11-104246 •
• berriolition
City of Federal Way
Community&Econ.Day.Services Permit #: 11 -104246-00-DE
33325 8th Ave S
Federal Way,WA 98003
Ph:(253)835-2607 Fax:(253)835-2609 Inspection Request Line: (253)835-3050
Project Name: ALAVEKIOS
Project Address: 30020 20TH PL SW Parcel Number: 012103 9114
Project Description: Demolition of(2)small cabins.
Owner Applicant Contractor
JAMES ALAVEKIOS JAMES ALAVEKIOS GRIFFITH CONSTRUCTION
9832 NE 27TH ST 9832 NE 27TH ST GRIFFC*072C5(7/28/13)
BELLEVUE WA 98004-1847 BELLEVUE WA 98004-1847 7417 MYERS RD E
BONNEY LAKE WA 98391
Additional Permit Information
Demolition Valuation 7500
CONDITIONS:
The following permits must be obtained before work begins:
1.Hydrologic Project Approval(HPA) from Washington State Department of Fish and Wildlife is required.
2.Right-Of-Way permit is required for 21st Avenue SW Street end use.
PERMIT EXPIRES Friday, June 21, 2013
Permit Issued on Tuesday, June 4, 2013
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and,the use will be in accordance with the laws, rules and regulations of the State of Washington
U and the City of Federal Way.
Owner or agent: (
/, /� :
AA�,y �1i��-�/� Date: �., .
FINALED
•
411114..464.
THIS CARD IS TO PMAIN ON-SITE •
CITY OF Construction Infection Record
Federal Way INSPECTION REQUE TS: (253) 835-3050
PERMIT#: 11-104246-00-DE Address: 30020 20TH PL SW
Project: JAMES ALAVEKIOS FEDERAL WAY, WA 98023-3404
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 lktig Date to (2.3 (ic
❑ Rough Electrical ❑
Approved Final Electrical
Approved Right
Approved of Way
By Date By Date
B❑y Date
:*,:,:.::.:... REC
r
Federal ocT 7 9 P RMIT �MF CO ME PL DE EN FP
C 253-8 1TV DIVE FAX
253-T SERVICESnci ,,I A T I O N
2.53-R3.5-2607•FAX 253-R3.5-2609 IT
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CDS
SITE ADDRESS
SUITE/UNIT#
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VALUE OF MECIIANICAL WORK $ (a copy of bid or estimate must be proi'iclecl) d
Indicate how many of each type of fixture to be installed or relocated as part of
GAS his pro OUT oject. DTS onof include existin OTHER(Defixtures o r remain.
AIR HANDLING UNITS FANS
AIR CONDITIONER
FIREPLACE INSERTS HOODS(commercial)
BOILERS FURNACES HOT WATER TANKS(Gas)
COMPRESSORS GAS LOG SETSREFRIGERATION SYST
DUCTING
GAS PIPINGWOODSTOVES
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TOILETS WATER PIPING
BATHTUBS(or Tub/shower combo) LAVS Rand sinks)
DISHWASHERS RAINWATER SYSTEMS
URINAL —
S
DRAINS SHOWERS OTHER(Describe)
VACUUM BREAKERS
(Kitchen/utility)—
WATER HEATERS(Ekctdc)
DRINKING FOUNTAINS SINKS WASHING MACHINES `` `' g(' iiii
HOSE BIBBS
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SUMPS ...:..:::.::" ......
