20040491.pdfDATE RECEIVED
FPERMIT EXPIRES
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
USE PERMIT
ZONE NUMBER
JOB SUITEIAPT#
ADD A E S S
OWNER NAMEINAME OF BUSINESS
PLAT NAMEISUBDIVISION NO. L 0 T NO.
LID NO.
LID FEE $
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MAILII`jG ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
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RW Permit Required [3
Street Use Permit Roq'd [3
Inappection Requ, od [3
Sidewalk Required E3
underground
wiring fuquu.. C3
CITY ZIP
T E PHONE
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 13 NO
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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0 STREET TO EIR CLEANED OP DEBRIS
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ENGINEERING REV"ItWIRETPOW" ve LIMB DATE
0 WATER METER TO BE BiRminwn o%n
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NEW �X RESIDENTIAL PLUMBING MECH
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REMODEL MULTIFAMILY SIGN
LOT COVERAGE
ALLOWED PROPOSED
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FRONT SIDE REAR
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FRONT LIR SIDE REAR
PARKING
REQ'D PROVII ED
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IL
GRADING FENCE
REPAIR CYDS ( X FT)
REMARKS
DEMOLISH TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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CHECKED BY
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GROUP
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NUMBER OF
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NUMBER _00/
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINALINSPECTION REQ'D
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
GLAZING %
I
LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
ILI PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
A
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
-
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
W ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Landscapelnsp.
Total Amt. Due
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF 1 HIS PERMIT SHALL NOT BE
DEEMED TO MODIF`r� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee
Receipt #
1/6 Ll
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
-W ...... 6
APPLICATION APPROVAL
GIVEN IS CORRECT AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGRiE 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
Building 011icial or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF TIIE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged if) space provided.
WORKMEN'S C?
,fid%NSATION INSURANCE AND RCW 18.27.
(4251
OFFICIALS SIGN ATURE DATE
/--7 -7
SIGNATURE WNERAA AGENT)
DATE SIGNED
771-0220 RELEAS
ATTENTION E)ff 1333
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
I
71 M
ORIGINAL FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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Ageacy Case No. PUGET SOUND CLEAN AIR AGENCY Date Received
I 10 Union Stree4 Suite 500
Seattle, WA 98101-2038
wwwpscleanair.org r, I
200400434 NOTICE OF INTENT
Agency use Only
r
Proiect Tvne: 1. 13 Fri2ble Asbestos Removal 2. W Friable -Asbestos Removal Demolition 3. 11 Demolition Only
Asbestos PLAAASEPItINTCLF-Aldt. THIS WILL -87 rGUR NA7URNMAJUNGLA a&
Contractor:
. . q
Owner/CEO: PAI
W
Ailing Address:
Phone: AVIMiT
-Gmtractor
Job.No.:
-Tz-ip
ity-
State:
Fax: P01-1�
Site—
-Address* P21fKc-,1 City-, 4146yo Zip:
Site
Manager: "L7-. Loca&Wone:��W/ 2-
J - 9,> -
>tAsbestoS Surveyor No. of Date of Asbestos Was Friable Asbestos Identified? )AYes UNo
El M20 Presumed -I-Structures: ok Surver. X-2�: ��g Was Nonfriable Asbestos identified? ElYes IRNo
iERA Buildilg Certification /4VP?v' Attach a copy of the survey whenfiIable asbestos
Inspector: has not been identified.
17-Al AJ 1'% f% Exp. Date: a - _7 -,q
AHERA Survey is requLred before all demolition projects
Demolido No. of 02 U T
'n s I raining Fire (List Firc.DepQ
Informad TD 7stluctures: 2. 0 Ordered Demolition (attach co2y of Order)
Demolition Insert demolition contractor's mailingpddress on ba& Will nonfiiable asbestos be left in place during demo? U Yes No
Contractor: tc> e-- J e:(-42-�r vi, i If yes, list t3W and qty. Iff
Fri2ble Asbestos
Project Inform2tion: _
FS. Da�. ��z
0 'Pe
Corr4iletion
Date: fZe�05�
WorkDays:.M T W Th F Sa Su
Hours:
Will all friable asbestos Yes
matefials be removed? 81"110
tal Qty. to be Removed: Linear Ft.
Sq FL
ermal System Insulation: I LJ Boileff—umace Ins. ---- 0 Duct Ins.
U Pipe Ins.
