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06-100794 R CEl\JU 44 1 �'1 CITY OF FEB \� 1 Lr Federal Way got% �' - -� o 0 7 COMMUN17YDEVELOPMEAT SERVICES %1,1 WA Fime®E PERMIT SF MF CO ME EL PL DE EN FP 333253.83 A 5 8TM AY,W 253-835-2609SOUTH•1 !OX 9718 18eu4�®��APPLICATION FEDERAL WAY,FAX 3 TD / / www.cittioffederalwa u.corn The following is required information—an incomplete application will not be accepted. Please print legibly in ink)or type. ::.. ■ .PROPERTY INFORMATION . . _: .. . . SITE ADDRESS -i 3 c2 ! 3 t LC_, ; 3-5-6 - (,� ' SUITE/UNIT# ASSESSOR'S TAX/PARCEL# I t) Z I 0 3 - g 1 ,3 LOT SIZE(sf) LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) )Attach separate page for lengthy legal description) _;.'PROJECT INFORMATION: .. TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM PROJECT DESCRIPTION (Provide detailed description of work included on this permit only) PROJECT NAME(Name of Business or Owner Last Name) PEOPLE INFORMATION PROPERTY NAME OWNER l\ \z)iJ �n it,..- /� PRIMARY PHONE _ rb l� / (e.,.t� ) MAILING ADDRESS CITY,STATE,ZIP CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE 1Z7: ) !-1 o vvv E N c maw ^.FAQ. ( ) - MAILING ADDRESS CITY,STATE,ZIP CELL PHONE CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER • / / ( ) _ B L CONTRACTORS REGISTRATION NUMBER co y of cardiequired with each application) EXPIRATION DATE 14. O * % c Z 1 / / . APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE -0—E3 1 Ho Wki5 i_,(_C' a1t4 Thflec a . ( ) // -0i1:5 -/ MAILING ADDRESS CITY,STATE,ZIP CELL PHONE . 1-14/'I'.0 7)460 /f, 6,0x i0-pps,1 id% / ( - ) zzy - Li.,33 RELATIONSHIP TO PROJECT FAX NUMBER ❑Architect 0 Tenant ❑Agent 0 Other(Describe) )vIL!>£1Z. ( ) 4 -C) 1,2c(S CONTACT NAME • PRIMARY PHONE E-MAIL ADDRESS --.)A/ 134 (zh3,)z.zy - 673 LENDERzAVS: t , �- Kuxg^ eye a t O N NAME MAILING ADDRESS CITY,STATE,ZIP PHONE ( ) ■ DETAILED BUILDING INFORMATION EXISTING USE PROPOSED USE .�iA�c.5- -����t 7.-4.e.,--;-r/ / I,6,-;;;;01.4 EXISTING ASSESSED/APPRAISED VALUE $ 1/006 VALUE OF PROPOSED WORK $ ZZ5IQ/oO SPRINKLERED BUILDING? 0 YES El NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES ,41.NO WATER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE q TACOMA 0 PRIVATE(WELL) SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE p PRIVATE(SEPTIC) PROJECT FLOOR AREAS AREA DESCRIPTION EXISTING PROPOSED TOTAL SQ.FT. SQ.FT. SQ.FT. BASEMENT FIRST SECOND THIRD FOURTH ADDITIONAL FLOORS(DESCRIBE) DECK(COVERED?) GARAGE 0 CARPORT 0 L 2/ti/�j nX1STDIo PROPOSED iota ,,,=.-r 1; K�C1' NUMBER OF FLOORS $ "*NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $ FIXTURES Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain. MECHANICAL Value of Mechanical Work $ AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS BBQS FANS HOODS(commercial) WOODSTOVES BOILERS FIREPLACE INSERTS RANGES MISC(Describe) COMPRESSORS FURNACES GAS WATER HEATERS DUCTS GAS PIPE OUTLETS PLUMBING BATHTUBS(or Tub/shower Combo) SHOWERS WATER CLOSETS frouet) 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 is 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 made by any person,including the undersigned,and filed against the City of Federal Way,but only where such claim arises out of the reliance of the city,including its officers and employees,upon the accuracy of the information supplied to the city as a part of this application. NAME/TITLE /1.� f/ .� DATE ?,/5'�C ignature) V (Title) e RELATIONSHIP TO PROJECT LI Owner ❑ Agent 0 Contractor 0 Architect 0 Other l-a-irr,14)41(9411:— se. 11: �...�s XitD1 ,,; ..,�' ' .i � 0`t i 9 „ �r ® Y ti it . err f s i P T '' t a }}i 3 a 1 D � VI Y r a vW -.;.