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ITCAAREAS ON ROPEWATER PURVEYOR
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EXISTING/PREVIOUS USE LOT SIZE(In Square Feet) 1•`, EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes❑ No ❑ Yes ❑ No
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AREA DESCRIPTION(in square feet) 1 EXISTING PROPOSED TOTAL _._
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FIRST FLOOR (or Mobile Home)ril — —
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COVERED ENTRY
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GARAGE 0 CARPORT 0
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.. ..................................................................................... EXISTING PROPOSED TOTAL
Area Totals
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ESTIMATED SELLING PRICE$ # OF BEDROOMS
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••••"-• Additional Information
AREA DESCRIPTION Occupancy Group(s) Type Stories
in S ware Feet
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ADDITION
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Area Occupancy Additional Information
AREA DESCRIPTION Feet P y Group(s) Type Stories
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TENANT AREA ONLY
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Bulletin#100—April 14,2010
Page 2 of 3 k:\Handouts\Permit Application
• •
COMMUNITY&ECONOMIC DEVELOPMENT DEPARTMENT
33325 8°Avenue South
c"'OF ,s Federal Way,WA 98003-6325
eller l 253-835-2607;Fax 253-835-2609
www.citvoffederal way.co m
SHORELINE SUBSTANTIAL DEVELOPMENT PERMIT EXEMPTION
APPLICATION
Name of Applicant: (%11>�r- b-0 o\ \.( a\-Qc-1 'Tr kk,,V i,e1 4 1%4101\ --".°i-`
-.. kM 1 �,, +\ Ve.vetc
- ,<Ds ki
Site Address: '3c)0-2--c-2 2°4, tat g , [ I -.0_. LA../ay 141,4 9 z (::).2-
, T'
Proposal; 1 cs it 5il -d ✓`le,-,--n u - v .-4 (14,,.-2s usf,-/
a C +- C.,c cc-Iv-a_
WAC Exemption Citation: 17 3 - 27 0 t-/C(i) ( )
(Departmental review below)
File: # 11-104228-00-SH
The proposed development is consistent with:
Yes No
Q 0 Washington State Shoreline Management Act
Q 0 Federal Way Shoreline Master Program
' _ _ 0-/Z_Approval ,� _ ✓ _ _ _ Date
Isaac Conlen,Planning Manager for Patrick Doherty,Director
Condition(s)attached: 0 Yes WI No
Additional Permit Information:
1. Washington State Department of Fish and Wildlife will require Hydrologic Project Approval
(HPA)for the scope of construction activities associated with this exemption approval.
2. Right-of-way permit from Federal Way Public Works Department is required for access from 21st
Ave SW.
3. Puget Sound shoreland between subject property and 21St Ave SW is private property.Applicant
is responsible for obtaining permission to access adjacent properties.
Bulletin#143—March 14,2012 Page 1 of l
k:\Handouts\Shoreline Exemption
DEPA,RTMENTOF COMMUNITY DEVELOPMENT SERVICES
33325 8th Avenue South
PO Box 9718
CITY OF ''' Federal Way WA 98063-9718
Federal Way 253-835-2607;Fax 253-835-2609
e.•ww.c;Fa Ei;demi 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 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 datedheap resentatives.
1.ASB 7 •. 'BATEMENT JUN 2 g 2011 6.ELECTRICITY
(Copy o(•p • • form'and asbestos surve 4r�,P,uge6,`jyi,Clean Air (Electric shutpfff er rem ed)
Agency); ,.) u 11/ �_ , .�_apt
Ift / ity,, � CQ3 Z` C (Puget Sound Energy)
Cof Fed al W., : ;':ng 'i 1,. )/
rr.
2.GAS SUPPLY 7.FUEL STORAGE TANKS
(Gas to be shut off, meter removed and fins ill paid) (Above or below grade fuel tanks, have been pumped or removed
under Fire Department permit prior to any dismantle/excavation)
Puget ound Energy)
(South King Fire and Rescue)
3. SEPTIC SYSTEM 8.WATER- Public Source (Check applicable box)
(Tank to be removed or tank to be drained and filled) o Meter to be removed and final utility bill paid //—./t7
`/&
-To- ren -' o uhok 1<-4-e
d Meter to remain and be protected
--fl
g County Er(vir ental krvices) (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 se r line remain and be used by propos new structure o Private well to be used for other purposes
( '
(Lakehaven Utility District) (King County.invironmental Services)
5.GARBAGE
(All household garbage disposed off and final bill paid)
/V1-1.
(Waste Management/Other Company)
❑ Completed Construction Permit Application form
0 Provide the following fees: 1.Demolition Permit Fee Based on valuation.See table on pg 4 of the construction permit application.
