835-7000 Fax (253)835-2609 Inspection request line: (253) 835-305C
Project Name: LAUSIER-BALDWIN
Project Address: 2718 S STAR LAKE Parcel Number: 516000 0010
Project Description: Demolition of existing mobile home
Owner Applicant Contractor
CATHY BALDWIN QUALITY CONSTRUCTION&FIX-IT QUALITY CONSTRUCTION&FIX-IT
28081 24TH PLS 28517 47TH PLS 28517 47TH PL S
FEDERAL WAY WA 98003 AUBURN WA 98001 AUBURN WA 98001
(253)859-4421
PERMIT EXPIRES July 26,2007.
Permit issued on July 26,2005
I hereby certify that the abo - -.s formation is correct and that the construction on the above described property and
the occupancy and the . e will ,e in:.• . da ith the laws,rules and regulations of the State of Washington and
the City of federal
Owner or agent
€ r ra
� z
•
CITY RECEiEQ •
Federal Way 0 51 1 v
PERMIT —f
COMMUNITY DEVELOPMENT SERVICES
JUL 2 6 20it CJ J SF MF CO ME EL PL fie N FP
33325 D AVENUE SOUTH•PO BOX 9718 L I C AT I O N
FEDERAL WAY,WA 98063-9718 �(A� P ro /
253-835-2607•FAX 253-835-26091TY OF FE D E 4'qu {
wwwdtyoffederalwatl.cam BUILDING DEPT. /
The ollowi • is re•uired in urination—an incom.tete a..lication will not be acce.ted. Please .rint le.ibl in in or .e.
■ PROPERTY INFORMATION .
QU
( ` Vre `
SITE ADDRESS 2- 5C: S I.�� ( V � `�'b•�. C2 SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# C � Co 0 a D - () IC LOT SIZE(s) /01-.5-0
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) to Aoic ru.f j-i jl,.}Ss t ;J to L'"r
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING ❑ PLUMBING 0 MECHANICAL
74.UEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlq),
D44n -?.=1 -,� ,_-, 1 ,,�.1 L . Luz--62- i L, 4,-)1,,,,,_
PROJECT NAME(Name of Business or Owner Last Name) '7 &-/A l;(,/I ,/..%
;: PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER 6/ 1 O6(, 1 Al ( " 4 2'/ _s-( g
MAILING ACAESS CITY,STATE,ZIP
,W 1l 2 '/9 so ff 66,u / a/ 9 8-00 3
CONTRACTOR cqt4PANY NAME APPLICANT OFFICE PHONE
,t
& 24 �4'--s' i)(. -- �, (2 )S',59 - 4-42/
Al SS D/ C/^� gT
� �� / l K� C►'.'/�AT�„e. P) !/1- q(7 jtd1 CELL PHONE -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER �` f�+ rYi/t G=/►1/uEXXPII FRATION DATE �AX NUMBER
. c -i -i C. I 7 4-B L / / / 05-- (Z3) g c•
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
6: LiAL. Is- C. .E16 / fidl 24 /4- iO
APPLICANT COMPANY NAME/ p �/�, py, 7/�` F J�`Al' IC�A(NT NAME OFFICE7PHONE /�
pa44-
DRESI�S/. ;i4,, C�� / ,-(-f W 1 �� (! 3) Y -44Z'
� ING AA yy�n f CITY,STATE,ZIP CELL PHONE
,;2 '57 zi-7. t'(� / c„i0,„eil1(.4 S'' C ( ) -
RELATIONSHIP TO PROJECT ( FAX NUMBER
0 Architect 0 Tenant ',agent 0 Other(Describe) (255)g$-9 -0 2 3 3
CONTACT NAME j_ ') ., PRIMARY PHONE E-MAIL ADDRESS
Ira,`' '1/4:-..i11,‘,‘^‘— (253) SSW -0ZI uehhl6iISt e.tieil7 -
LENDER NAME
lit SN.C•
iC ice:•2±. 4:.': : e 5
:' ,','. '' '
MAILING ADDRESS CITYfA7E,ZIr
• . . • . . • • . ■ DETAILED BUILDING INFORMATION •
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? 0 YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? o YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
. ‘,—'" PROJECT FLOOR AREAS +
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ. FT. SQ.FT.
BASEMENT A / A-
FIRST 1Vl/
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESC )
DECK(COVERED?)