� x;3,z' 3 ����'"iA '' P - '� �"�`�,, `'S,,,-�k��,e r✓.X �^k d � �r_ a %, a<. ,.r �'s t ® �}�,�''�p� ���"�� �0 �J 68 .+f Ki a ,sl''%w xt n�:�,J r � 9 ,. >n. ,, m:`� .?r,^a7v: �§ ,� � �'�»ixda�. 3�'mz`.&A.EL�rr a�b ��rx. .i& .•t Mkt, � ������� '�'�' �,w -. - a10 _ :, � � L( O'�',` Ts3 ixm ' r� �^ �t `5 ittil` +'( z y '�: '1 am u* �i< '"�u�r�-�,���,D ® �. .v D D r a¢ ;;'� 1.s ,;�a� rr sops 4��" ����xil� ®�.`,���, r."'"( xbu�.� � �.& .,,� .wsAcaa�L''i. ,� ..t.<Gx �wi.�a "'off& r,?zz.,uas;. :1YT`af f c�r�e'�x>rs�.ry.s s� S� yr�� � s: � i T . ,F y � s �-:m ifir� i�" s ,<,,D... ,g r... vx-" P.=. a'. r W r;sV,a' q tr,%'" /0 m 9 ® D t � k ,.n a,�I'r' a "''$ �,.� ... w s,�:�.� ,aw,?::=<:�.se.;a�.�,..�.�a..+.�a�w�,,... ats nuta3z��.:uv.�,...�:�.yurrz5z.. .,riiaza... .« ,r.,,, x �., t�,cti��;�,.r.�u:,.,, ,.»�w,..�� .. >f�...�k�E,�.j.�;:., Bulletin#100 January 1,2006 Page 2 of 4 k\Handouts\Pemut Application 411 • A DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES 33325 8th Avenue South PO Box 9718 CITY OF Federal Way WA 98063-9718 Fe d e ra I Way 253-835-2607;Fax 253-835-2609 www.eityoffederalway.com 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. ❑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.AS ESTOS BATEMENT 6.ELECTRICITY (Copy pprova/form and asbestos survey from Puget Sound Clean Air (Electricity to be shut off and meter removed) Agency rov' e'" (Puget Sound Energy) (City of F eral Way Building Official) 2.GAS SUPPLY 7.FUEL STORAGE TANKS (Gas to be shut off,meter removed and final bill paid) (Above or below grade fuel tanks,have been pumped or removed under Fire Department permit prior to any dismantle/excavation) (Puget Sound Energy) (Federal Way Fire District#39) 3.SEPTIC SYSTEM 8.WATER- Public Source (Check applicable box) I ank to be remove:or tank to be drained and filled) a Meter to be removed and final utility bill paid r' 2 l 5-/� ❑Meter to remain and be protected (King County Environmental Services) (Water Supplier) 4.SANITARY SEWER (Check applicable box) 9.WATER-Private Well(Check applicable box) o Sewer line capped at property line o Private well filled and capped o Existing sewer line to remain and be used by proposed new structure ❑Private well to be used for other purposes (Sewer District) (King County Environmental Services) 5.GARBAGE (All household 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#122—March 9,2005 Page 1 of 1 k:\Handouts\Demolition Permit Requirements Feb-03-2006 15:25 From-PSE TRIC 1ST RESPONSE 253 395 680 T-008 P.002/002 F-192 Ko /'rkri buc..krIc'r 3 2 �� . ;3` l r Di Aicrm SNT OF COMMUNITY LIEVEI,trl•MI±Nr SERVICES i ` Fo 3 33325 8'�Avenue South CITY OF C► c2 Ja P9718 9 Federal Way WA 98063063-9718 Federal Way. 253-835-2607;Fix 253-835-2009 w ww,ci I voffalcra iway.corn 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 sec if the proposal exceeds thresholds that trigger an environmental review.An environmental review and submit!*►of;tri environmental checklist may be required,which will extend the time period before a demolition permit can be issued_ L.1 Prior to submitting a demolition permit,the following items(as applicable)must l,t signed by the respective agency(see attacked Demolition Permit Contact List). Non To Amcor,: Utilities shall be ditconnented and soviets'performed,if applioeble.prior to issuance of rho demolition permit,Ali applicable farms below are la be seamed qpd daL' by the respective agency representatives. I.ASBESTOS ABATEMENT 6.ELECTRICITY KiYY1 ?74ari r t �.