2.Automation Fee $6.00
3.WA State Surcharge $4.50
Bulletin#122-January 26,2010 Page 1 of 1 k:\Handouts\Demolition Permit Requirements
DEPARTMENT OF CONITY DEVELOPMENT SERVICES •
4111
A 33325 8`h Avenue South
CITY OF PO Box 9718
Federal WayFederal Way WA 98063-9718
253-835-2607;Fax 253-835-2609
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
www.pscleanair.org
2. Electricity: Puget Sound Energy Tacoma Public Utilities
Attn: Construction Coordinator Customer Service
22828 68th Avenue South, Suite#102 —OR— 747 Market Street
Kent,WA 98032 Tacoma, WA 98402
888-225-5773 253-383-9600 or 253-383-2471
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: South King Fire&Rescue
33325 8th Avenue South/PO Box 9718
Federal Way,WA 98063
253-946-7248
Bulletin#109—March 1,2007 Page 1 of 1 k:\Handouts\Demolition Permit Contact List
DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
33325 8th Avenue South
I �` liPakPO Box 9718
Federal Way WA 98063-9718
Federal Way 253-835-2607;Fax 253-835-2609
v„ iti'.G Dtli-leraii;da 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 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 TOAPp�IGIJVT: ftilities shall be disconnected and services performed,if applicable,prior to issuance of the demolition permit.All applicable
items below'aM iigte AgenOyoencyrepresentatives.
1.ASBESTOS ABATEMENT 6.ELECTRICITY
(Copy of approval form and asbestos survey from Puget Sound Clean Air (Electrici e d meter remo d)
Agency provided) C i
•j 'r/i
(City of Federal Way Building Official) (Puget Soun Ener y)
2.GAS SUPPLY
7.FUEL STORAGE TANKS
(Gas to be shut off,meter re rived and final bill paid) (Above or below grade fuel tanks,have been pumped or removed
under Fire Department permit prior to any dismantle/excavation)
(P get Sound Energy)
(South King Fire and Rescue)
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 final utility bill paid
o Meter to remain and be protected /
(King County Environmental Services) ��
(Water Supplier)
******OR******
4.SANITARY SEWER (Check applicable box) 9.WATER-Private Well(Check applicable box)
❑Sewer line capped at property line o Private well
o Existing sewer line to remain and be used by proposed new structure ❑Private well to filled be used for other purposes
(Lakehaven Utility District) (King County/Environmental Services)
5.GARBAGE
(All household garbage disposedoff and final bill paid)
(Waste Management/Other Company)
❑Completed Construction Permit Application form
❑,Provide the following fees: .1.Demolition Permit.Fee .Based on valuation.See table on pg 4 of the construction permit application.
2.Automation Fee $6.00
3.WA State Surcharge $4.50
Bulletin#122—January 26,2010
Page 1 of 1 k:\Handouts\Demolition Permit Requirements
Agency Case No. i
• PUGET SOUND CLEAN AIR
2011070 . 110 AUnionCY
y
14 ='" Street,Suite 500
��r - . %,!...‘,Tx:..: Seattle,WA 98101-2038 •
+� 9
u�i 2 LQ1l
_ www.pscleanair.org
i i: l,� NO r CE OF INTENTy-.-?tr~•,-cam,,,,
A.Pro'ect T e; 1• �� Age!"
Use t
❑ Friable Asbestos Removal 2. l Friable - bestos Removal&Demolition 3.�
B. w
Properly Owner: Gado 11
Demolition Onl
Phone: ,:1-! — 112 1—1 ,C'e-1
Marlin_ Address: Cil �� NEM 1p
C. Asbestos PLEASE PRINT CLEARLY.THIS WILL _ Ci �`�L- (` �l�,Al,�i
Contractor: BE YOUR RETUR ,.
Mailin: Address: ____Inli
ti:]:
immiminsiim: ` —VPhone: Contractor
Job No.:
D• Site /�
utiwm
Address: �)�20 .7-0f�`1 ; 1.-- L
,,p UZ 1 a
Zi.: C1 e992
A
Local Phone:
E. 17-' Asbestos Survey or No.of
• Mat'1 Presumed Date of Asbesto Was Friable Asbestos Identified? `Ail
;es���' o
AHERA Building Structures:
Survey_L U G 0 3
Inspector: C V\ I\;,�✓ Was Nonfriable Asbestos Identified? r es �r°
L Certific:,.ion#: L�'f Attach a copy "
(. ✓ o the survey
An AHERA Survey is required before all demolition projects Ex Date: 17 has not been identifred when fria.le asbestos
F. Demolition Start
Information: Date: No.of
Demolition Insert demolition contractor's mailing address on back Structures:
1 ■ Training Fire(List Fire Dept.)
Demolition
2• ❑ Ordered Demolition attach co. of Order
Will nonfriable asbestos be left in place during demO? I Yes ■ No
C�� If yes,list type and qty.
