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HomeMy WebLinkAbout1225 W Lauridsen Blvd - Building HOUSE MOVING APPLICATION and PERMIT CITY OF PORT ANGELES BUILDING DIVISION °-- SECTION 14 32 030 PAMC PERMIT NO The following materials are hereby provided in application for a House Move Permit: 1 Name of applicant: NvOnz, IZQVOIZ149 2 Address of Applicant: )00. &x 6d. 6) 3 Telephone of Applicant: �6a 77q-- L--,COC Date of proposed move and duration 4 Name of insurance company and agent and copy of certificate of insurance een Z — MC.ci ulk-,c 5 Original location (address) of building ZA2 P1 e-r-6 EInSeoolm WA Legal description of original location of building ' ,W I / f0 O,U� 6 New proposed location of building `2 L�=L"' C l l/ rt d U42, 6 " -A Legal description of new proposed location of building E 2 LID I� `�A( Lr)1 « « t�l pCk 7 Route to be taken from old location to new location EYDuI f, �, �Yy GI[ y� T ©Lp U� 8 Description of current building. 1,V0ZIP PJ2444 0 0 X ��2 9 Written confirmation that the following have been contacted including individual's name, telephone and date AGENCY CONTACT PERSON DATE PHONE NO Police Department -1— 0 Fire Department z 31.1 C y Z o6 "tt 1 —4 b a33 Public Works Engineering for Signals,Water,Seweriml —� d Building Division ►� 1151ZL 240 YO —M City Light Department t! QWest Communications Le Wave Broadband Telecable LelqL c9 S2 State Dept.of Trans. gad, 4(��y 7r�- L 317 CPI(Fiber Optics) L1 }'-'l� J I hereby acknowledge that I am responsible for injuries,damages,and any expenses incurred by the City or other agencies during the moving of this structure and that the structure is to be restored to minimum Building Code requirements at its new location and ready for use within one(1)year from the date of moving the structure. In consideration of the granting of this permit, it is further agreed by the applicant that the City of Port Angeles and any of its officers or employees shall be saved harmless to the applicant from any liability or responsibility for any accident,loss or damage to persons or property happening or occurring as the proximate result of any work undertaken under the terms of this application and the permit or permits which may be granted in respons hereto and that all of said liabilities are hereby assumed by the applicant. Signature Date *OFFICIAL USE ONLY Date move took place: Treasurer's Receipt No. Bldg. Permit# Right of Way Constr Permit# Damage and or incidents en route and comments: Original Site Restoration completed: Date ok for occupancy* Refund Date. Refund Amount:$ Check No. APPROVED BY BUILDING INSPECTOR: DATE. BL 1105_02 [9/04] SECTION 11 12.050 PAMC } PORT NGELE,S - RIGHT,OP 1NAY.USE W A S H I N G T O N U S A PERMIT NAME OF APPLICANT DATE MAILING ADDRESS PHONE NUMBER STREET ADDRESS OF PROPOSED STREET USE DESCRIPTION OF REQUEST(include drawings required for clarity) [If street closure is requested please state the name of the street and limits of closure together with the duration of closure IS THE USE TEMPORARY OR PERMANENT? HOW LONG WILL THE OBSTRUCTION BE IN PLACE? W HAT ARE THE HOURS OF OPERATION? HOW IT WILL BE LIGHTED? EXPLAIN THE NECESSITY TO USE THE PUBLIC STREET SIDEWALK OR PLANTING STRIP ARE THERE ALTERNATE AREAS THAT COULD BE USED? HOLD HARMLESS and INDEMNIFICATION AGREEMENT In compliance with the Port Angeles Municipal Code and inconsideration of the issuance by the City of Port Angeles of a Right Of Way Use Permit to the undersigned allowing the placement of the above described street use or obstruction the undersigned for his or herself and for his or her successors in interest,hereby agrees to indemnify hold harmless,and defend the City of Port Angeles against any claims or lawsuits for personal injury or property damage arising out of or in any way connected with the placement of the use or obstruction on the City street, sidewalk, planting strip or right f way DATED this day of 200 Applicant Seal SUBSCRIBED and sworn to before me this day of 200 NOTARY PUBLIC in and for the State of Washington residing at (This permit,if approved,may be terminated by the City of Port Angeles without cause and at any time) [OFFICE USE ONLY] Review copies Date application received Fee paid $ Receipt# sent to: Certificate of Insurance per PAMC 11 12 140(B) Agreement to Remove Encroachment signed and Police on N/A recorded on N/A Fire Application reviewed and recommendation by City Engineer Date is to deny or approve and with the following conditions Application approved or denied by the Director of Public Works Date Approved copies to: Applicant O Fire O Police O Street O Other O Address file O RUP file O RU P # C:\WINNT\Profiles\dyasumur\Personal\RIGHT OF WAY USE APPL Ale T B FOR OFFICIAL USE ONLY BUILDING PERMIT - APPLICATION Date Rec. Perin it#• Fill out COMPLETELY and in INK.Your application and site plan MUST BE Date Approved: COMPLETE to be accepted for review If you have any questions,call Date Issued: PERMITS(360)4174815 F,eAX(360)4174711 Applicant-or Agent: Phone: Q-6aLbhon Owner NO -1� C�Ic�rM— ICS [DYl c31 UStViGiIUeO Q:S QJ 2 Address. 