+',5 :% :i 69Z3 (Cony of aPprovei form and asbestos survey from Fuger Sound Clean Air (Elea rloty ro be shut• and meter removed) Agency provided) - Puget Sound Energy) ,er Way Building official) 2.GAS SUPPLY 7.FUEL STORAGE TANKS (QS to be Shut c,ff,meter ref and final bill paid) (Above or below grade rue)tanks,have been pumped or removed Ar under Fire Department permit prior to any dismantle/excavation) (Pug Sound Energy) (Federal Way IFfi DI'Triet 039) 3.SEPTIC SYSTEM • S.WATER-Public Source (Check applicable box) (rank to be removed or tank to be drained and filled) a meter to be=loved and final utility bill paid XMINSIEWIlegfrefitiebriOgieefed ( ng County Envlronmenml Services) _ (Water Supplier) ******OR 4.SANITARY SEWER (Cheek applicable box) "9.WATER-Private well(Check applicable box) Li Sewer line capped at property line in Private well filled and capped rt ilostIng sewer iine to remain nd d by proihrsed new structure LlPrivate welt ro he used for other• •'r I r Dl trIct) -� (King Coun, Environmental Services) 5.GARBAGE (All household gar bane disposed off and final bill paid) • (RST Disposal/Federal Way blsposel) • O Completed Construction Permit Application form ❑Provide the following fees; 1.Demolition Permit li'ee 565.50 Z.Automation Fee 5.00 3.WA State Surcharge 430 4.Cash Bond Deposit 500.00 (Refundable upon Completed Final Inspection) 5575.00 Eiullelin#122-January I.2006 Pagel of I k:\Handeutj\Dcmulivan Pcrmit Requirements JAN-23-2006 01:01 , 15 , P.03 ....... _........ _...... ......_ ' .A ' '' ,n fat;(....,kiicr ,._,-. • • -.,-t.t..i‘''„,..,-..,•-•;v14,4' . -;:•:st."1.ii,'.. 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"4 ift.:,• I, ,1,.',','47`.,;.-..,:,,,•4:••;.''' ,,, DEMOLITION PERMIT REQUIREMENTS ; • ‘-',:i A,V,'-;k.'',..".2'•, t;.2.,:.•(>.ir'',:'`4, -,..,,,. ., ,-q.i»4. .',,," .;'''''t.,•'-'.,,,?..e,,,7,'", , A ikmalitinn permit IA frilOircO,,,o remove tiny strOcItit•or sttueturou tio o3ubjeot ptriperty.Check with the Cky's Pkwatills , • -' '.,.?..-, i'; ',.:', .',‘.,,',:,‘•,"y,,,.;„; W, Dtvizoon to 3cG if tbc nsupwel ext.eeds threaholds that trigger an ehrttlerlIttertil teView.Ay epohnirm.Ar ti41 review and ,..l'.1.;' ‘ minimal rear enviltitment4 cheeitia it mty he requited,which will extend the time perkni hetete a demolition permit ' ••., '4:':'''•I''',.4'r'r': ,;''- ',i'i l',,e,„ Tet,1';, be isnuvd, ' ' ,.," 4,Z,,' „.•'..‘ ,T,,,,,,.i4-e."',,...-. - ';.;:',,,:-.;c4"-"':"..,''.',-,.."',:'•:',;i:r..,:,' n Prior to submitting a demolition permit,the following iternt(is npplisable)must bo st2ned b,the respective ussuay itee atiachtil 1)tmolition Permit Coated List). ' '',.„4'‘.;'•.-,'• •z‘'.;: ,,'elf,.; ,,' ;'''•.'.,t.-1!"In.'''„&.',.fr,:'''f .'4;'`* .'. ':7'!•'‘,;'''S-.;" :'A:',''', A "4"i :''1' NMT 6.)APOUt.4,7! 1 iritiffil OM iNf aln.4.11i4ftee art itrtk CY"Stfilrillf4 if applicaVs.in ivr tr.,woopitx w Uri dtaaltit*Nt ramie.All iIPPiterabii ;;, Volt 5 below ilfi,et:,1,iihasa 4,040.144(*),gut rrArevtive ogtay rcp,r4efueettva ' j r.'::,'="!..,.'L.;•' •,:" 4, it.r•..1„,,. •,...,,•„,,,,,••!,t,,•.,,o. •„ vi,,,z,1 fa, ,., . ',,::'.,,,,,.•,,,f-',,i:-.;.• • .,r,4:''',,'.1-W"'-''‘,7..:, yo‘ WI‘,44.4(i 4:.:.4:•4•.‘.';'..*.•;,:;," •,'.: '''',•t, ,,'4:' 1-MENTOS ADATD4P4r ft.Et refltVCITY Liell Obre topthig4;3034.441 fwit A414 ii'aSoito.,-,vNeyi4•oh NFL foxid Cies,1 Afr (01:&44 1:e Awl iit nod itaato namwsh. ' ,''' • •..d.•'.*''iit•- ;.. Alorry provisam :- • ,. -, - ,,, , . , ' ..""'" ",i: ')'''. ,," - ,,- _,.. -----_ * ;FT—. .' 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' ----tt4ittg6;7Fr '-''''''-''''''''''--:= . ' ''' ' -'l',4,;=.'=:,; ::g=*--L.