20030411.pdfa
RECEIVED
PERMIT EXP IRES
WL�DATE
CITY OF EDMONDS
USE PERMIT
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NUMBER2003-1P
CONSTRUCTION PERMIT APPLICATION
JOB S E/ #
ADDRESS zM-1-cl
OWNER NAME/NAME OF BUSINESS
AQA\42*9V__ kk "I e S
PLAT NO. LOT NO. LID NO.
3!!/SUBDIVISION
LID FEE $
MAILING ADDRESS
SEN11
TESCP APPMW
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
Street We Parrnit Req'd
CITY zi EkEPHONA
6V
EXISTING - PROPOSED inspection Rtqtwod
Sidewalk Required
REQUIRED DEDICATION- FT UnderWourid
NAME
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES[3 NO 13
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
CITY ZIP TELEPHONE
0 PR&INSPWI3014 UQUIRM
NAME
0 ST=r To OR Ciam"M Or Emm
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ADDRESS
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ROPE= UNE
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FIRE RIWEW
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CITY TE PHOgj� zf e
HIDS8 10119 WMI AVB INWAUM
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VARIANF 0 OND
EXPIRATIO1 DATE CHECKED BY VOMP ONIAsTEo
STATE LICENSE NUMBER I
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EAT1011 kA J26
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PROPERTY TAX cc PARCEL NQ.
I& a ��j Mosm HEIGHT
OMPL T%lRKL fULdUb Qkmow 091.&1 PROPOSED
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FOR INSPECTION IREQUIR13N ENTS
EXP
NEW RESIDENTMI. PLUMBING MECH
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
COMPLIANCE OR
COMMERCIAL
ADDITION CHANGE OF USE
REMODEL MULnFAMILY 0 SIGN
PARKING PLANNING REVIEWED BY DATE
LOT AREA
RECID I PROVIDED
1116
GRADING FENCE
REPAIR 1:3 CYDS 13 X FT)
REMARKS
o OTHER
DEMOLISH 0 TANK
RETAINING WALL
o GARAGE r FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
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(TYPE OF Y;P. BUSI 95P OR AC71VTM EXPLAIN:
0 OCCUPA111-
CHECKED BY TYPE OF CONSTRUCTION CO-99. n P
C GROUVA
120
NUMBER NUMBER OF r CRITICAL
DWELLING AREAS 2477--Z-30
-SPECIAL INSPECTION OCCUPANT
LOAD
UNFTA NUMBER AV.4lVett-0
]AREA
REQUIRED [j S
YE
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REO'D
VALUATION
A\btm 05 2-
Description
FEE
Description
FEE
Plan Check
State Surcharge
�E GLAZING % LOT SLOPE %
H7T SOU
Building Permit City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLX ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURSS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180DAYS
C6 PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE 13ACK OF PINK PERMIT FOR MORE INFORMATION
"APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OF WHArEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapeinsp. Total Amt. Due
2:
DEEMED TO MODIFX WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
- -
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE AW ORDINANCE PROVISION.-
Receipt #
Recording Fee I
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
CALL This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
Building Official or his/her Deputy: and Fees are paid, and
FOR INSPECTION receipt Is acknovAodged in space provided.
WORKMEWS SOPENSATION INSURANCE AND RCW 18.27.
OWFYLS AIURE YATE
SIGNATUR WN ENT) DATE SIGNED
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V'-Tz25) 00 149-31
6RELEAS&W'
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771-0220 DATE
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--- ATfENTION f
EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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Agency Case No. !E IR AIM- 7r, Datiltectived I
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Seatfle, WA 98101-2038
V#IWW.pscleanair.org JUL 22 20
20030072a
NOTICE OF INTENT
A. Proiect Type: 1. Q Friable Asb stos Removal 2. -Friable Asbestos Removat& Demolition- 3. Demolition Only
B. property Owner: AC%Y\
Phone((-),?
I
MailingAddress: --Loy 'rs-
I., - -4 i0c'm C)J
city:/-�
statecdA.
--
I zip: ?90a
PLE4SNPRhVTCU4,RZV, TIPSWILL Ilk' YOX/ft REMAN MAILING LAW 0 U
C. Asbestos Pk
Contractor: Owner/CEO: A
Sontractor
Mailing Address: Phone: 1A6% Job No.:
Ci!z: State: ZiE: Fax:
D. Site
Address. ai ��4;n V
Ci
Ezi :9 ma 6
Site It %
Manager:
Local Phone:LLIZ� Z- I
I
entified? L]Ycs
E. Asb4stos Survev or No. of Date of Was Friable Asbestos Id wo
r t1l Presumed Structurqj_. Survey: AlleNtlos Was Nonfriable Asbestos Identified? Uy"bs allo
--AHERA Buildin Celiffication Attach a copy of the survey unlessfriable asbestos
_g
Inspector. Y\ EXP is identified,
&�Uh _ _. Date._ C4- sr'� 2 4
An AHERA, r'"u* d before all demolition projeets T1 T 7 3 77
Lay.eylf 3
7Z- Training Fire (List Fire Dept.)