7aJS (!'(/Q 11 CL S City. Zip Architect/Engineer Phone: Contractor State License# Exp* Phone: Address: Cit}'' Zip PROJECT ADDRESALot: ZONING.d1-15LEGAL DESCRIPTIO 5 iBl Block: S`� Subdivision. CLALLAM COUNTY PARCEL NUMBER. TYPE OF WORK. SIZE/VALUATION >CResidential ❑ New Constr. ❑ Re-roof ❑ Stove -7 SD SF @$ /SF =$ ❑ Multi-family 'pL Addition )SC Move❑ Garage _:LSO SF @$ /SF =$ ❑ Commercial 5k Remodel ❑ Demolition ❑ Deck qy SF @$ /SF =$ ❑ Repair ❑ Sign ❑ Other TOTAL VALUATION $—X0 .160 0C) BRIEF DE CRIPTION OF THE PROJECT 4D 1 '5t Elo r Ct�Gl COMMERCIAL/RESIDENTIAL. Occupancy Group: Occupant Load. Construction Type: No.of Stories: Lot Size: D 00 Existing Sq.Ft. ��� &Proposed Sq.Ft-7 �`� 6=TOTAL Sq. Total lot coverage APPROVALS: PLANNING USE ONLY PLAN BLDG: DPWU FIRE. ESA/Wetland(s): ❑Yes❑No SEPA Checklist required?❑ Yes❑ No Other- OTHER. VALUATION OF CONSTRUCTION In all cases,a valuation amount must be entered by the applicant. This figure will be reviewed and may be revised by the Building Division to comply with current fee schedules. Contact the Permit Coordinator at 417-4815 for assistance. fee is due it must be submitted at the time the building permit application and construction plans are PLAN CHECK FEE.IF a plan check submitted. All other permit fees are due at the time of permit issuance. EXPIRATION OF PLAN REVIEW If no permit is issued within 180 days of the date of application,the application will expire. The Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant(see Section R105.3.2 of the International Building/Residential Code,2003). No application can be extended more than once. I hereby certify that I have read and examined this application and know the same to be true and correct. I am authorized to apply for this permit and understand that it is my responsibility to determine what permits are required,not the City's, and that I must obtain such permits prior to work. T•\FORMS\131dgPermitApp1.wpd Applicant: Date: — . 1 '' J .'�'. .tF:iifs�{S{F,�..�,•_ \\ � �. A' r - '�-mgt{- Y R M•'�' C Fr ♦ \ a r4. '�'cltrr, . a te -j'•. ^:Y;�.. .4brr � �' ,tom•4 z I PYY r r :� , Application Number 08 00000515 Date 5/06/08 Application pin number 792765 Property Address 1225 W LAURIDSEN BLVD ASSESSOR PARCEL NUMBER 06 30 00 0 4 5885 0000 Application type description ELECTRICAL ONLY Subdivision Name Property Use Property Zoning RS7 RESDNTL SINGLE FAMILY Application valuation 0 Application desc New Home Owner Contractor HOMEWARD BOUND ELECTRIC SERVICE t� 1225 W LAURIDSEN BLVD 82 DRAPER RD )� PORT ANGELES WA 98363 PORT ANGELES WA 98362 N (360) 452 6424 Permit ELECTRICAL NEW RESIDENTIAL Additional desc Permit pin number 125765 Permit Fee 113 00 Plan Check Fee 00 Issue Date 5/06/08 Valuation 0 Expiration Date 11/02/08 Qty Unit Charge Per Extension 1 00 69 0000 ECH EL-R SQFT FIRST 1300 69 00 2 00 22 0000 5C EL R SQFT ADDITIONAL 500 44 00 Fee summary Charged Paid Credited Due Permit Fee Total 113 00 113 00 00 00 Plan Check Total 00 00 00 00 Grand Total 113 00 113 00 00 00 r INSPECTION ELECTRICAL TYPE DATE RESULTS INSPECTOR DITCH SERVICE 60 Z A4- ROUGH - IN 6-le--) � FINAL COMMENTS: Application Number 08 00000272 Date 3/04/08 Application pin number 264704 Property Address 1225 W LAURIDSEN BLVD ASSESSOR PARCEL NUMBER 06 30 00 0 4 5885 0000 Application type description ELECTRICAL ONLY Subdivision Name Property Use Property Zoning RS7 RESDNTL SINGLE FAMILY Application valuation 0 Owner Contractor HOMEWARD BOUND ELECTRIC SERVICE 1225 W LAURIDSEN BLVD 82 DRAPER RD PORT ANGELES WA 98363 PORT ANGELES WA 98362 (360) 452 6424 Permit ELECTRICAL TEMPORARY SERVICE S� Additional desc EL SVC/ TEMP SVC Permit pin number 122028 Permit Fee 40 00 Plan Check Fee 00 Issue Date 3/04/08 Valuation 0 r Expiration Date 8/31/08 I Qty Unit Charge Per Extension BASE FEE 00 1 00 40 0000 ECH EL TEMP SRV 0 60 SRV FDR 40 00 Fee summary Charged Paid Credited Due Permit Fee Total 40 00 40 00 00 00 Plan Check Total 00 00 00 00 Grand Total 40 00 40 00 00 00 C G SPECTION ELECTRICAL TYPE DATE. RESULTS INSPECTOR DITCH SERVICE slog � - ROUGH - IN FINAL 31x1 � COMMENTS : CITY OF PORT ANGELES PUBLIC WORKS UTILITIES DIVISION 321 EAST 5TH STREET PORT ANGELES,WA 98362 Application Number 06 00001038 Date 9/21/06 Application pin number 413634 Property Address 1?