Other
rfacing Mat'l: I U Fireproofing LJ Paints
LJ Plaster Ll
Textured Coatings
Odm-.
sc. Mat'l TU Cement Bd. U Cement Pipe
U Friable Flooring or Roofing Mat'l
Cd=-.
Asb;es1-6s/DiEmaffriaff 1—ro—Jec`t-Cabit6r-lesi----
Notification Period
Project Demotition
Single -Family Residence:
Fee Surchare
Asbestos Removal Project Only
A. Prior Notice
Demolition Project (with or without asbestos removal project)
B. 10 Days*
-A—M
�13. -S-5-O—)
*(Asbestos removal can begin upon nodfication; demolition must wait 10 days)
Ite. If the singlefamily residence is owned by onefamily who has been or wifl be using the residence as their domicile, the above boxes
or 1B maybe checkeit A single family residence does not include rental prope multi-famifyunitsora mixed -use building.
U All Other Demolitions With No Asbestos Removal Project
10 Days
$200
Friable Asbestos Projects (other than Single Family Residence):
Asbestos Demo
U ;-> 10 - 259 linear feet and/or 2t 48 - 159 square feet of asbestos
Prior Notice— 10 Days
$100 SIGO
U 260 - 999 linear feet and/or 160 - 4,999 square feet of asbestos
10 Days
$200 SIGO
U > 1,000 linear feet and/or >5,000 square feet of asbestos
10 Days
$750 $250
U Emergency Asbestos Project or LJ Emergency Demolition Project
Prior Notice
I I
Twice Project Fee
(Single -Family Rcsidences are exempt ftom emergency fee; however, propetty owners must provide a
written ernerg t)
Iccrtify that the informanwonc tained in this notification &suppkm=tal data is, to thcbcstof rnyknowicdgcac-curatc&cornpJetc. y Use Only
ta7t//7 sign A 4vresentinz Date R, ie�,d
t Sound Clean Air Apf-nry r-nrni Wn - fA-iAn nini% �v
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The Puget Sound Clean Air Agency requires advance notification before anyPerson commences a fiiable asbestos projec . t
involving materials equal to or greater in size dian 10 linear feet oi-`481.-sq�. feet and for all demolition projects
(regardless of asbestos content) involving structures with a projected r . 00"f"airea &eater diari 120 square feet (Regulation
Ell, Article 4). All asbestos removal and demolition notifications mtik'b'�*.'subfnitted' the Agency on current Agency
Ao
forms. Asbelos removal and demolition p Jects involving matee"nabn and structures below the notification threshold . are
still subi 6ct to all other reguirements of Re tulation 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.
I DeamUtion PfxASE PM7 CLEARLY.
Contractor.
Owner/CEO:
Mailing Address:
Phone:
Contractor's
Job #:
I!d
City:
State:
Zip:
Fax:
GUIDELINES FOR SUBMITTING AN ASBESTOMEMOLITION NOTIFICATION
Step 1. Check the appropriate project type in Box A. Friable asbestos includes p . opcom ceiling material, sheet vinyl flooring, cement
asbestos board sidino, and duct insulatiom Nonfliable asbestos is normally found in vinyl floor tiles, window putty and most roofing
materials.
3tep 2. Enter property owner iriformition in Box B.
3tep 3. Enter the asbestos contractor or property owner information, if the property owner is conducting a single-family residential
3roject, in Box C. Print clearly this is your return mailing labeL I
3tep 4. Enter the site address for all notifications in Box D. For multi -structure projects, attach supplemental sheet.witha 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.
'tep S. Check either asbestos survey or material presumed in Box E. All demolitions require that an Asbestos Hazard Emergency
tesponse Act (AHERA) asbestos survey be conducted by a certified AH'ERA building Inspector. - Attach a copy of the surygy to the
totification of a demolition project when only m—fKable asbestos or no asbestos is identified on the survey.
;tep 6. Enter the project information in Box F. and check the training fire or ordered demolition box if appropriate (a copy of the
ifficial order must be attached). All asbestos must be removed prior to conducting a training fire. Additional training fire
equirements are contained in Regulation 1, Section 8.08. If any nonfriable asbestos materials will be left in place during demolition,
heck yes and list the type and quantity of material.