GARAGE 0 CARPORT 0 NEXISTING PRO ILD
TOTAL g t"TOTA•L]OSTep.F"„+. y OTA[,PROPOSED 3F , w' ['OTAL 8P k
NUMBER OF FLOORS
r his
*`NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
•
...............
Indicate number of each type off.xture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL 7
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(comm<rctaq WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(orTDh/shower Combo) SHOWERS WATER CLOSETS crone)
MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom sinks) VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK .
I certify under penalty of perjury that the information furnished by me{s true and correct to the best of my knowledge, and further, that I
am authorized by the owner of the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claim), which may be mad . any person,including the undersigned,and filed against the City of Federal Way,but only where such claim
arises out of the reliance he -ty, incl di cers and employees,upon the accuracy of the information supplied to the city as a part of
this application. /
NAME/TITLE
sii-ipircifve.A.A,,
DATE (ti/ C��
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner r Agent Contractor 0 Architect 0 Other
®R ®FF R .gyp
t k�9� a SDI O ®�
-�. .,.;.,�. a •uws;,_s ufr ,num �. ,v41_ 1 1 ® ...-•,77.. d wa`+s
.,—
).A.:14:0°, .®,, s`. e UIl,2ED YES ® � '!"'''''%
� - 1.,,^47,
PA S, : r� s MESS'
7-&„ ®tom?4 .-r,D.�.. � `--- ®.,"'" �., ° ® / , ,P:,6 0 1 „.D e �# ° �„^�"' ®.. ®n.'�, .;'s ..
Bulletin#100—January 7,2005 Page 2 of 4 k\Handouts\Permit Application
• •
.,
A., RECEIVED DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
33325 8`h Avenue South
PO Box 9718
CITY OFs'"' JUL 2 2005 Federal Way WA 98063-9718
Fecleral253835-2607;Fax 253-835-2609
CITY OF FEDERAL WAY www.cityoffederalway.com
BUILDING DEPT.
DEMOLITION PERMIT REQUIREMENTS
A demolition permit is required to remove any structure or structures on a subject property. Check with the City's Planning
Division to see if the proposal exceeds thresholds that trigger an environmental review. An environmental review and
submittal of an environmental checklist may be required, which will extend the time period before a demolition permit can
be issued.
El Prior to submitting a demolition permit,the following items(as applicable) must be signed by the respective
agency (see attached Demolition Permit Contact List).
NOTE TO APPLICANT: Utilities shall be disconnected and services performed, if applicable,prior to issuance of the demolition permit.All applicable
items below are to be signed and dated by the respective agency representatives.
1.ASBESTOS BATEMENT 6. ELECTRICITY
(Coy of approval orm and as st s survey from Puget Sound Clean Air (Electricity to be shut off and meter remov
Agdnct pr 'ided ;oo �//
�r Pi ` S L4ilt Sound Energy)
" 6'/ City of Fed I Way Building Official)
. GAS SUPPLY 7. FUEL STORAGE TANKS
(Gaslto •
e�shut off,meter removed and final bill paid) (Above or below grade fuel tanks, have been pumped or removed
►J .
undec ki e Department permit prior to any dismantle/excavation)
(Puget Sound Energy) IN 4)1c
(Federal Way Fire District#39)
•
t 3.SEPTIC SYSTEM 8.WATER- Public Source (Check applicable box
(Tank to be removed or tank to be drained and filled) ❑Meter to be removed and fi utif '' 'aid
VIUL3 Vt-g-44"4400(41)it4v• it,.,k.) 1)0-1 )Meter to remain and be of ed
(King County Environmental Services) ater Supplier)
******OR******
4.SANITARY SEWER (Check applicable box) 9.WATER- Private Well (Check applicable box)
o Sewer line capped at property line ❑Private w II filled and capped
o Existingewer line to remain and be used by proposed new structure ❑Private w II to be used for other purposes
(Sewer District) t" P( (King County Environmental Services)
5. GARBAGE .
(All hilus fi
�olld garbage disposed off and final bill paid)
(RST Disposal/Federal Way Disposal)
❑ Completed Construction Permit Application form
❑ Provide the following fees: 1.Demolition Permit Fee $63.50
2. Automation Fee 5.00
3. WA State Surcharge 4.50
4. Cash Bond Deposit 500.00 (Refundable upon Completed Final Inspection)
$573.00
•
Bulletin 4122—March 9,2005 Page 1 of 1 k:\Handouts\Demolition Permit Requirements
•
DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
33325 8`h Avenue South
PO Box 9718
CITY OF Federal Way WA 98063-9718
Federal l Wa ` 253-835-2607;Fax 253-835-2609
Ia y www.cityoffederalway.com
DEMOLITION PERMIT CONTACT LIST
This list of agencies may assist you in expediting the demolition permit process.Refer to the demolition permit
requirements for signature blocks.All applicable signatures are required prior to permit approval.