—?-S 12 LAURIDSEN BLVD ASSESSOR PARCEL NUMBER 06 30 00 0 4 5885 0000 Tenant nbr name NORTH OLYMPIC HSG Application type description MOVING PERMIT Subdivision Name Property Use Property Zoning RS7 RESDNTL SINGLE FAMILY Application valuation 12000 Owner Contractor JONES BRENT / RANDI MONROE HOUSE MOVING INC 1028 W 13TH ST PO BOX 686 PORT ANGELES WA 98363 QUILICENE WA 98376 (360) 765 3917 Permit M MOVING PERMIT Additional desc Permit pin number 87411 Permit Fee 130 00 Plan Check Fee 00 Issue Date 9/21/06 Valuation 0 Expiration Date 3/20/07 Qty Unit Charge Per Extension BASE FEE 130 00 Fee summary Charged Paid Credited Due Permit Fee Total 130 00 130 00 00 00 Plan Check Total 00 00 00 00 Grand Total 130 00 130 00 00 00 Separate Permits are required for electrical work,SEPA,Shoreline,ESA,utilities,private and public improvements.This permit becomes null and void if work or construction authorized is not commenced within 180 days,if construction or work is suspended or abandoned for a period of 180 days after the work as commenced,or if required inspections have not been requested within 180 days from the last inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction. Signa re of contractor or Authorized Agent Date Signature of Owner(if owner is builder) Date T-ft icier\1102.15R[1105] PERMIT INSPECTION RECORD CALL 417-4807 FOR UTILITY INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT INA CONSPICUOUS LOCATION. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE INSPECTION TYPE DATE ACCEPTED COMMENTS YES NO PW UTILITIES (Engineering Division) WATERLINE/METER Q SEWER CONNECTION SANITARY STORM SITE DRAINAGE �} SITE EROSION CONTROL PARKING SIDEWALK CURB&GUTTER DRIVEWAY APPROACH BACK-FLOW DEVICE Iv N FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO CONSTRUCTION RW/PW/ CONSTRUCTION R.W ENGINEERING 417-4807 PW/ENGINEERING FIRE 417-4653 FIRE DEPT N PLANNING DEPT 4174750 PLANNING DEPT �\ BUILDING 4174815 BUILDING T•\Policies\l 102.15R[1/051 y,*pOR� CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY DEVELOPMENT BUILDING DIVISION 321 EAST STH STREET PORT ANGELES,WA 98362 Application Number 06 00000062 Date 1/20/06 Application pin number 216556 Q Property Address 12.� LAURIDSEN BLVD Izzs NI �QVY'�clSet-t IJ'�� ASSESSOR PARCEL NUMBER 06 30 00 0 4 5885 0000 Tenant nbr name BRENT JONES Application type description DEMOLITION �C[ Subdivision Name OZ/1508 Property Use Property Zoning RS7 RESDNTL SINGLE FAMILY S� Royer'Vess 1 let-kr Application valuation 500 Owner Contractor JONES BRENT / RANDI OWNER 1028 W 13TH ST ` PORT ANGELES WA 98363 ,v Permit DEMOLITION _1 Additional desc Permit pin number 69203 Permit Fee 47 00 Plan Check Fee 00 Issue Date 1/20/06 Valuation 0 Expiration Date 7/19/06 Qty Unit Charge Per Extension -� BASE FEE 47 00 Fee summary Charged Paid Credited Due Permit Fee Total 47 00 47 00 00 00 Plan Check Total 00 00 00 00 Grand Total 47 00 47 00 00 00 p Off, Separate Permits are required for electrical work,SEPA,Shoreline,ESA,utilities private and public improvements.This permit becomes null and void if work or construction authorized is not commenced within 180 days,if construction or work is suspended or abandoned for a period of 180 days after the work as commenced,or if required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction. / Zo� Signature of Contractor or Authorized Agent Date Signat of Owner(if owner is builder) Date T•\Policies\1102_15 building permit inspection record05.wpd[1/4/2005] r BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS.CALL 417-4735 FOR ELECTRICAL INSPECTIONS. CALL 417-4807 FOR PUBLIC WORKS UTILITIES PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER,INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT INA CONSPICUOUS LOCATION KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE. INSPECTION TYPE DATE ACCEPTED COMMENTS YES NO FOUNDATION- FOOTINGS WALLS FOUNDATION DRAINAGE/DOWN SPOUTS PIERS POST HOLES(POLE BLDGS.) PLUMBING UNDERFLOOR/SLAB ROUGH-IN WATER LINE(METER TO BLDG) GAS LINE FINAL DATE ACCEPTED BY. BACK FLOW/WATER