-...7.,:i'_ .::==',;11:Rair '' '” ''''';'I. .' ':;''''7:i..5•,!: . . --'''. ' . '''' 4 1;. ,, ',- .4 ,.,'it'•4,, 1 ' .4* takkiffifiir laturoctehawrgartaia Ugliest '0_:_rt___I/klts-. )_.....;, ;___ , ° ;.' , . , ,v..,.cr•-'1:,,',, ,' A;,,,,11 .: • • , „ v:,,..v •"Y''-,44., ,, g,;.i.,..±.6?04,)-ti-xth,,, ,,-- -iet. -.:4-1--- : • : • ,, •,,,,,-;,--,,,., •...:4:-.:‘,4,..4,,t, ,,-‘4,-. , „, ,,,,•,,o.f.',„:„.;..,. ,..•,7,:::.,r,,,,-A:.,'''..'.. ' .- •' , ; '',:,',.:.,t,','-'•,'" •*.,,: 1::,i.i',le.';',; . „. . .;.--1-.'tit-t.,,s . ;•,,.•-.0..,,,. .,•i , ,,,,) 'I,...,;..-. ,:',, -:.‘,.,,,,,._.„-.., ..............,_... • .„,i,,,,?,,-,., i;.,•;,' ';‘,,,,,,-,,v9,..:,.',,' • ;',1-44114-7F:,: ':--,,.= -, i.;-.4-.!:_•r ' ' .1,.'1.. IT 1144E7 ' , -,,-... -''-i-i-, - .,: '- ' - . ',,,-.„ ',,z t-.i.•• k. t..1.-vi,-.t...t '',,'.14,`,..b-... , '''.'";-'0'4• ...'', fp ,,- 'ff..,-,- -al ,..:.:11.:': -,,l-,,,..,-.1E.:3:1 /.-c-,,-",,.i-',.,,Jc",.. 1.;''.'...4 .:uiririt thiat Inowmatoq , .',f,''''', '' " '4•-,r'7.•.'4"), .';-; ''.'""'":.'s'.•:..',''. ',•4;'‘;,',.-.11.:'•''''' ,,7 .,,,t7... ,1 , : 4-i‘•,4*.14)41irirl,liar,NAritlit%s4sirurnortte--- ''.' '-'`-''''' ‘:.' - i.,'T', ! - ,'; •";,"' '''C'-;''141a.'"4,4: '11' ..• ;''ke!*,,;),V-, ', ,4,..'.v, '..0).: 'L,''''','..';,1,..:',;---•: ;"';;'.' =:1=4=4',- ='=, gill" JAN-31-2006 TUE 01 55 PM CENTURY 21 SWRRTHOUT FAX NO. 253 862 9270 P. 11/34 Fi 40 ___11._________. _____ �y ( ass 11°9 1 3 1 UGET SOUND CLEAN AIR Date Received s" , i AGENCY PS JAN 312006 J f, ..y ,:;,, 1;0 Union Street,Suite 500 I R . -C 0 6 L, .� -_ `�'''`'' Scenle,WA 98101-2038 www.pscleanair.org Agency Use Only iiiiikilial Agency Use Only NOTICE OF INTENT A-ProitstTvne: I. U Friable Asbestos$gmoyj 2- 14Friable Asbestos Removal&Demolition 3, Zi Demolition Only B. Property Owner: Kath f rC1 I') 1J()(4,2e.i _ Phone: 24g77z-/627 i Mailing Address: ; 7/`�• 5 jJ �_ P 1 City:,'� t--F+ -• State 4 Zip:91/7? C. Asbestos I'LeA.Ntf.PRIAT crE4PI Tilts Fru HE YOUR Re T_IRN MAILING _,..." Contractor: ( er/C (i11�� (���� - n i.�o.-ter- O ! wn (� Contractor Mailin Address: • • _ w�� Phone: �� Job No.: 06-00093 City: °CI ! )71 61 ----' State: (A) I �$. _ Fax: 1 ?r!. Sitzi / 1I Address: e 3 27 ft,_.) -53 � 1 City: Thyje_r�l`/L),0 t Zip: 2,8'02.3 Site /gyp�cl 11 L( cert., - Manager: t`lam 1Local Phone: E. * Asbestos Survey or No. of Date of Asbestos Was Friable Asbestos Identified? '`Yes Q Mat'l Presumed Structures; / Survey: /- 7 L-06 Was Nonfriabie Asbestos Identified? .2Yes pNo AHERA BuildingCertification il: ;° I-11-O7 Attach a copy of the survey when friable asbestos Inspector: kP ielvl/l''J/ /j Z y,' Exp.Date: `n/q/2 has nor been identified. AH5R4 Survey is required before all demolitiosirojects •! F. Demolition Start . • 1. Training Fire(List Fire Dep _� Information: Date: 2 7.1. �__�� 2. 0 Ordered Demolition(attar • of Order) Demolition Insert demolition contractor's mailing address on hack Will nonfriable asbestos be left in place during demo? Yes No Contractor: To /3 GLG Y�,std If yes,list type and qty. Note disposal requirements in Step 6(on back). v G. Friable Asbestos Work Days: M T W Th F Sa Su Project Information: Start Date: Completion Date: Hours: Will all friable asbestos © Yes Total Qty.to be Removed: 3 Linear Ft. Square Ft. materials be removed? ❑ No 13 Boiler\Furnace insulation A Duct Insulation ❑Pipe Insulation U Fireproofing al Paints Plaster Textured Coatings U Cement Board © Cement Pipe Q Friable Flooring ❑Friable Roofing Material Other, H. Asbestos/Demolition Project Categories: Notification period Project Demolition I. Single-Family Residence(owner-occupied): Fee Surcharge A, ❑ Asbestos Removal Project Only A.Prior Notice A. E.V„Demclitio n Project(with or without asbestos removal;project) B. 10 Days' $50�' `(Asbestos removal can begin upon notification;demolition must wait 10 days) I 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 I A or 1 B may be checked If this is not an owner-occupied residence,one of the categories listed below must be used instead. A single famil residence does not include rental property, multi family units, or any mixed-use building. 