G Friable 9gbestos
Wirer Information: Start Date:
Com,letion Date: Work Days: M T W Th F Sa Su
Total Q .to be Removed: �1'� Hours:
ThermalotalQSystem Insulation:moved: ■ Linear'Ft. • One. Will alls friable asbestosd
Boiler\Fumace Ins. • S.uare Ft. materials be removed? ❑ Yes
• Fireproofing ■ Paints • Duct Ins. ■ Pipe Ins. ❑ No
leaugai Plaster • Other:
■ Cement Bd. • Cement Pipe ■ Textured Coatings Other.
Friable Flooring or Roofing Mat'l Other:
H. Asbestos/Demolition Project Categories:
1• Single-Family Residence:
A. ❑ Asbestos Removal Project Only Notification period Project Demolition
B. Demolition Project(with or without asbestos removal project)
Asbestos removal A.Prior NoticeFee Sur— chime
can be:in u.on notification;demolition must wait I0 da s B. 10 Days* A. $25
Note:If the single family residence is owned byY B. $50
or If Ana be checked A d sin le a one family who has been or will be
2. All Othere D mil residence does not include rental,ro,a usingmthe residence as their domicile,the above boxes
Demolitions With No Asbestos Removal Pii� ect ,multi-anvil units or an
Asbestos Pro•ects other than Sin le Famit Residence : mixed-use butldrn
3 • > 10-Friable Asbestos
feet and/or> 10 Da s
48- 159 s.uare feet of asbestos AsbestosNotice Demo $200
4. ■ 260-999 linear feet and/or 160-4,999 si uare feet of asbestos
5. • >1,000 linear feet and/or>5,000 se uare feet of asbestos Prior 10 Da s $100
10 Da s $100
6. ■ Emergy Asbestos Project or ■ Emergency $200 $100
(Single-Familyerge Resider g YDemolition Project 10 Das $750
ce,vare exemptfrom em :envy fee;however,,ro $250
Perry owners must,rovide a Prior Notice Twice Project Fee
F. I certify that the info written emergency request)
rpuitigrt con • ed in this notification&supplemental data is,to the best of my knowledge,accurate urate&complete. Agency Use Only
/ Signature '
Representin_
uget Sound i ., Air Agency Form No.: 66-160 Da Reviewed By
(Revised 9/03)TS
• III
The Puget Sound Clean Air Agency requires advance otification before
involving materials equal to or greater in size than 10 linear feet or 48
involving
of asbestos content) involving rteruths with1a projected any person commences and fs a friable demolitionasbestos projects
III, Article 4). square feet and for all fee (Regulationti
All asbestos removal and demolition notifications must be submitted to of area greater than I g
forms. Asbestos removal and demolition .ro'ects involving materials ands square feet
still sub'ect to all other demolition
oti Re.ulation III the Agency on current Agency
After receiving a complete notification with thea structures below the notification threshold are
Article 4.
copy tor the asbestos and ete iconthr by appropriate project fee, the Agency will review the form
J. Demolition mail. The returned copy will be and return a
P�..�Sf.P Nr, ,may nits WILL YOUR your validated notification.
Contractor: ''
RE77JRNSy,JJJNG LABEL
_ a c'2/
Mailing Address:
e‘� 6) Owner/CEO:
Phone: Contractor's
immenimmomminsimaraffiranJob#:
GUIDELINES FOR SUBMITTING AN ASBESTOSIDEMOLITION NOTIFICATION
Step I. Check appropriatethe CATION
Cbheck the project type in Box A. Friable asbestos includes popcorn ceiling material,sheet vinyl
asbestosesols_ siding,and duct insulation. Nonfriable asbestos is normally found in vinyl floor tiles,window u
Y flooring,cement
Step2. putty and most roofing
matEnter property owner information in Box B.
Step 3. Enter the asbestos contractor or property owner i
prmproject,in Box C. Print clearly this is your return mailing Idnei anon, if the property owner is conducting atingle-family residential
P P
Step 4. Enter the site address for all notifications in Box D. For multi-structure roe
(include an address for each site)and a list of the type and amount of friable asbestos o is' attach supplemental sheet with a site
Step 5. Check either asbestos survey or material presumed in Box E. be removed from each structure. map
Response Act(AHERA)asbestos surveyAll demolitions require that an Asbestos Hazard Emergency
notification of a demolition .ro'ect when onl nonfriable asbestos or no asbestos is identified
be conducted by a certified AHERA building Inspector. Attach a
� of the surve t the
Step 6. Enter the project information in Box F. and check the training fire or orderedon the surve .