AIR SEAL WALLS CEILING FRAMING JOISTS/ GIRDERS SHEAR WALL/HOLD DOWNS WALLS/ROOF/CEILING DRYWALL(INTERIOR BRACED PANEL ONLY) T-BAR INSULATION SLAB WALL/FLOOR/CEILING MECHANICAL HEAT PUMP/FURNACE/DUCTS GAS LINE WOOD STOVE/PELLET/CHIMNEY FINAL DATE ACCEPTED BY. COMMERCIAL HOOD/ DUCTS MANUFACTURED HOMES FOOTING/SLAB BLOCKING&HOLD DOWNS SKIRTING PLANNING DEPT SEPARATE PERMIT#'s SEPA. PARKING/LIGHTING ESA. LANDSCAPING SHORELINE. FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO ELECTRICAL LIGHT DEPT 417-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION RW /PW/ CONSTRUCTION R.W ENGINEERING 417-4807 PW/ENGINEERING FIRE 417-4653 A jFIRE DEPT PLANNING DEPT 417-4750 I�/H 199 PLANNING DEPT BUILDING 417-4815 /M BUILDING T•\Policies\I 102_15 building permit inspection record05.wpd[1 4/2005] ,v0, r FOR OFFICIA US ONLY r, 1Zo O(G Date Rec. BUILDING PERMIT - APPLICATION Perm it N. 'OGZ Date Approved: 0 Fill out COMPLETELY and in INK.Your application and site plan MUST BE Date Issued:( �(o COMPLETE to be accepted for review If you have any questions,call PERMITS(360)417-4815 FAX(360)417-4711 Applicant or Agent:R V-f-Z -C' 6 f1 QS Phone. 7-.7$ - O 7:7 59 Owner- a 14 Phone- N 1 .4 Address. )0�$ Iwy. 13 ` S'�'. City ?pr�y4n sp-�C l zip Q'S 3 6 3 Architect/Engineer-_ N 114 Phone: Contractor M A- State License# Exp Phone: Address City- Zip PROJECT ADDRESS We-S g-"v- C1e*1) 'fid o►aG( ZONING 1Z.S ?- LEGAL DESCRIPTION Lot:JS Ifo ± 17 Block: 468 Subdivision CLALLAM COUNTY PARCEL NUMBER. 06 B0000 y 5 88:5 Credit Card Holder Name- Billing Address: Credit Card Type VISA MC # TYPE OF WORK. SIZE/VALUATION ❑ Residential ❑ New Constr ❑ Re-roof ❑. Stove SF @ $ /SF =$ ❑ Multi-family ❑ Addition ❑ Move❑ Garage SF @S /SF =$ ❑ Commercial ❑ Remodel )<Demolition ❑ Deck SF @ $ /SF =$ ❑ Repair ❑ Sign ❑ Other TOTAL VALUATION $ BRIEF DESCRIPTION OF THE PROJECT cif-Mn tsh CAV-y-f y1+ b"LN&i Y%% s CAC&r oke COMMERCIAL/RESIDENTIAL. OccupancyGroup- Occupant Load. Construction Type: No.of Stories:_ Lot Size- Existing Sq Ft. &Proposed Sq Ft. =TOTAL Sq Ft. Total lot coverage PLANNING USE ONLY APPROVALS: PLAN BLDG DPW U ESA/Wetland(s): ❑ Yes❑No SEPA Checklist required?❑ Yes❑ No Other- FIRE OTHER. VALUATION OF CONSTRUCTION In all cases,a valuation amount must be entered by the applicant. This figure will be reviewed and may be revised by the Building Division to comply with current fee schedules. Contact the Permit Coordinator at 417-4815 for assistance. PLAN CHECK FEE IF a plan check fee is due it must be submitted at the time the building permit application and construction plans are submitted. All other permit fees are due at the time of permit issuance. EXPIRATION OF PLAN REVIEW If no permit is issued within 180 days of the date of application,the application will expire. The Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant(see Section R105.3.2 of the International Building/Residential Code,2003) No application can be extended more than once. 1 hereby certify that I have read and examined this application and know the same to be true and correct. I am authorized to apply for this permit and understand that it is my responsibility to determine what permits are required,not the City's, and that I must obtain such permits prior to work. Applican __ Dater Northwest Asbestos Consultants 406 Reed St. Port Townsend, WA 98368 360-385-0584 northwestasbestosconsultants@cablespeed.com Date:, 12/20/05 Job Location, 1229 Lauridson St. Port Angeles, WA 98362 Owner: Brent Jones 1028 W 13th St. Port Angeles, WA 98363 Subject: Demolition Inspector- Bob Witheridge AHERA - Building inspector / Management Planner WAMOA - 0042-05 Expires - 10/12/06 .P ORT NGELES WAS H I N GTON, U S A. PUBLIC WORKS & UTILITIES DEPARTMENT January l(,2006 N!k '� f.ti1J.rSa Brent Jones 1028 West 13"'Street Port Angeles, WA 98363 • " fir:. RE. Port Angeles Landfill Waste Disposal Application,WDA 05-42 Building demolition g sP PP W at 1229 West Lauridsen Blvd �'!�$'-'C� a�'i tiff• ¢ X We have received your application for disposal of building demolition debris from the referenced � s ,,, site and.rev>.ewed the testing results for lead asbestos content. Based on the testing results the N debris appears to be acceptable for use in the landfill. A copy of your approved application is attached. This approved application must be shown to the landfill scale attendant at the time of disposal. N, Please be advised that this disposal application is only for the materials and quantities listed in ` the application. Materials not listed or in excess of the quantities noted may require separate Sr applications and approval. << Please call if you have questions. 