;tep 7. Enter asbestos project information in Box G. List types of friable asbestos material to be removed: surfacing material such as
opcom ceilings or plaster, sheet vinyl flooring, duct and pipe insulation, cement asbestos board siding or pipe, etc.
tep 8. For Single -Family Residential projects; check BOX H1A for renovation -projects, BOX HIB for demolition projects with or,
rithout asbestos removal. Asbestos removal may be conducted after a complete notification is -received, but demolition activities can
nly begin on the 10'h day after the notification is received. Mote. If the singlefamily residence is owned bypnefamily who has
een or will be using the residence as their damicile� boxes 1A or IB may be checked A singlefamily residence does*not include
?ntal property, mufti -family units, or any mixed -use building.
or Commercial asbestos projects (or projects that do not qualify as Single Family Residential); check the project category H2 -
that matches the amount of friable asbestos that will be removed. If a demolition is involved, include the appropriate surcharge
idditional fee) in your payment. To file for an emergency asbestos or demolition project, check the appropriate box I — 5 and the
?plicable emergency box in H6. All emer en re 11-0 must be accon-manied bv a letter from the nmne.rtv num,-r th.
tep 9. Please certify the accuracy and completeness of the information provided by signing the notification in Box 1.
landatory amendments to the notification are required for changes that increase the project category, change the types of asbestos
iatcrials to be removed and changes to start date, completion date and work schedule for asbestos projects. No fee is required for
ork schedule changes if the contractor is participating in the Agency work schedule Fax program. A $25.00 processing fee is -required
,r all amendments.
iget Sound Clean Air Agency asbestos regulations and forms can downloaded from the Agency web page at w%vw.pscleanair.org.
)r technical assistance contact (206) 6894058 and for administrative inquiries contact (206) 6894090.
get Sound Clean Air Agency Forrn No.: 66-160 (Revised 9/03) TS
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RABANCO Cant #
WASTE SHIPMENT RECORD
1. Waste Generated Site Name and Address: Owner 's Name:
Owner's Phone No.:
JA 14
2. 'Operator's Natne and Acrdfes
Operator's Phone No.:
vv
3. Waste Disposal Site (WDS) Nome. Address. and Physical Site Location:
WDS Phone No.:
RABANCO REGIONAL LANDFILL
1-800-927-5641
500 Roosevelt Grade Rd.
Roosevelt. WA 99356
4. Responsible Local. State or EPA Agenc y Name and Address:
PSAPCA
I 10 Union Street
Seattle, WA 98101
5. Description of Waste Materials;
6. Containers
7.
Total Quantity
No. Type
3
M (YP)
Asbestos Containing Matedals
8. Special Handling Instructions and Additional Information:
DOUBLE BAGGED & LABELED
9. OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described
above by proper shipping name and are classified. packed. marked and labeled, and are in all respects in proper
conclition for transport by highway according to applicable international and government regulations.
Printed/Typed Nome
Signature
Month
Day
Year
10. Trartsi owledgm&nV& Receipt of Materials
Printed/Typed Name
Signature
Month
Day
Year
1, -1
-
11. Transboo�er 2 4cknowI6Zfdm6nt g(Receipt"of Moterlols�
Printed/Typed Name
Signature
Month
Day
7jor
Rabanco Transfer
2733 3rd Ave. S.
-2,
I- -�.'
7
4,
Seattle, WA 206 -646-2565
12. Discrepancy Indication Space 14-
Waste Disposal RRLC
13. Authorized Waste Disposal Site Owner or Operator: Certification of receipt of asbestos materials covered by this manifest
except as noted in item 12
Printed/Typea Nome
Signature
Month
y
Year
0
WHITE: Peturn to Operator YELLOW: Waste Site PINK: Transporter WHITE- Operator
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RABANCO RECYCLING CO.
A DIVISION OF RABANCO COMPANIES
2733 3rd Avenue South
Seattle, Washington 98134
(206) 623-4080
C/
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197 0 3.15 8
T I �.W-
TICKET NUMBER 10-5
J.
ls�) — Co -�o GHsH AcCOUNT Jo b: tl
ANTHONY
7 RUCK 01 1 VAN EDMONDS
PRODUC T AS ES I Q8
SL; A L E
0 4 11.14 1 N
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4600 L)3L5--MAi\1 W) 001
WIVI X.
R E F I) !,;I 'I k x 6 0.1 C10
4
UJOINdE
We X41 -ev DEVYN
CUSTOMER SIGNATURE 'y
Recycled I HAVE READ AND AGREE TO THE CONDITIONS 6dTHE REVERSE SIDE.