Stepial ordertmust be attached). All asbestos
official
e are natt in Regulation I,Stosion must
be
If anym ved prior
tobcond materials demolitionbox if.appropriate(a
prior conducting a trainingfire. copy of the
requirements
yes and list the type and Additional demolition,g fine
quantity of material. will be left in place during
Step 7. Enter asbestos project information in Box G.
popcorn ceilings or plaster,sheet vinyl flooring,duct and pie insulation,cement asbestos board
types of friableasbestosmaterial to be removed:surfacing material such as
StepStep 8. For Single-Family siding or pipe,etc.
8.ut asbestos S n le_Fami.y Residential projects;check BOX H1A for renovation projects,BOX H1B for demolition r
only begin on the 10's dayAsbestos removal may be conducted after a complete family
is received, but demolition activities has
with or will aftere the notificationol is received. Note: projects with or
c
be using the residence as their domicile If the single residence
rental property,multi family units,or boxes IA or!B may be checked 4 slis owned by one family who has
anybeemired-use building, g family residence does not include
For Commercial asbestos projects(or projects that do not qualify as Single Family
5 thate matchesmthe amount f friable asbestospothat willd be
fee) your paymentremoved. If a demolitionis involved,ed, includekthe appropriate surcharge
To file for an emergen. project the category H2-
ap(additional emergency box in H6. All emerf an emergere . asbestost be o r demolition project, check the appropriate
applneed to conduct the xt atel in accordance with ebox I s g
anied b a letter from ere roe 5 and the
Step9, the re.uirements in Re: lation III Section 4.03 owner demonstratin the
Please certify the accuracy and completeness of the information provided by signing
Mandatory amendments to the notification are required for changes that increase the the notification in Box I.
materials to be removed and changes to start date, completion date and work schedule for asbestos
work schedule changes if the contractor is project category, change the types of asbestos
work for all nif Participating in the Agency worka Projects. .0 fee is required for
g Y schedule fax program, A $25.00 processing fee is
rePuget Sound Clean Air Agency asbestos regulations and forms can downloaded from the
Agency web page at www.pscleanair.°rg.
For technical assistance contact(206)689-4058 and for administrative inquiries contact 206
( )689-4090.
Puget Sound Clean Air Agency Form No.: 66-160(Revised 9/03)TS
Agency Case No.
• PUGET SOUND CLEAN "'°
AGENCY +P.
e.RtTeivn,liZI,
201107013 I�' 110 Union Street,Suite 500 JUN r
Seattle,WA 98101-2038 �� f
. www.pscleanaiir.o�rTg i
( it ,rti 'lir i:;e rte � iiiik.� OF I RI{ Ln�i7l:A
TENT {''7 cRure
1 Ca Friable Asbestos Removal 2. ► Fr
B. Friable Asbestos Removal&Demolition 3. '� Demolition Onl
Property Owner: �ULr0 I 1
�I
v) SRMIIIIIIIIIII Mailin: Address: / MI xi, - nes Phone: i (IC2 —`4p�c
C. Asbestos PLEASE PRINT CLEARLY.THIS WILL BE YOUR RETURN a r
,' /
Contractor: .
�,p s
Mailin: Address:
f li r Ii, asOwner/CEO:
A OUST Contractor
'hone:
(��, 1. O Job No.:
State: - pall
IEIIIIIIIIIIIIIIIIIIIIIII
D. Site ` �a —�.■�
Address: �,I. g n 0111 r `�� 1f p
Ci :
d t L,„„t Zi t: * (Xi
E. `� Asbestos Survey or No.of Local Phone: ,
a Mat'1 Presumed Date of Asbestos Was Friable Asbestos Identified? .r- es '<
AHERA Buildi Structures' Surve
�� Was Nonfriable Asbestos Identified? • °
Inspector: lLr, n�•
Certification#: i . ❑Yes ►4�.
��vv � , Attach a copy of the survey when friable ctsbest,s
An AHERA Sun, Ex..Date= has not been identified.
Survey is required before all demolition project
F. Demolition Start
Information: -7/ /( No. of
Date: 1. ■ Training Fire(List Fire Dept.)
Demolition Insert demolition contractor's mailing address on back Structures: 2.