11 S ~k: Very truly yours, V) V AS "4 Gary W Kenworthy,P.E. 5 "= City Engineer ,<n Deputy Director of Engineering Services Q ry GWK:tf ~ Encl. WDA 0542 copy: Ken Loghry N:\PWKS\ENGINEER\WDAPPUC\05-42WPD FILE:landfill Solid Waste Disposal Applications :f 321 EAST FIFTH STREET • P O BOX 1 150 • PORT ANGELES WA 98362-0217 PHONE 360-417 4805 0 FAX 360-417 4542 0 TTY 360-417 4645 E MAIL publicworks@cityofpa us t , �0F poAT,��C PORT ANGEI,rS LANDFILL WASTE DISPOSAL APPLICATION To City of Pori Angeles City Engineer 321 E Fifth Street Phone (360) 417-4803 P O Box 1150 FAX. (360) 417-4709 Port Angeles, Washington 98362 NOTE. All questions must be answered for waste to be approved. 1 Generator Information Company Name. III tS Mailing Address w �3 7F wo Contact: ,�,ii7 i�tics Phone • Project Name: Project Location. 2, 2. Other Contacts (if applicable) Consulting Firm 2S�chC- Adryoc C Contact. -r�ncY dr Phone Contractor Name , Contact. Phone �-- Laboratory- Contact � Phone -olOo City of fort Anirlos Lrcncl/ill W,cslo Disposal Application I .iflci t 3 Source of Waste _--- _ Check the appropriate box below and briefly describe the project Process n will or has produced the waste requiring disposal Include the gasoline service stationand/or-cleanup (if applicable) number CERCLA/MTCA Remediation Agency Contact. Independent Remedial Action UST Removal Unused Chemical Product Spill _ Other Source 4 Waste Material Composition. (check all that apply and Include percent of total) Soil — % Foundry Slag Concrete/Asphalt - Dredge Sediments Preserved Wood Debris Coal Ash % Other(list) Wood Ash NOTE. Total must a ual l00% % 5 Waste Material Contaminants (check elf that apply) Gasoline Solvents Metals Diesel Healing Oil PCBs Unused Motor Oil Used Motor Oil/Waste Oil Other � 'O Jaz.C�c�o !�� C�CcP Ls.e� A "`-1 Other Petroleum Product Unknown ' NOTE Supply any MSDS information with application if available Cily of Puff Angelos Landfill Waslo Disposal Applu.ation 6 Estimated quantity of Waste for Disposal Cubic yards /------- 3C _ Tons (estimate both) Drums / Other Tons (estimate both) NOTE. Estimated quantity for disposal must be within 20% of the quantity actually dis os (10% for projects over 7,500 tons or 5,000 cubic yards ) P ed 7 Frequency of Disposal. One time Monthly Annual Other 8 Waste Sampling Proper characterization of the waste for disposal requires the collection of representative samples The methods and equipment necessary for obtaining representative samples of a waste, and the frequency of sampling will vary with the type and form of the waste. Check the appropriate box and briefly describe how and where the waste wassampled. Include site maps with sampling locations If possible p • Number of COMPOSITE samples -L_& number of discrete samples per composite Number of DISCRETE samples -:5- NOTE 1 Unless prior approval has been granted by Port Angeles the following sampling frequency will be used plin g 0 - 25 cubic yards = 25 - 10o 1 composite sample cubic yards = 3 composite samples 101 500 cubic yards = 5 composite samples 501 1000 cubic yards = 1001 2000 cubic yards = 7 composite samples 10 composite samples >2000 cubic yards = 10 plus one sample for each additional 500 cubic yards NOTE 2 One composite sample shall contain a minimum of three/maximum of five discrete samples City of Pori Angelos landfill Waste Dispc�st�l Ahl�lict�lion Page 3 9 Waste Analysis The Dangerous Waste Regulations" (WAC 173.303) shall be utilized to determine appropriate analytical requirements for waste characterization. Ecology Publication #91130 (Revised April 1994) "Guidance for Remediation of Petroleum Contaminated Soils" shat be used to characterize petroleum contaminated soils from UST releases Submit all labors I also be r analytical results QA/QC data and Chain of Custody sheets along with this application. tory (NOTE. The laboratory must be accredited by the Washington State Department Eo � partment of Ecology) a) List all analytical test methods used F IT Z/�� l3!l 7ovvlS b) Provide a narrative as to why the above analytical methods were selected � o+sigicr�s' v� NOTE. Additional sheets attached: YES NO 10 Soil Classification. ("FOR PETROLEUM CONTAMINATED SOILS ONLY"" Based on the analytical data and Ecology Publication #91-30the soil classification is. one) , assi (check Class 1 Class 2 Class 3 Class 4 Calculated Hazard Index 11 Dangerous Waste Affidavit. Based on a review of the analytical test results site history and the aLPplicable(Cregul)ations waste is classified as (check one) this Neither Dangerous Waste (DW) nor Extreme) Hazardous zardou �W Dangerous Waste (DW) and Waste Code Extremely Hazardous Waste (EIIW) and Waste Code City ul Purt Anticli�s Landfill Wasto Disf�osal Alrl,lu. rtwn P090 4 12 Certification We, THE UNDERSIGNED certify that this application information provided is correct and the enclosed analytical results represent*the propos d All our know e material to the best of our a y ities waste F Wast enerattor Sig lure Printed Name ?'f-VoM c. ass �r,C Company � D!P s Date Cit• ' � f>:w.' .............. Yat.P+att:Jhh eles-;Ap ..� .•::.. <:•;.' { .. 1. r,.y•...::;'' .,9�.;'�L#. a ?`F:•t..:..':l'i«) fi? may... ,.� ,.., ;'t ,•.'a•'•.sem.:`•:?SS tSy�. Yi;%�•:. � •: � .,•:�F' > �3 . .: ,ua.,:, •'•,�.�y„'`�,3s '{,. � ... ....... ,icy;.•. r .i: ...As:.�.r;a. r:?#... „fit?`;tftfty9 aZ„ �':t'"^•'•Sj• Y.. C;.. 5.. 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Seattle,VITA 98103 Voice:206.547.0100 Fax:206.634.1936 FAX COVER SHEET To Tracy Oudgel 1pw ly Zenovic &Hssociaies, inc. �nai rll/rnlinr• Men? .A 47 nC4A 1 CA^ 111.11 I M.Arl kVVV/T11-VV IT Toll ni Imhar• /4Rn% A 17_nRn4 Email address_ tracv@zanovic.net nnh= 1/R/innR From Iffa Tadesse Total pages: 3 DESCRIPTION OF DOCUMENT (S) Results for NVL Batch P 2600096.00 COMMENTS Privileged and Confidential Laboratory-Client Communications This facsimile message is privileged and confidential and is intended solely for the use of the individual named above. If you are not the intended recipient, you are hereby advised that any dissemination, distribution or copying of this communication is prohibited. If you have received this Fax in error, immediately notify sender by telephone and return the original Fax message to sender by mail. If all pages are not received, please notify sender as soon as possible at(206)547-0100. JAN 6- 2006- S 54AM—NVL LABORATORIES INC N0. 4190—P NVL Laboratories Inc. 4708 Aurora Ave.N.,Seattle,WA 58103 � ANA IH#101861 w���sT�o AW Tel:106.547.0100, Fax:206.6341936 www.nvilabs.com Anal its Report WA DOE#C1765 LARO�t/!'Q�irr Toxicity Characteristic Leaching Procedure-Lead (Pb) Client Zenovlc&Associates,Inc. Batch#: 2600096.00 Address: 519 South Peabody Street,Suite 22 Matrix: Bulk Port Angeles,WA 98362 Method: EPA 70006 Client Project#- 06002 Attention: Mr Tracy Cudgel Samples Received: 1 Project Location: 1229 W Lauridsen Blvd Samples Analyzed: 1 Port Angeles WA RL Results Results in Lab 11 Client Sample# mg/L in mg/L PPM 26000417 06002A 0.5 < 0.5 < 0.5 Sampled by Client DRAFT Analyzed by, Iffa Tadesse Date Analyzed: 01/06/2006 mg/L=Milligrams per liter RL=Reporting Limit ppm=parts per million '<' =Below the reporting Limit Note. Method QC results are acceptable unless stated otherwise. Bench Run NO: 25-1223-1 Page 1 of 1 ;AIN 6 2006 8 5.4AM NVL LABORATORIES INC NO- 4190P3 WVL Laboratories. Inc. huAl*1 -A/%lIt--TAMIV 4708 Aurora Ave N,Seattle,WA 9010 `"..'..v '~`�` `"'� • •■ /'err- Teal:206_s47_o100 Emerg.Pager 208.3A4.1879 SAMPLE LOG ►.Otso.fruL.utoa �oo7ALG7J _ talent Zenovic&Associates Inc. NVL Batch Number Street S 1 g South Peabody Street, Suite 4Z CIW Job Number - 7otai Samples Pon Angeles Tum Around Tune ❑14-Ir ❑24 Hfs ❑4 Days project manager_ racy C;" .sG _ O 2+ks 11 Days 0 6 Days project Location ,(-���L c��0cw 'g/T— 0 44 irs ❑3 Days , 3 6 to 10 Days f'��• Plem call Ibr TAT lees 04in 24� r pf1®ddre3s 'TZA[els. AA�--- Phone: (360) 417-0601 Few. (360) 4i i-06U Q Asbestos Air ❑PQNI•(NlQ8H 7400) D TEM(NIOSH 7402) Ei TEM(AHERA) D TEM(EPA Levet II) ©Other D Asbestus Bulk 10 PLM(EPA/600/11 116) ❑PLM(EPA Point Count) p PLM(EPA Gravim!M ©'CEPA Bulk KTAIS Deet. d Matrix RCRA Aitad ❑All 8 Mar Metals ls V 1411 3 ❑Xiial Meters Apg) C1 Air Filter ❑Paint Chips ❑Arsenic(As) D Lead(Pb) D aper(Cu) VTC1P [3 ppb(OFAA) C]Drinking water p Paint Chips(Area) Q Barium(Be) ❑Mercury(Hg) LJ bustwipe ❑Waste Water D Cadmium(Cd) ❑Selenium(Se) 0 Nickel(NO D So9 D C#xarnium(Cr) [7 Std(Ag) Q Zinc(Zn) p Other Types D Fiberglass O Nuisance Dust O Rotoirreter Calibration D Other'(Spetaify) of Analysis ❑ Silica D Respirable Dust G Moo/Fung 0 Condition of package:D Good D Damaged(no Spillage) []Severe dsrna„ge(spillage) Seq.4 Lab 1D Cilant Sample Number Cralnnewft AIR 2 3 4 6 6 7 8 9 10 11 12 13 14 _ 15 v r Print Below Sion Below .W Date Tim Sampled by r'd qey Relinquished by c / t7.t " ?! Received by (. (P Analyzers Rmults Called by Results Faxed Special Instructions: Unless requested in writing.an samples will be disposed of two(2)weeks ager analysis. Notficataon of Demolition Permt It b unlawfbl foto any person to ester or&Dow the demolitioe (or major renovation)of say strrtctare unless sII s.