'.. _, �.i i -, 4.1 , ; ; !.... *
Agency Case No. PUGET SOUND CLEAN AIR AGENCY Received
110 Union Street� Suite 500
Seattle, WA 98101-2038
pscleamir.org
200400434 P
NOT.ICE OF R4TENT C - I V� ;,�rency vse,om.ly -
.-Proiect Tvipe: 1. El Friable Asbestos Removal 2_ M Friable Asbestos Removal Demolition 3.d-Derpolition Only
Asbestos P=.,
Contractor:
'.ailina Address:
Owner/CEO:
Phone: MINIM
M11- tau.
10�0
o.:
ity- I State: Zip: Fax: P7. iii�o_v
site__.
Addressi glog '23 5/- SA,1 _ty-!!� . �Z�Avo�s Zip:
Site
Manager: _Amqg 04 -
t7-.
?aaau -,� — I L._Mr.rte-�
4
.WAsbestos Survey Or No. of Date of Asbestos Was Friable Asbestos Identified? XYes UNo
C3 M20 Presumed Structures: Survey- Y-'- S�-e 74" Was Nonfriable Asbestos Identified? QYes IRNo
IERA Building Certification I M 10pro// Attach a copy ofthe survey whenfilable asbestos
Inspector: Tpipy,; Exp. Date: Z - _q - tv has not been identified.
AHERA Survey is required before all demolition projects
Demolidon Start No. of I. U Tramiing Fire (List Fire.D��L)
Information: Date: StrMt1res, �,p R2'. Q Ordered Demolition (attach copy of Order)
Demolition Insert demolition contractor's mailingpddreu on back- Will nonfriable asbestos be left in place during derno? U Yes Jff No
Contractor: If yes, list type and qty.
Friable Asbestos
Project Information.*
Start Date: :�,�o
'oe
Completion Date:
, Work Days: . M T W Th F Sa Su
Hours:
Will all friable asbestos Yes
materials be removed? 9"110
tal Qty. to be Removed: Linear Ft.
Square Ft.
ermal System Insulation: U13loilerkFurnaceins. Upuctins. UPipeins.
Other.
rfacing Mat'l: I U Fireproofing U Paints
0-Plaster LJ Textured Coatings
Other.
sc. Mat'l I U Cement Bd. U Cement Pipe
U Friable Flooring or Roofing Mat'l
Other
Asb;eMs/M-md1itidff 1-r—ojeEt_Calit�6rifie�;
Notiflcation Period
1 Project Demolitio-n-
Single-Fan-dly Residence:
Fee Surch
Asbestos Removal Project Only
A. Prior Notice
Demolition Project (with or without asbestos removal project)
B. 10 Days*
-A-12J
��- �110
*(Asbestos removal can begin upon notification-, demolition must wait 10 days)
Ite. If the singlefamily residence is owned by onefamily who has been or Wit be using the residence as their domicMe, the above boxes
or 1B maybe checked. A singlefamily residence does not include rental prope multi -family units, or a mixed -use budding.
LJ All Other Demolitions With No Asbestos Removal Project - ,- r- -
g A I ig� Jt9 Days
$200
Friable Asbestos Projects (other than Single Family R idenc4f, fc-- I`
'Alb9-to's- Demo
U 2t 10 - 259 linear feet and/or;-,, 48 - 159 square feet of asbestos
Pp*x Votice 10 Days
$100 $100
LJ 260 - 999 linear feet and/or 160 - 4,999 square feet of asbestos
-
10Days
$200 $100
LJ > 1,000 linear feet and/or >5,000 s�uare feet of asbestos p. .-plir-tiT
-0 —Emergency
.;FRVICIES CISDays
$750 $250
Asbestos Project or U Emergency Demolition Proje6r'__ClTy OF
f DWML)43rior Notice
Twice Project Fee
(Single -Family Residences are Cxempt from emergency roe, however, property owners must provide a
written emergency request)
n
I certify that t c info t ntained in this notification & suppkm=tal data is, to the best of nry knowledge. accurate & complete, Age y Use! Only
U
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Sig.-tyK —hepresenting Date Re viewAed B
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The Puget Sound Clean Air Agency requires advance notification before any person conimences a ftiable asbestos project
involving materials equal to or greater in size ffiari 10 linear feet of `48 :-Square ...feet and for all demolition projects
(rcgara�csi of asbestos content) involving structures with a projected ro6ia'rea &eater than 120 square feet (Regulation
111, Ax-ticle 4). All asbestos removal and demolition notifications m6t b�' . 96iiitted.to the Agency on current Agency
forms. Asbesto*s removal and demolition-proiects involving materials and"structur:es"below the notification ireshold . are
still subi&t to all other requirements of Regulation 1H, 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.
