20140116112029951.pdfApproved Transaction
https:Hsecure.pscleanair.org/Asbestos/Approved.aspx
psolean air.org
PtagPt Sound QNn fair Agency
This page must be printed. A printout of the notification, all amendments to the notification, and the asbestos survey shall be available for
inspection at all times at the asbestos project or demolition site (Reg III, 4.03(a)(6)).
Fee Amount Paid $65.00
Credit Card Transaction # VUJFB57EA425
Transaction Date
01/13/14
Owner's Name
Steven Andersen
Project Street Address 1114 A Avenue South
City
Edmonds
Contact Person
Steve Andersen
Mailing Address
3405 172nd Street PIE #S-161
Arlington, WA 98223
Phone (206) 972-1967
Zip 98020
Phone (206) 972-1967
This project includes a demolition.
Demolition Start Date 01/23/14 Completion Date 02/28/14
Demolition will be completed by a demolition contractor
Demo Contractor Property Owner Contractor Job #
Contact Phone
Mailing Address
(1) I certify that the information I have provided is to the best of my knowledge true and accurate.
(2) I understand that I must file an Amendment to this Notification if:
® The type of project has changed. The project types are asbestos and demolition.
® The quantity of friable asbestos to be removed meets a larger project category.
® The projects start or completion date has changed.
(3) I understand one Notification must be filed for each structure. The only exception is for
a single-family residence that includes multiple ancillary structures, such as a detached
garage or other outbuildings having the same street address. If there is no street address, I
have used a building number.
(4) I understand the fees for this Notification are nonrefundable.
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If you have questions, contact us at asbestos@pscleanair.org or 206.689.4058.
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