�eatos- containing nufariab have been removed from the area to be demoNshe& Work shall not eonotau mee an as asbestos project or demolition ualess the owner or operator Las obtained wrk hm approval from ORCAA. A written application for a duos shall hwhrde a eerd&stion that there is me lawn asbestos-containing material remaining in the arra Of the s6ructane. PtgectSite,Ad&i=- Ja4q We-St t-Cnc(5,of% �Uc�14.XxrG� County: L CI Am city ov-V tPs r4- yip; cf 3Co Starting lata j 1.101C)6Compledon Date: I 3D *(There is a 10 working day advance notification period from receipt of pemut Wlicad n) Property Owner: '�> r C/n k 3 Q,'�CS Teiephn�i�0 -7-7 S �- 4- Marling Addeo: city cx t" c.� u 5 State:. LAJ/� Demolition Contractor S ! State license#- Mailing Address: City State: Tag: contactPerson: Telt phone. yaw .- YES NO Demolition by Wrecking or Dismantling? ($25.00 fee)check# _jL,-' Training Fire Demoliti m? (If yes,attach fire deparOment request for training fu e) i z Renovation,Alteration,Remodeling,,Maintenance,or other Construction? IZ Asbestos fond or suspecteP *An ORCAA"Natke of fated to Bemove or Faxapuda*Asbebter fa m'aad appmpnm fee must be mimed prim to any asbestos removal wolf[. Asbestus nemorai projects invak* demolition mast be peforamd by a Ceatifod Asbestos C xor and Ali ftiabk at potentia[[y friable asbestos must be nmwved befam may demolition begwL Refer to ORCAA Regdadoe 1 Article 14 for addomol requirements&M guy 9Wy Asbestos Surrey Completed by AIUKRA CortlfW Inspecbnr 13c�-( Cerbificatioft1=177 0/j DQ 2 Int I This approved permit must Fatelm g23 f Cestific cion of the Asbestos Survey must V be available at job site Proeessng Fuc accompany dus farm 2940 B limMd Lane NW Olympim,Wwhmgtoa 900 364-%6-[044 * 804422.5623 * fax 3604914M bomspW-w+ww otc.ag * end: mfo4-o.caa_OM Rer 07/21/02 ASBESTOS BULK SAMPLE DATA Northwest Asbestos Consultants 406 Reed St. Port Townsend, WA 98368 360-385-0584 northwestasbestosconsultants@cablespeed.com To Clayton Services Date: 12/8/05 Job Location. 1229 Lauridson St. Port Angeles, WA 98362 Owner. Brent Jones 1028 W 13th St. Port Angeles, WA 98363 Sample #1. Kitchen floor vinyl with mastic. Off white with blue and tan. Sample #2: Northwest bedroom 9" x 9" floor tiles with mastic. White paint on tan, gold speckled vinyl. Sample #3. Northeast bedroom 9" x 9" floor tile with mastic. White paint on peach vinyl. Inspector. Bob Witheridge AHERA - Building Inspector / Management Planner WAMOA - 0042-05 Expires - 10/12/06 Please call with test results when completed. See attachment. Thank you, 6A 0'4� Bob Witheridge, EFM Scope of work 1) Inspect for asbestos containing building materials (ACBM) 2) Survey, sample and record suspect materials. 3) Report to owner Brent Jones with results of testing by Clayton Services. 4) Copies for owner, City of Port Angeles Permit Center, Olympic Region Clean Air Agency and on site for demolition. Ins.=tion Re=t The inspection started with a visual survey looking for Asbestos Containing Building Material (ACBM) Single story wood frame home. Composition roofing material with wood siding. Electric and wood heat with fiberglass insulation. Approx. 700 sq ft. Sample results as follows: Sample #1. Kitchen floor vinyl with mastic. Off white with blue and tan. Sam 1p a #2. Northwest bedroom 9" x 9" floor tiles with mastic. White paint on tan, gold speckled vinyl. Sample #3. Northeast bedroom 9" x 9" floor tile with mastic. White paint on peach vinyl. Sample was sent to lab. See results. Litt.-17—GI0UJ 11 Jri r ui 4' " A�SBiL+STNS BULB SIPLE D?A� 'ALog#• 4Q677 NVLAP LAB CODE#10110" Prioritys RegularB 4476 E. W�So Satire 740 Accredited Laboratory Project#1 900.7S S®ole.WA9g13a E l2001�7„µ Number of Samgles: 3 Client Name: Northwest Asbestos Consultants Contact=Bob Withelridge Job Location. 