Contractor: Will list table asbestos be(eft n place dunnlg demition attach■ yes ■°Nor
If yes,list type and qty.
G. Friable Asbestos
Pro'ect Information:
Start Date: Com.letion Date: Work Days: M T W Th F Sa Su
Total Q .to be Removed: Hours:
Thermal System Insulation: ■ Linear Ft. `� Will all friable asbestos ❑ Yes
BoilerlFtunace Ins. ■ `Ins. S.uare Ft. materials be removed?
■ Fireproofing ■ Paints ■ Due, fns. ■Textured
Pipe ❑ No
Plaster ■ Other
' ■ Cement Bd. ■ Cement Pipe .� Textured Coatings Other.
Friable Fl•>oring or Roofing Mat'1 Other.
H. Asbestos/Demolition Project Categories:
1. Single-Family Residence:
A. Asbestos Removal Project Only Notification Period Project Demolition
B Demolition Project(with or without asbestos Fee5 Surcharge
Asbestos removal removal project) A.Prior Notice A. $25
can bean u'on notification;demolition must wait 10 da s
B. 10 Days* B. $50
Note:If the singlefamily
N e:or IB ma be e a checked le s owned by one family who has been or will be using the residence as their domicile,the
2. ■ All Other Demolitions With No Asbestos Removal p o not include rental'ro,e
multi-amil units or an m above boxes
Pro'ects other than Sin le Famil Residence : mixed-use buildin.
3. ■ >
Friable
- Asbestos feet and/or>_ 10 Da s $200
4. • 260-999 linear feet and/or 160 8 4,999 s.uare feet of asbestos Asbestos Demo
111111111111....
5. • >1,000 linear feet and/or>5,000 s.uare feet of asbestos Prior Notice ]0 Da s $100
10 Da s $100
6. ■ Project or • $200 $100
(Single-Family Emergency Asbestosses are t from e Emergency Demolition Project 10 Da s $7 $250
emergency fee;however, Prior Notice Twice Project Fee
Property owners must provide a written emet••envy requesrequest). t Certify tha the ir!1-o[mati. contai,C.in this notification&supplemental data is,to
the best of my complete•knowledge,accurate&
L Agency Use Only
1 is azure
Representing
get Sound Cl� 66 160
Air Agency Form No.: I is e Reviewed By
(Revised 9/03)TS
Z./
The Puget • •
g 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
(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 projectsy
forms. Asbestos removal and demolition ro•ects involvin_ materials and structures below the notification threshold re are
still sub'ect to all other r-'uirements of Re•ulation III,Article 4. g y on current Agency
After receiving a complete notification with the am .priate 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 'LEASE PRI 11 Y.nnsPau azrov
Contractor: AuruvcuaEc
_ G G2 C,
Owner/CEO:
Mailing Address:
Phone: _ Contractor's
maimmininawirsisaJob#:
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
mberias board siding,and duct insulation. Nonfriable asbestos is normallyfound in vinyl floor tiles,window u
materials.
e Cols. y most
putty and roofing
Step 2. Enter property owner information in Box B.
Step 3. Enter the asbestos contractor or property owner information, if thero e
rt
project,in Box C. Print clearly this is your return mailing label. P P 'owner is conducting a single-family residential
Step 4. Enter the site address for all notifications in Box D. 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 certified AHERA building Inspector. Attach a co of the surve to the
notification of a demolition •ro'ect when onl nonfriable a .stos or no asbestos is identified on the surve . g y
nv v
Step 6. Enter the project information in Box F. and check the training fire or ordered demolition box if appropriate(a co
official order must be attached). All asbestos must be removed prior to conducting a training fire. Additional trainingfire
requirements are contained in Regulation I, Section 8.08. If any nonfriable asbestos materials will be left in place duringdemo of the
check yes and list the
type and quantity of material. demolition,
Step 7. Enter asbestos project information in Box G. List types of friable e 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 Single-Family Residential projects;check BOX HIA for renovation projects,BOX HIB 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 10`s day after the notification is received. Note:If the single family residence is owned by one family who has
been or will be using the residence as their domicile,boxes 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,
(additional fee) in your payment. To file for an emergency asbestos or demolition project, check thelude appropriate b xthe apropnite surcharge
5 and the
applicable emergency box in H6. All emer enc r uests must be accom anied b a letter from the ro e owner demonstratin the
need to conduct the .ro•ect immediate! in accordance with the requirements in Re• lation 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,
materials to be removed and changes to start date, complc•ion date and work schedule for asbestos projects. No fee is required for
the Agency
work schedule changes if the contractor is participating g ry> change the types of asbestos
work schedule fax program. A $25.00 processing fee is
required for all amendments.