1. Asbestos Removal: Puget Sound Clean Air Agency
110 Union Street, Suite 500
Seattle,WA 98101-2038
206-343-8800—OR—800-552-3565
http://www.pscleanair.org
2. Electricity: Puget Sound Energy
Attn: Construction Coordinator
22828 68th Avenue South, Suite#102
Kent,WA 98032
888-225-5773
3. Gas: Puget Sound Energy
805 156th Avenue NE
Bellevue,WA 98004
888-225-5773
4. Telephone: Qwest Communications
801-962-2475(phone)/801-237-6491 (fax)
5. Water: Lakehaven Utility District Tacoma Public Utilities
Technical Service Division Customer Service
31623 First Avenue South —OR— 747 Market Street
Federal Way,WA 98003 Tacoma,WA 98402
253-941-2288 253-383-9600 or 253-383-2471
6. Garbage: Waste Management
655 Second NW
Auburn,WA 98071
253-833-3333(residential)—OR—253-939-9792(commercial)
7. Sewer: Lakehaven Utility District
Technical Services Division
31623 First Avenue South
Federal Way,WA 98003
253-941-2288
8. Septic: King County Environmental Services
14350 SE Eastgate Way
Bellevue,WA 98007
206-296-4932
9. Fire Department: Federal Way Fire Department#39
31617 First Avenue South
Federal Way,WA 98003
253-839-6234
Bulletin#109—October 1,2004 Page 1 of 1 k:\Handouts\Demolition Permit Contact List
JUL-20-05 TUE 10:07 AM •TGATE ENVIRON. HEATH FAX NO, 60. F, 02/03
FROM :QUAL'-Y CONSTRl.1TiON1 FAX No. :2;,3-859-02215 Ju:, 5 ZNE D3:X.AH f
}
DErmamk.N1U;COMWe,"LAITY DENILOrlklaNT Se tY1CM
3331.5 kth Avenue outl:
P4 Box 971F,
CITY OF Fede i Way WA 9E063-9716
Federal '!'tray
253-935-2tiC�7;Fay:253.535-2609
, . '.:
DEMOLITION PERMIT REQUIREMENT
A demolition permitis required to remove any struoture cu structures on a subje:t property.Check with the City's Planning
Division to sec if the proposal exceeds thresholds that trigger an environmental review.An environmental review and
submittal of an environmental checklist maybe miuired,wtich will extend the time period befors a demoiititar permit can
be issued.
Cl Prior to submitting a demolition permit,the following itcan;! (as applliccble)must be signed by the respective
xuency(sec attached Demolition Permit Contact List).
Nair To r?Pl1C•llvT: Utilities shalt be cilsc„nnceted a+idparksr/He!c+ (fopplicaile,prior to issuonoe of the dcmv1ition permit..11'oprlll.i.nble
hEIew ore tv be gnea.ati drsu Lby rhe rrapn.tiw:ope,icy reprrirrrGrivo-s.
1,AS13T5TOS ABATEMENT 6.ELECTRICITY
(Copy of approv2l Form and astesrus survey from Puget our.d Cliaan leet c1 +�tD be shut off rd w.er rernov
Agency provided) new
(City 6("re t- µlay Building Off1.;3i}
2,GASSUPPLY 7.FUEL STORAGE TANKS
(Gus tot, phut ort,mets removed and fuel tai's paid) — (Above or blow grade fuel tw ks, have been pumped or removed
} urd i f)eparbmnt periilt MD?to any dismantie:/:X0Yation)
(Puget SoundrfnAr9y)
(IaralWayistr+d X39) ,
f-,..,_,._ .,..__—_, .._.___.. • 8,WATER-public Spume (Check applIcat�le box
P 3:r tc be emovedM n Meter to be removed and utira. •d , 1'
(lark tc be removed rr tank,to be drained urd Med) ) Meter to remain and be fir
t } '���1 •" f1Y•�7rr1C11 •C � -- v is _.