I Denwiltion
Contractor's
Mailing Address: Phone.
Job #:
city-, State: zip: Fax:
GUIDELINES FOR SUBMITTING AN ASBESTOSIDEMOLITION NOTIFICATION
Step 1. Check the appropriate project type in Box A. Friable asbestos includes popcorn ceding material, sheet vinyl flooring, cement
-isbestos board siding, and duct insulation. Nonfriablc asbestos is normally found in vinyl floor tiles, window putty and most roofing
:naterials.
3tep 2. Enter property owner informition in Box B.
3tep 3. Enter the asbestos contractor or property owner information, if the property owner is conducting a single-family residential
)roject� in Box C. Print clearly this is your return mailing labeL
3tep 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 eaclx site) and a list of the type and amount of friable asbestos to be removed from each structure.
;tep S. Check either asbestos survey or material presumed in Box E. All demolitions require that an Asbestos Hazard Emergency
tesponse Act (AHIERA) asbestos survey be conducted by a certified AHERA building Inspector. Attach a copy of the sMM to the
totification of a demolition l2roiect when only nonfriable asbestos or no asbestos is identified on the surve
;tep 6. Enter the project information in Box F. and check the training fire or ordered demolition box if appropriate (a copy of the
ifficial order nmst be attached). All asbestos must be removed prior to conducting a training fire. Additional training fire
equirements are contained in Regulation I, Section 8.08. If any nonfriable asbestos materials will be left in place during demolition,
heck yes and list the type and quantity of material.
;tep 7. Enter asbestos project information in Box G. List types of friable asbestos material to be removed: surfacing material such as
opcorn ceilings or plaster, sheet vinyl flooring, duct and pipe insulation, cement asbestos board siding or pipe, etc.
tep 8. For Single -Family Residential projects; check BOX H1A for renovation. projects, BOX H111 for demolition projects with or
tithout asbestos removal. Asbestos removal may be conducted after a complete notification is -received, but demolition activities can
aly begin on the 10'h day after the notification is received. lVote. Lf the singlefamily residence is owned by pnefamily who has
een.or wifl be using the residence as their domicfie� boxes 1A or 1B may be checked. A singlefamity residence does*not include
wal property, multi -family units, or any mbced-use building.
or Commercial asbestos projects (or projects that do not qualify as Single Family Residential); check the project category R2 -
that matches the amount of friable asbestos that will be removed. If a demolition is involved, include the appropriate surcharge
idditional fee) in your payment_ To file for an emergency asbestos or demolition projcct, check the appropriate box 1 — 5 and the
?pUcable emergency box in H6. All emergencv reauests must be accoMpanied by a letter from the prope= owner demonstrating the
-ed to conduct the proiect immediately in accordance with the requirements in Regulation a Section 4.03 (c).
tep 9. Please cer* the accuracy and completeness of the information provided by signing the notification in Box I.
landatory amendments to the notification are required for changes that increase the project category, change the types of asbestos
aterials to be removed and changes to start date, completion date and work schedule for asbestos projects. No fee is required for
ork schedule changes if the contractor is participating in the Agency work schedule fax program. A $25.00 processing fee isrequired
,r all amendments.
iget Sound Clean Air Agency asbestos regulations and forms can downloaded from the Agency web page at www-pscicanair.org.
)r technical assistance contact (206) 6894058 and for administrative inquiries contact (206) 6894090.
get Sound Clean Air Agency Fonn No.: 66-160 (Revised 9/03) TS
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RABANCO Cont-#
WASTE SHIPMENT RECORD
1. Waste Generated Site Name and Address: Owner's Nome:
(Sv�r s Phone No.:
IAI %1 1
)14 — I -
2. Operators Name an Acrdfes!s:
operator's Phone No.:
ilovQ
3. Waste Disl3osol Site (WDS) Nome. Address, and Physical Sitb-00o—tlon:
WDS Phone No.:
RABANCO REGIONAL LANDFILL
1-800-927-5641
SW Roosevelt Grade Rd.