2. 1 All Other Demolitions(with no Asbestos removal orNonfriabie 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. Cl z IO-259 linear feet and/or>_48- 159 square feet of asbestos Prior Notice 10 Days $100 S100 4. ❑ 260-999 linear feet and/or 160-4,999 square feet of asbestos 10 Days $200 $100 _ 5. U >1,000 linear feet and/or>5,000 - uare feet of asbestos _10 Days $600 $100 _ 6. Z.1Emergency Asbestos Project or /131 Emergency Demolition Project Prior Notice $50 Emergency Fee (Single-Family Residences arc exempt from emergency fee;however,property owners must.rovide a written curer•en r••nest I. I certify that the information contain, this not- tcation&supplemental data is,to the hes .f my knowledge,accurate&complete. Ag S'Us: Only fir 402 41......s I __ 1�,� (---- - % /3/a '. / _ ' ignature Repre ming '" ', ' 1 Date Reviewed B s SI Sound Clean Air Agency Form No.; 66-160(Revised 7/05)TS . .-.1 ") 0 0 , A3 C-C g+�' v • i 030g3R C. ed A 0 ., /I. JAN-31-2006 TUE 01 :56 PM CENTURY 21 SWARTHOUT FAX NO, 253 862 9270 P. 12/:4111111/ 40 The Puget Sound Clean Air Agency requires advance notification before any person 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 III, Article 4). All asbestos removal and demolition notifications must be submitted to the Agency on current Agency forms. Asbestos removal and demolition projects involving materials and structures below the notification threshold are still subject to all other requirements of Regulation III, Article 4. After receiving a complete notification with the appropriate project fee, 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 PLf4,k-nU""[LEA ICLY MS WILL UB FOUR MILAN furca.«:COAL Contractor: Owner/CEO: Contractor's Mailing Address: Phone: Job 0: City: State: Zip: Fax: 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. Norlfriable 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 this is your return mailing label. Step 4. Enter the site address for all notifications in Box A. 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 A}IERA building Inspector_ Attach a copy of the survey to the notification of a demolition project when onlynonfriable asbestos or no asbestos is identified on the sure y. 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 are 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 ieuioved: 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 111A for renovation projects or BOX H1B for demolition projects (with or without asbestos removal). Asbestos removal may be conducted after a complete notification is received, but demolition activities can only begin on the 10th day after the notification is received. Note: .(f the single family residence is owned by one fancily who has been or will be using the residence as their domicile,bares IA or IB 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. AlLemergency requests must be accompanied by a.letter from the property owner demonstrating the aced to conduct thQprQiect immediately in accordancg with the regpiretnents in Regulation III. Section 4,03(c), 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