Y ' (Check sc_app'�,za4!a Cbox)�( r/�,(i'1,J r' rkasas O•raRF IF/PFAuf
SI:1lllCtt
"` �cWATKR-Private Wall(Check apvliceble box/
'' .4,5AN1TARY :�
be used
Private w�Yl filled and c'stoPed
er
n c,ewer line capedille at pea lane new structure n Pr'vete w ll to be used tor other pur pa5rs
n f�cix'ang er Iinm remain and ..y ramose
_7e Oistri } --_ (Kin9-1.:'rFY li?vlrfmmental
5.GARB GE •
(pll hy�#Uj garbage disposed ofr and final va'�) -- -
rNit4,41Si-
- po�7re3erafGay ci . a}r -
- ��
G7 C ompleted t oustruttian Permit Application form (,4 1 �7(,t �1-rte l r�(• ,
'i Provide the following fees: 1, pemalitinn Permit Fee 563.50
Z.automativrr Ycx 5030
3.WA State Surcharge 4.50
4,Cash Bond T1aposit 500.09 (Refundable upon CQn 1e cel Final Intpeetit,n)
5573.00
BUnciln 122-Ntxrch 9,2403: --�R r r 1 et 1 k:`tisr kra!s�DrrnaLiits Print Nequa-cMcO ts
• •
PUGET
SOUND
ENERGY
July 13, 2005
Dear Mr. Pat Rima:
Regarding your request of the status of PSE service order number 194-460-434 stated as
follows:
"Please remove meter and electric service for demolition and rebuild per owner."
On May 5th, 2005 one of PSE service lineman completed this field request. The meter and
electric service have been removed.
If you have further questions please feel free to call me at my office at 253-395-6919.
Thank you,
461,4,1
Cody Olson
PSE
Electric First Response
. • • •
r 17
F.S.&GS.
Services inc.
7/15/05
Puget Sound Clean Air Agency
110 Union Street
Seattle, WA 98101
To Whom It May Concern:
RE: Asbestos Removal , Agency Case#200502496,2718 Star Lake Rd. So., Federal
Way, WA 98003
I am writing you this letter as a statement of completion, that the asbestos removal
work done at the above mentioned address was completed on 7-11-05. In accordance
with 40 CFR subpart E, all asbestos material, as identified in the survey, has been
removed and properly disposed of This project is now complete.
All closeout paperwork will be forwarded to Quality Construction&Fix It as soon as
possible.
Respectfully,
ukitaita),(--Aa'dmu4--)
Gordon Williams
g,(
President
Cc: Quality Construction&Fix It
16214 57th Ave East, Suite A Phone: 253-548-1011
Puyallup, WA 98375 Fax: 253-536-8488
JUL-26-05 TUE 10:07 fiM liTG(17 ENVIRON, HEAVH FAX NO. 61110 P, 31/03
•
TO: Pat FROM: ERNIE NAVARRO
DIVISION: health Dept._
FAX; 253-859-0233
FAX 206-296-4919
DATE: 07-20-05 DATE; 07-20-05
Number of pager including this cover: 3
Message XX Urgent Review Ci Comments
Don't need to see tank is out. OK to removed/demo septic tank
after pumping
16/28/2005 TUE 10:56 FAX 2535368488 FS & GS Services 444 PSAPCA i001/002
110 Union Street,Suite 500 � JUN
� +,� 2005
' r: c.:;•1;.;c..0;9%
;��;,.; : Scattl., WA 98101-2038 • PS,�I IV L
6A4 y � a
* ,3f40 ,r�, w",.wv.pscicanair-org
2 0 0 5 0 . 9 6 NOTICE OF INTENT
Agency Use Only Clean Air Agency Agency Use Only
A.Project Tyne: 1. 0 Friable,Asbestos Removal 2. Ilif Friable Asbestos Removal&Demolition 3. LI Demolition Only
B.