Roosevelt, WA 99356
4. Responsible Local, State or EPA Agenc y Nome and Address:
PSAPCA
110 Union Street
Seattle, WA 98101
5. Description of Waste Materi als;
6. Containers
7. Total Quantity
No. Type
3
M (yd')
Asbestos Containing Materials
8. Special Handling Instructions and Additional Information:
DOUBLE BAGGED & LABELED
9. OPERATORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described
above by proper shipping name and are classified. packed. marked and labeled, and are in all respects In proper
condition for transport by highway according to applicable international and government regulations.
Printed/Typed Name
Signature
Month
Day
year
14
10. Transporter IAcknowIeddm&nt/cf Recei�t of Materials
Printed/Typed Name
So-ociture
Month
Day
year
L
4
Trons�oi�er 2 Pfcknowledgme"n'i qf Receipt "'of Motericilli
Printed/Typed Name
Signature
FM—ionffi-
Day
Yea r
Rabanco Transfer
Ave. S.
L-,2
2733 3rd
Seattle, WA 206-646-2565
12. Discrepancy indication Space
Waste Disposal RRLC
13. Authorized Waste Disposal Site Owner or Operator: Certification of receipt of asbestos materials covered by this manifest
except as noted in item 12
Printed/Typed Nome
Signature
onth
y
r
0
WHITE: Peturn to Operator YELLOW: WaSte Stte PINK: Tronsporter WHITE- Operotor
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RABANCO RECYCLING CO.
A DIVISION OF RABANCO COMPANIES
2733 3rdAvenue South
Seattle, Washington 98134
(206) 623-4080
TICKET NUMBER 04/;:�0/04
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I HAV E READ AND AGREE TO THE CONDITIONS 6d�HE REVERSE SIDE.
TABLE OF CONTENTS
Page
Subject
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1.0 SCOPE OF WORK
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2.0 SURVEY METHOD
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3.0 LABORATORY INFORMATION
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4.0 BUILDING DESCRIPTION
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5.0 FINDINGS
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6.0 CONCLUSIONS AND RECOMMEND ATIONS
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7.0 LIMITATION S OF SURVEY
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APPENDICES
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Sample Locations (Map)
Laboratory Results
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AHERA Certifications & Laboratory Qualifications
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9005 238th Street SW, Edmonds, WA
Project # 2004-177
1.0 SCOPE OF WORK
An investigative survey for asbestos containing materials (ACM) was conducted at a single
family residential structure and an adjacent shop/RV shelter located at 8005 238th Street SW,
Edmonds, WA.
The inspection was conducted on April 5, 2004 by John Terrill, an AHERA certified building
inspector. This inspection was performed at the request of Mr. Tony DiPangrazio, Owner.
The purpose of this inspection was to identify asbestos containing materials that would be
impacted by the planned demolition of this structure.
The asbestos survey section is written to comply with the AHERA asbestos sampling
procedure as stated in 40 CFR 763.86. This protocol is required for all asbestos surveys prior
to a building demolition under the Puget Sound Clean Air Agency, (PSCAA), Regulation I 11,
Article IV, revised July 13, 2000.
The asbestos survey also satisfies the "Good Faith" asbestos inspection requirements as
stated in Washington Administrative Code (WAC) 296-62-07221(2), "identification". As stated
in this regulation, the owner of a structure scheduled to be renovation/demolished must provide
a contractor with a written report of the asbestos containing materials to be disturbed during
renovation/demolition.
The National Emission Standards for Hazardous Air Pollutants (NESHAP), 40 CFR Part 61
requires a survey by an accredited asbestos inspector prior to demolition of a structure.
A floor sketch indicating sampling locations has been included In Appendix A.
NVL Laboratories, Inc., Page 1
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
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8005 238th Street SW, Edmonds, WA
Project # 2004-177
2.0 SURVEY METHOD
Asbestos Survey Method
A walk-through inspection of all accessible areas of this structure was performed to identify
inspection included a review of the
Ing materials. The walk-through
potential asbestos -contain locations. and types of potential asbestos
The
internal and external aspects of this structure. r tile,
noted. Sufficient bulk samples of building materials (vinyl floO
containing materials were of the
to satisfy the requirements
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were obtained of each material
roofing, wall materials, etc. ples
Act (AHERA) rules and regulations. These sam
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Asbestos Hazard Emerg ency Response
Into plastic sample bags, numbered and recorded.