F. Dem6lA#*'!- C3
I Start '2,.CK)3 I No. of _py of Order)
Informaddn: I Date I Structures: Ordered Demolition (attach co
Dernolition Injert demolition conliactors mading address on back. Will nonfriable asbestos be left in place during demo? U YesA NiD
Contractor: If yes, list type. and qty.
G. Friable Asbestos
Pr9ject Information: 1StaitDate:
Cornoletion Date:
Work Days: M T W Th F Sa Su
Hours:
Will all friable asbestos Q Yes
materials be removed? E3 No
Total Q!v. to be Rerrioved:
Linear Ft.
Square Ft.
List �Tcifs) of material to be removed:
H. Asbestos/Demolition Project Categories:
Notiffcation Period
Project Demolition
1. Single -Family Residence:
Fee Surcbm
A. Ll Asbestos Removal Project Only
A. Prior Notice
A. $25
B. 19 Demolition Project (with or without asbestos removal project)
B. 10 Days*
B. $50
. *(Asbestos removal can begin upon notification; demolition nwst wait 10 days)
I
Note, If the singlefamily residence is owned by oneftmily who has been or will be using the residence as their domicile, the above boxes
1A or 1B may he checked. A single-family residence does not include re�talpropert;, mMq��ily unigs, or niLved-use bulMing.
2. 7--F—Ail Other Demolitions With No Asbestos Removal Project
10 Days
$200
Friable Asbestos Projects (other than Sinple Family Residence);
Asbestos Demo
3. U �: 10 - 259 linear feet or a 48 - 159 square feet of asbestos
Prior Notice 10 Days
$150 $50
4. 13260 - 999 linear feet or - 160 - 4 999 square feet of asbestos
10 Days
$300 SIGO
5. U 1,600 - 9,999 linear feet or 5,000 - 49,999 square feet of asbestos
10 Days
$750 $250
10,000 linear feet or > 50,000 square feet of asbestos
10 Dan
$2000 S1,000 _
7. C3 Emergency ,+sbestos Project or 01t-m—ergency Demolition Project
I
Prior Notice
Twice Project Fee
I
__ASingle-Family Rf4XIcnces are exempt from emergency fee; however, property owners must -provide a
written emergency request)
I certify th info Ai ontained in this notificatiun & supplemental data is, to the best of iny knowledge, accurute & complete. Agency Use Only
03
!S9 resentin I 7—Amr1pe—, Reviewed By
Puget Sound Clean Air Agency Form No : 66-160 (Revised 3103) TS AUG 0 8 2003
DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
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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
IA'L
,,,,rrd1essVf asbestos content) involving structures with a projected roof area greater than 120 square feet (Regulation
111, Article 4). All asbestos removal and demolition notifications must be submitted to the Agency on current Agency
forms. Asbestos removal and demolition nroiects involvine materials and structures below the noti5ea-tion t—hrosb—oldare
§till subject to all other regljirements of Regulation 111. 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 m#. The returned copy will be your validated notification.
J. Dtmolltlon PIFASEIWINF Vit, W1, Walocroj""E, NHAILINGLANU.-
Contractor: V\;;;)
0i&mer/CE0:
Contractor's
Mailing Address-
Phone:
Job
Citv:
State:
ZiR..,
Fax:
GUIDELINES FOR SUBMITTING AN ASBESTOSWEMOLITION NOTIFICATION
Step 1. Check the appropriate project type in Box A. Friable asbestos includes popcorn ceiling material, sheet vinyl flooring, cement
asbcstos board siding, and duct insulation. Nonfriablc 4§be.9tos 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 D. For rruilti-strUCtUTC projects, attach supplemental sheet with a site map
Qnclude an address for each site) and a list of the type and amount of friable asbestos to be removed from each structure.
Step S. 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 die- survey to the
notification of a -c am
demolition Rroject when onlv nonfriable asbestos or no asbestos is id"tified on th -ey.
Stop 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 1, Section 8.08. If any nonfriable asbestos rnaterialb will be left in place during demolition,
check yes and list the type and quantity of material.
Step 7. Enter asbestos project infomiation in Box G. List types of friable asbestos material to be removed: surfacing material such as
popcom ceilings or plaster, sheet vinyl flooring, duct and pipe insulation, cement asbestos board siding or pipe, etc. -
Step 8. For Single-Fandly 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 10h day after the notification is teceived. Note: If the singlefamily residence is owned by onefamily who has
been or wig be using the residence as their domicile, boxes IA or 1B may be checked. A singlefamily residence does not include
rental Property, muld-famlly units, or any mUed-use building.
For Conmiercial asbestos projects (or projects that do not qualify as Single Family Residential); check the project category H2 -
6 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 I — 6 and the
applicable emergency box in H7. All emergency reguests must be accompanied by a LeLer.LpoM.1he propsMLowncr deMnstruting ft
needAo—co-nduct the lDroiect immediatelv in accordance with the-reouireme in Rep-ulation 111, Section 4. 3 (c).
Step 9. Please certify the accuracy qnd completeness of the information provided by signing the notification in Box 1.
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 fi)r 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 fbrrn*� can downloaded from the Agency web page at www.pscleanair.org.
For technical assistance contact (206) 6894058 and for administrative inquiries contact (206) 6894090.
Puget Sound Clean Air Agency Fortn No.: 66-160 (Revised 3/03) TS
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