Property Owner: Catherine Baldwin Phone: 253-945-7399
Mailing Address: 28081 24th Place So. City: Federal Way State WA Zip: 9x003
C. Asbestos Put;AS'EPRINT CLEARLY,THIS WILL BEYOUR RETURN MAILIMYiLABEL.
Contractor: F.S. &GS. Services.Inc. Owner/CEO: Gordon L.Williams
Contractor
Mailing Address: 16214-57th Ave.E. Suite A. Phone: 253-548-1011 Job No.:
City: Puyallup State: WA Zip: 98375 Fax: 253-536-8488 05217
D. Site
Address: 271& Star T ke Rd. SV City: :F4..cr_1 Way t Zip: 98003
Site
Manager: Pat Rima-Quality Construction Local Phone: 253-859-442!
E. til Asbestos Survey or No.of Date of Asbestos Was Friable Asbestos Identified? Wes UNo
❑ Mat'l Presumed Structures:1 Survey: 6-10-05 Was Nonfriable Asbestos Identified? ❑Yes k1No
AHERA Building Certification#: I016333 Attach a copy of the survey when friable asbestos
Inspector: Charlie Jobe Exp.Date:6-8-06 has not been identified.
An AITERA Survey is required before all demolition projects
F. Demolition Start No.of 1. ❑ Training Fire(List Fire Dept.)
Information: Date: 7-14-05 Structures: 1 2. ❑ Ordered Demolition(attach copy of Order)
Demolition Insert demolition contractor's mailing address on back. Will nonfriable asbestos be left in place during demo? ❑ Yes ❑ No
Contractor: Quality Construction`2`Fix It dyes,list type and qty. Note disposal requirements in Step 6(on back).
G. Friable Asbestos Work Days:(Wt.,6 Th F Sa Su
Project Information: Start Date: 7-11-05 Completion Date:7-13-05 Hours: 8 am-4 pm
Will all friable asbestos US Yes
Total Qty-to be Removed: Linear Ft. 900 Square Ft. materials be removed? ❑ No
LI Boiler\Fumilce Insulation ❑Duct Insulation ❑Pipe Insulation U Fireproofing U Paints ❑ Plaster U Textured Coatings
-❑ Cement Board Cement Pipe Frixblc Flooring Friable Roofing Material Other:
R. Asbestos/Demolition Project Categories: Notification Period Project Demolition
I. Singlc-Family Residence(owner-occupied): Fee Surcharge
A. ❑ Asbestos Removal Project Only A.Prior Notice A. $25
R. ❑ Demolition Project(with or without asbestos reruuvai project) B. 10 Days* B. $50
*(Asbestos removal can begin upon notification;demolition must wait 10 days)
Note:If the single family residence is owned by one family who has been or will be using the residence as their domicile, the above boxes
IA or IB may be checked. If this is not an owner-occupied residence,one of the categories listed below must be used instead. A single
family residence does not include rental property, multi family units, or any mixed-use building.
2. ® A• ll Other Demolitions(with no Asbestos removal or Nonfriable Asbestos 10 Days $100
only or less than 10 linear feet and/or 48 square feet of friable Asbestos)
Friable Asbestos Projects(other than Single Family Residence): Asbestos Demo
3-I ? 10-259 Iinear feet and/or>_48- 159 square feet of asbestos Prior Notice 10 Days _$100 $100
4. la 2• 60-999 linear feet and/or 160-4,999 square feet of asbestos 10 Days I0 .100
5-U >• 1,000 linear feet and/or>5,000 square feet of asbestos 10 Days :•600 $100
6- ❑ Emergency Asbestos Project or L Emergency Demolition Project Prior Notice $50 Emergency Fee
(Sing-le-Family Residences are exempt from emergency fee;however,property owner must provide a written emergency rcqucst)
I. 1 certi' that the information contained in this notification&suppictncntal data is.to the best of my knowledge,accurate Sc complete- Age y/Usc 0 my
1,_%„, t a1/ I ES46S &Tyke 02e0.3 �' •
Slgnattnre Re.resenlin• Dale Revi wed.S Air
-
Puget Sound Clean Air Agency Form No.: 66-160(Revised 2/05)TS ' ��
i ��d D
06/28/2005 TUE 10:66 FAX 2535368488 FS & GS Services 444 PSAPCA 2002/002
The Puget Sound Clean Air Agency sires advance t otif'fcaron before any Pers commences a friable asbestos project
involving materials equal to or greater in size than 10 linear feet or 48 square feet and for all demolition projects
(regardless of asbestos content) involving structures with a projected roof area greater than 120 square feet (Regulation
LII, Article 4). All asbestos removal and demolition notifications must be submitted to the Agency on current Agency
forms. Asbestos removal and demoliti n ,r 'gets involving materials and structures below the notification threshold are
still subject to all othetrequircments of Regulation III, Article 4.