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were placed
Homogeneous Materials
Homogeneous materials are defined as an area of Asbestos -Containing Ma terial (ACM) or
appears similar throughout in terms of
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bestos-Containing Materi al (PACM) which
Presumed As g for homogenous materials will
date of material a pplicabon. The report listin
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color, texture, and
appear as follows:
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Location Asbestos Area Friable
Sample Material fe es/no
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Number Descri tion
.ob#-01-01 whitefloortile kitchen
tile kitchen
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suspect
Under OSHA Guidelines, a minimum of three negative analysis of a single rfacing
a negative result for su
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homogeneous asbestos containing material is required to pro ve
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materials and thermal sy stem insulation.
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NVL Laboratories, Inc., Page 2
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 Fx (206) 634-1936
.11., M
E, -
8005 238th Street SW, Edmonds, WA
Project # 2004-177
3.0 LABORATORY INFORMATION
Laboratory Analysis — Asbestos
Samples are analyzed in our laboratory using polarized light microscopy (PLM) with dispersion
staining. If samples are not homogeneous, then subsamples of the components were analyzed
separately. All Bulk samples are analyzed using EPA Method 600/R-93/116 with the following
measurement uncertainties for reported % Asbestos (I %=0-3%, 5%=>l -9%, 1 0%=5-15%,
20%=10-30%, 50%=40-60%). For samples containing more than one separable layer of
materials, the report will include findings for each layer (labeled Layer: 1, Layer: 2, etc.). The
asbestos concentration in the sample is determined by visual estimation.
Laboratory Accreditation
Professional accreditations for NVL Laboratories, Inc., include the following:
NVL Laboratories, Inc., is currently accredited by the National Institute of Standards and
Technology (NIST) under the National Volunteer Laboratory Accreditation Program (NVLAP)
program for bulk asbestos fiber analysis. NVLAP Lab Code 102063-0.
NVL Laboratories, Inc., Is approved by the American Industrial Hygiene Association (AIHA)
Asbestos Analysts Registry (AAR) program for airborne asbestos fiber analysis, Counter ID
7412.
NVL Laboratories, Inc., is currently accredited by the American Industrial Hygiene Association
(AIHA) under the Industrial Hygiene Laboratory Accreditation Program (IHLAP). The IHLAP
program is designed specifically for laboratories involved in analyzing samples to evaluate
workplace exposure. Certification Number 563.
NVL Laboratories, Inc.,
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
Page 3
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8005 238th Street SW, Edmonds, WA
Project # 2004-177
4.0 BUILDING DESCRIPTION
General Building type:
This property is a two level, wood framed residential structure with an adjacent shop/RV
shelter.
Primary external components:
The primary external components on the house ate wood siding. The exterior of the shop is
metal siding.
Type of foundation:
-grade concrete
The house rests on a full, below grade, concrete basement. The shop is an on
slab.
Roofing materials:
Roofing is asphalt shingles over roofing felt on the house and metal on the shop.
Window types:
Windows are wood framed and utilize glazing compounds.
Flooring:
Flooring is primarily bare wood under carpeting, There is sheet vinyl in the bathrooms and
kitchen and linoleum in the wet room and closet on the second level.
Thermal systems w/insulation types:
The heating system is a forced air furnace without suspect thermal insulation. No suspect
thermal insulation was noted on the water heater.
Finishing:
Interior finishing on walls, lids, and partitions is plaster and/or gypsum wall board. There are
some ceiling tiles in the west room on the second level.
NVL Laboratories, Inc.,
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
Page 4
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.8005 238th Street SW, Edmonds, WA
Project # 2004-177
5.0 FINDINGS
Inventory of Suspect Asbestos -Containing Materials
Sample
Material
Location
Asbestos
Area
Friable ?
Number
Description
(ft2)
(ves/no)
2004-177
1: blue/white sheet
upstairs bathroom
1: ND
-1-1
vinyl
2: gray felt
2: ND
backing/mastic
3: gray felt
3: ND
4: black felt
4: ND
2004-177
12" x 12" ceiling
stapled on -in upstairs west
ND
-2-1
tile
room
2004-177
1: brown sheet
kitchen flooring
1: ND
-3-1
vinyl
2: gray felt
2: ND
backing/mastic
3: beige sheet vinyl
3: ND
4: gray felt backing
4: ND
with mastic
5: particle board
5: ND
2004-177
1: brown linoleum
residual piece in closet of
1: ND
-4-1
2: black felt
west room on second level
2: ND
backing
2004-177
1: brown sheet
on floor by furnace
1: Nb
-5-1
vinyl
2: grey felt backing
2: 45
10
yes
2004-177
1: mortar
chimney, basement
1: ND
-6-1
2: gray flue sealant
2: ND
3: tan flue sealant
3: ND
4: brick
4: ND
2004-177
1: ceramic tile
main bathroom
1: ND
-7-1
2: mastic
2: ND
3: plaster
3: ND
4: grout
4: ND
5: caulk
5: ND
2004-177
1: gray sheet vinyl
flooring in main bath
1: ND
-8-1
2: gray felt
2: ND
backing/mastic
3: tan sheet vinyl
3: ND
4: tan felt
4: ND
backing/mastic
5: tan linoleum
5: ND
6: black felt
6: ND
backing/masbc
ND - None Detected
NVL Laboratories, Inc.,
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
Page 5
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8005 238th Street SW, Edmonds, WA
Project # 2004-177
Asbestos - continued
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ND - None Detected
Any suspect material(s) not identified above should not bp disturbed, and tested immediately.