Puget Sound Clean Air Agency asbestos regulations and forms can downloaded from the Agency webg a e at www.pscleanair.org.
For technical assistance contact(206)689-4058 and for administrative inquiries contact(206)689-4090.
P
Puget Sound Clean Air Agency Form No.: 66-160(Revised 9/03)TS
• •
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• •
Asbestos Survey
Shed not inspected
1• 44ft
AACM415 A
laundry room-vinyl tile ACM 410 and 413
ACM 420 sheet vinyl in kitchen, dining -oom
basement bathroom and bathroom /�
vinyl floor / \
ACM 401 Slope
asphaltic wet patch
on roof 27ft
29.5ft
ACM 405
front window caulk '
One car garage Entry
16.56fi
NOV 24 2003 10: 07AM HP LASERJET 3200 p. 2
NVL Laboratories, Inc. lKva
4708 Aurora Ave. N., Seattle, WA 98103 #102063
Tel: 206,547.0100, Fax: 206.634.1936
www.n,vliabscom Bulk Asbestos Fibers Analysis
By Polarized Light Microscopy
Client: Lucus Building inspections Batch #: 2315324.00
Address:2219 Lakewood Road
Arlington, WA 98223 Samples Received: 22
Mr. Chuck Lucus Samples Analyzed: 22
Attention: Method: EPA/600R-93/116
Project Location: 9832 NE 27th Street, Bellevue
Lab ID : 23094691 Client Sample #:401
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 1 Description: Black asphaltic material
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Asphalt/binder Cellulose 10% Chrysotile 12%
Lab ID : 23094692 Client Sample #:402
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 1 Description: Black asphaltic fibrous material with granules
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Asphalt/binder, Sand Glass fibers 20% None Detected ND
Lab ID : 23094693 Client Sample #:403
Location: 9832 NE 27th Street, Bellevue
Layer 1 of I Description: Black asphaltic fibrous material with granules
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Asphalt/binder, Sand Glass fibers 20% None Detected ND
Lab ID : 23094694 Client Sample #:404
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 1 Description: Black asphaltic fibrous felt
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: °!o
Asphalt/binder, Binder/filler Cellulose 65% None Detected ND
Lab ID : 23094695 Client Sample#:405
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 1 Description: Tan brittle material with paint
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Binder/Filler, Paint Cellulose 3% Chrysotile 2%
Lab ID : 23094696 Client Sample #:406
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 1 Description: Black asphaltic fibrous paper
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Asphatt/binder, Binder/filler Cellulose 65% None Detected ND
Sampled by: Client
Analyzed by: Wei Long Tai Date: 11/24/2003 DRAFT
Note:If samples are not homogeneous,then subsamples of the components were analyzed separately.All bulk samples are analyzed using EPA 600/13-93!116
Method with the following measurement uncertainties for the reported%Asbestos(1%4)-3%,5%=1-9%,10%-5-15%,20%10-30%,50%=40-60%).This
report relates only to the items tested. If sample was not collected by NVL personnel,then the accuracy of the results is limited by the methodology and acuity
of the sample collector. This report shall not be reproduced except in full,without written approval of NVL Laboratories,Inc. It shall not be used to claim
product endorsement by NVLAP or any other agency of the US Government
Page 1of6
ti I u - .