After receiving a complete notification with the appropriate project tee, the Agency will review the form and return a
copy to the asbestos and demolition contractor by mail. The returned copy will be your validated notification.
J. Demolition PLEASE PRINT erinTEY=WILI,LW YOUR KLIUKN MAILING LIBEL
Contractor. Quality Construction&Fix It Owner/CEO: Pat Rima
Mailing Address_ 28517 47`a PI. S Phone: 253-859-4421 Contractor's
Job;>!:
City: Auburn State: WA Zip: 98001 Fax: 253-859-0233
GUIDELINES FOR SUBMITTING AN ASBESTOSIDEMOLITION NOTIFICATION
Step 1. Check the appropriate project type in Box A. Friable asbestos includes popcorn ceiling material,sheet vinyl flooring,cement
asbestos board siding,and duct insulation. Nonfriable asbestos is normally found in vinyl floor tiles,window putty and most roofing
materials.
Step 2. Enter property owner information in Box B.
Step 3. Enter the asbestos contractor or property owner information, if the property owner is conducting a single-family residential
project,in Box C. Print clearly ibis-is your return mailing label.
Step 4. Enter the site address for all notifications in Box B. For multi-structure projects, attach supplemental sheet with a site map
(include an address for each site)and a list of the type and amount of friable asbestos to be removed from each structure.
Step 5. Check either asbestos survey or material presumed in Box E. All demolitions require that an Asbestos Hazard Emergency
Response Act(AHERA) asbestos survey be conducted by a certified AHERA building Inspector. Attach a copy of the survey to the
notification of a demolition oroieet when only nonfriable asbestos or no asbestos is identifiedon_the_survey.
Step 6. Enter the project information in Box F. and check the training fire or ordered demolition box if appropriate (a copy of the
official order must be attached). All asbestos must be removed prior to conducting a training fire. Additional training fire
requirements arc contained in Regulation I, Section 8.08. If any nonfriable asbestos materials will be left in place during demolition,
check yes and list the type and quantity of material. Note: Demolition debris containing nonfriable asbestos materials must be
labeled as"nonfriable asbestos-containing waste"and be deposited at an authorized waste disposal facility.
Step 7. Enter asbestos project information in Box G_ List types of friable asbestos material to be removed: surfacing material such as
popcorn ceilings or plaster,sheet vinyl flooring,duct and pipe insulation,cement asbestos board siding or pipe, etc.
Step 8. For owner-occupied Single-Family Residential projects, check BOX IIIA for renovation projects or BOX H1B for
demo tion projects(with or without asbestos removal). Asbestos removal may he conducted after a complete notification is received,
but demolition activities can only begin on the 10th day after the notification is received. Note:1f the single family residence is owned
by one family who has been or will be using the residence as their domicile, boxes 1A or 113 may be checked A single family
residence does not include rental property,multi family units,or any mixed-use building.
For Commercial asbestos projects (or projects that do not qualify as Single Family Residential); check the project category H2 -
5 that matches the amount of friable asbestos that will be removed. If a demolition is involved, include the appropriate surcharge
(additional fee) in your payment. To file for an emergency asbestos or demolition project, check the appropriate box 1 — 5 and the
applicable emergency box in H6. All emergency requests must be accompanied by a letter from the pro rty owner demonst a, ting the
need to conduct the pmject immediately in accordance with the requirements in Regulation III,Section 4.03 (el
Step 9. Please certify the accuracy and completeness of'the information provided by signing the notification in Box I.
Mandatory amendments to the notification are required for changes that increase the project category, change the types of asbestos
materials to be removed and changes to start date, completion date and work schedule for asbestos projects. No fee is required for
work schedule changes if the contractor is participating in the Agency work schedule fax program. A$25.00 processing fee is required
for all amendments.
Puget Sound Clean Air Agency asbestos regulations and forms can be downloaded from the Agency web page at www_pscleanair.org.
For technical assistance call (206) 689-4058 and for administrative inquiries call (206) 689-4090.
Puget Sound Clean Air Agency Form No.: 66-160(Revised 2/05)TS