The suspect material must be treated as asbestos conta(6,ing until testing proves otherwise.
Page
NVI- Laboratories, Inc.,
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
-8005 238th Street SW, Edmonds, WA
Project # 2004-177
6.0 CONCLUSIONS AND RECOMMENDATIONS
ASBESTOS
-Containing Materials (ACM) and
The following summarizes the homogeneous Asbestos I
Presumed Asbestos -Containing Materials (PACM) identified at a single fami y residential
structure and shop/RV shelter located at 8005 238th Street SW, Edmonds, WA on April 5,
2004.
1. Vinyl flooring: (material number 2004-177-5)
-containing felt backing on the
There is approximately 10 ff of brown sheet vinyl with asbestos
basement floor by the fumace.
No suspect Asbestos -Containing Materials (ACM) or Presumed Asbestos -Containing Materials
(PACM) were noted associated with the shop/RV shelter.
If discovered, all ACMs that will be disturbed as a natural part of renovation/demolition and are
required to be removed and disposed of in accordance with Washington State Regulations.
Washington State Department of Labor and Industries and PSCAA require that the abatement
be performed using Certified Asbestos Workers under the direct on -site supervision of a
Certified Asbestos Supervisor. Further, NVL suggests that an AHERA inspector review this
property after abatement to ensure all ACM has been removed by the contractor. ..
Hidden wall and ceiling cavities that are not accessible during the time of surveying can
sometimes conceal ACM, Thus, NVL recommends that an AHERA inspector/project manager
be on site at the time of renovation/demolition to ensure that any potentially asbestos -
containing materials uncovered during the process of renovation/demolition be dealt with
properly.
NVL Laboratories, Inc., Page7
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 - Fx (206) 634-1936
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C1005 238th Street SW, Edmonds, WA
Project # 2004-177
7.0 LIMITATIONS OF SURVEY
The sole purpose of this survey report is to document asbestos -containing materials
discovered in the survey of suspect materials by NVL Laboratories personnel at a single family
residential structure and shop/RV shelter located at 8005 238th Street SW, Edmonds, WA.
This survey was performed on April 5, 2004.
This site visit consisted of a thorough visual walk-th ' rough of the building for the purpose of
viewing and sampling potential ACMs. As hazardous material surveys are non -comprehensive
by nature, NVL Laboratories, Inc., cannot be held liable for materials which require destructive
means to access, materials which are hidden from sight (e.g. materials hidden behind walls),
materials which cannot be found due ' to their bbscure nature, or which otherwise cannot be
discovered with reasonable diligence.
This document is the sole property of NVL Laboratories an d the property owner, or his agent,
authorizing this survey.
Inspected by: Reviewed by:
Paul W. Jackson
John Terrill Project Manager
AHERA Building Inspector
AHERA Certification No.: 1007611
AHERA Certification Expires on: February 3, 2005
NVIL Laboratories, Inc.,
4708 Aurora Avenue North, Seattle, WA 98103
Ph (206) 547-0100 . Fx (206) 634-1936
Page 13
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FINAL PR03ECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLPASESIGN
ENGINEERING DIVISION DATE A;' 2,jZ
PLANNING DIVISION DATE I
PROJECT
SITE ADI
PERMIT A ADBrr DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED AQi,,,-7,-,
A field inspection was conducted to determine compliance with -approved plans. Final approval
denotes that there are no objections from the above signed Department to tile release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GIANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
93
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:tem13:b1dg:fomis:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall...........................
Pier/Porch ..................
Retaining Wall.....
Slab Insulation ..........
PLUMBING:
Underground .............
,Rough -In ...................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
—7
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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