NOV 24 2003 10: 08AM HP LASERJET 200 P. 5
#.44MIMMONNIORMMIPIIM11.010 ......1LM.M......1001.1 ".."....... •...'.•••1110 N
NVL Laboratories, Inc. !Awa
4708 Aurora Ave. N., Seattle,WA 98103 #102063
Tel: 206,547.www,nvllabs,c0100 Fax: 206.634.1936om Bulk Asbestos Fibers Analysis
By Polarized Light Microscopy
Client: Lucus Building Inspections Batch #: 2315324.00
Address: 2219 Lakewood Road Samples Received: 22
Arlington, WA 98223 Samples Analyzed: 22
Attention: Mr. Chuck Lucus Method: EPA/600R-93/116
Project Location: 9832 NE 27th Street, Bellevue
Layer 2 of 2 Description: White chalky material with paper
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Gypsum/binder, Binder/filler Cellulose 27% None Detected ND
Lab ID : 23094705 Client Sample #:415
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 2 Description: Green vinyl
Non-Fibrous Materia's: Other Fibrous Materials:% Asbestos Type: %
Vinyl/13k. ar Cellulose 3% Chrysotile 2%
Layer 2 of 2 Description: Black asphaltic fibrous felt with mastic
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Asphalt/binder, Binder/fIller, Mastic/binder Cellulose 65% None Detected ND
Lab ID : 23094706 Client Sample #:416
Location: 9832 NE 27th Street, Bellevue
Comments:Composite result for whole sample equals less than 1% asbestos
Layer 1 of 2 Description: Tan compacted powdery material with paint
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Binder/Filler, Paint Cellulose 5% Chrysotile 2%
Layer 2 of 2 Description: White chalky material with paper
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Gypsum/binder, Binder/filler Cellulose 27% None Detected ND
Lab ID : 23094707 Client Sample #:417
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 2 Description: White compacted powdery material with paint
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type:
Binder/Filler, Paint Cellulose 5% None Detected ND
Layer 2 of 2 Description: White chalky material with paper
Non-Fibrous Materia`s: Other Fibrous Materials:% Asbestos Type: %
Gypsum/binder, Binder/f! r Cellulose 27% None Detected ND
Lab ID : 23094708 Client Sample #:418
Location: 9832 NE 27th Street, Bellevue
-Th
Sampled by: Client
Analyzed by: Wei Long Tai Date:11/24/2003 DRAFT
Note:If samples are not homogeneous,then subsamples of the components were analyzed separately.All bulk samples are analyzed using EPA 600/R-93/116
Method with the following measurement uncertainties for the reported%Asbestos(1% 0-3%,5%=1-9%, 10%=5-15%,20%=10-30%,60%=40-60%).This
report relates only to the items tested. If sample was not collected by NVL personnel,then the accuracy of the results is limited by the methodology and acuity
of the sample collector. This report shall not be reproduced except in full,without written approval of NVL Laboratories,Inc. It shall not be used to claim
product endorsement by NMLAP or any other agency of the US Government
Page 4of6
NOV 24 2003 10: 09AM HP LASERJET 3200 p. 7
• •
NVL Laboratories, Inc. awa
4708 Aurora Ave. N., Seattle,WA 98103 #102063
Tel: 206.547.0100, Fax:206.634.1936
www.nvllabs.com Bulk Asbestos Fibers Analysis
By Polarized Light Microscopy
Client: Lucus Building Inspections Batch #: 2315324.00
Address: 2219 Lakewood Road
Arlington, WA 98223 Samples Received: 22
Mr. Chuck Lucus Samples Analyzed: 22
Attention: Method: EPA/600R-93/116
Project Location: 9832 NE 27th Street, Bellevue
Layer 2 of 3 Description: Yellow mastic
Non-Fibrous Materis.. : Other Fibrous Materials:% Asbestos Type: %
Mastic/binder Cellulose 4% None Detected ND
Layer 3 of 3 Description: White brittle material
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type:
Binder/Filler Cellulose 5% None Detected ND
Lab ID : 23094712 Client Sample #:422
Location: 9832 NE 27th Street, Bellevue
Layer 1 of 2 Description: White compacted powdery material with paint
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Binder/Filler, Paint Cellulose 4% None Detected ND
Layer 2 of 2 Description: White chalky material with paper
Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %
Gypsum/binder, Binder/filler Cellulose 27% None Detected ND
r
Sampled by: Client
Analyzed by: Wei Long Tai Date:11/24/2003 DRAFT
Note:tf samples are not homogeneous,then subsamples of the components were analyzed separately.A/buk samples are analyzed using EPA 600/R-93/116
Method with the following measurement uncertainties for the reported%Asbestos(1%=0-3%,5%=1-9%,10°,6=`.�15%,20%10.30%,50%=40-60%).This
report relates only to the items tested. If sample was not collected by NVL personnel,then the accuracy of the results is limited by the methodology and acuity
of the sample collector. This report shall not be reproduced except in full,without written approval of NVL Laboratories,Inc. It shall not be used to claim
product endorsement by NVLAP or any other agency of the US Government.
Page 6of6
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ACM 517
Vinyl floor
loft .4 Shed roof