1229 Lauridson,Port Angeles,WA 98362 PO/JDb#- SAMPLE#: 1 RESULTS. OTHER FIBERS % Layers Homogenized for Analysis Cellulose 30 LAB#: 40677.1 SOiJTtCE. Vinyl with mastic No Asbestos detected LOCATION.Kitchen A$BESTQS TYPE PERCENT /o° OTHER MATERLALS Filler&Binder 13 R Vinyl Fillerand-Buider35 MATERIAL DLAYERED Foam 20 Off-white,blue and tan-beaked 1Rkyl wlrh tap Miseeltsneous Particles 2 fibrous backing and tan made Note: Unable to reparata oaoJtr♦Cfarltedirldtea!ra#nL�lf. LAYE1iLA SAA'IPLE.NY SHAP and A1FiFRA regulstfons regttlre.lsyers be analyzed and reported separately SAMPLE#: 2 LAYER 1 RES OTHER FIBERS % Cellulose 20 LAB#: 40677.2A . O B: 9"X9"Floor Tile with Mastic 1�To Asbestos Detected ASBESTOS_TYPE PERCENT T OC`TON:Northwest Bedroom /oo O MATERIALS Aspbalt Filler&Binder 20 Vinyl Piller and Binder 59 MATEMAL DE901PT10N: Paint I White paint on tan gold speckled vinyl with black fibrous backing and red and yellow residue and wood Note: Unable to Warote#teaidae far iadirldarad analysii: Wood not ane(rttd SAMPLE/€_ 2 LAYER 2 RESULTS. OTHER F-MER.S % 40677.28 50UR E: Not Noted No Asbestos Detected LOCATION.Northwest Bedroom ASBESTOS TYPE PERCENT OTHER MA'T'ERIALS Piller&Binder 100 MATERIAL DESCRIPTION. Gray nonefibrous material Note: 01 SAMPLED BY Bob Witheridge DATE: 12/8/2405 ANALYZED BY Katy Carlson DATE: 12/19/2005 COMPANY Northwest Asbestos Consultants mT RECEIVED BY Katherine Huber DATE. 12/12/2005 TTary Perkins or idler NVLAP Avprcnmd S' Cdaylen la oceedirod by NISTJWLAP Merediunion by MVL.AP does apt lndienm mdoraern m by N VLAP or any piles govnament agency.All bulk simples ore nnniymed in acsurdmwe wish tnedtad EFAtpaWM4.62�201Uetpmiter 1982).Autyat#Oft proeashtgto0 Mmugit imer and inva leburuory 0uslAy aeminwee prom#Qrerot verification The offiXitt value#tcomu.a above arc two m calllwated visual eentnoto by•duet union werriwtion by Palmam Ctin*is indicated.Tot rasultr raporlad relate only to Iht aanrplas submiucd by the cliara to Clq tmL T r=anwmut of oebmlos could paesrbly bt tdiedo0%r PLM dmvrrm negative results cannot be guaranteed.This rpe n shall oot be reproduced except in its emimry.without Claymtt Grextp Services pr eismm finRees:Chrysodle.Amosir And Crocidolite abeaes: Quditotive-03,Qaaantadve..12!7remg6te,Aalnplitp ted Aniltppayllue astteaops Qastitadvp-.0X.Qusndtativp 03 A nape Amount praApe#t0#4 dented as ose to ma Rags feed m duee stile ant a; Asbestos round in thi#ntmwnl veli be reported m"Trac Lim,Asbestus ContQLL any sample eentaaininC 1 pawnt or lms mbcem as vaifnod by PLM. LK—%--L (-qp ASBESTUS BULK SAMI TLE DATA Log#. 40677 wNVLAP LAD CODE#101106-U Priority: Regular 8- r.0(,IL"0'!way Sn Suitt 140 Accredited Laboratory Project#: 900.75 ( 76,736434 � Number of Samples: 3 Client Name: Northwest Asbestos Consultants Contact:Bob Witheridge Job Location. 1229 Lauridson,Port Angeles,WA 98362 PO/Job#- SAMPLE#:CY RESULTS. OTHER FTA % LAB# 40677.3 Layers Homogenized for Analysis Cellulose 20 SOURCE. 9efli;9"Floor lite with Mastic No Asbestos Detected LOCAnQ-N-:NorthBedroom ASBESTOS-L YPE PERCENT QTHBR MATERL4LS Finer A Binder is Asphalkfiller&Binder 30 IPT1074: LAYERED Vinyl Filler and Binder 30 Wkite paint on peach vinyl wick black fibrous Paint 2 backing and red and browb residue with wood piews Wolter Unable to 8eporatct residasforinrOtvldaat awaLysra. Woad not a(ra(ysed. SAMPLED BY Bob Witheridge DATE. 1218/2005 ANALYZED BY Katy Carlson DATE: 12/19/2005 COMPANY Northwest Asbestos Consultants DR AFT RECEIVED BY Katherine Huber DATE. 12/12/2005 Tracy Perkins r NVI AP Alppmved SiogtojX Cly wn i(deeMtf�isA1 by MS7INVLAp Aave&mlao by NVL%P dos tmt indicans mdwumm by NVL.AP or my cam govemmont agency. All bulk vomoice dee oti*ud L+atoordartm wits snatliod EpA16WM4-&?,=(Detranbex 190).Auslyatd aro afte-ekxka puWSn Inw or-d Ism WbVwaty qua:ny apmrmme P:oerems for veriGmioo 7Le pawn values mparfod AW,e m bpW on eW*wd vbuel mtisna m by volemo unless vesiLcatioa by Point Cuvnlira is indit itcd IcBI rtdutia 1c0arsc4 rctdre o..ty w rbc 9'TMtNes wbmlued by the otlent m Claytw.Tm=amoams ormbmtae could pussblr be m.itiod by PLM. shadlam negative results cmna be pwastwi This report shall not be ropred=W accpt in its cntinay.without Cliavton Gronv 5tr.ioae 00"aloa P.aw Rare.Ch+Yw+i Aimosite and Crocidolite 6: 0ualil9ova.03,Quamtt W Ve-12 f Trevire,A®nils and Anthoph)llite adettis OlWitaive..0L Queatitative..o3 A(rano amount orasbcaw ie 4cffimd atone io two rk0p ftnd is three elide mounts Asbam (bund in ibis mnmmt will be rgtmsrd as"Tmce" Law Asbestos Content,soy maMle comai uff 7 peseau or less mbesms=vviHed by PLM Summar of Ins ion. This survey includes all areas of inspection with the report results from Clayton Environmental Testing Labs. Sample #1. Kitchen floor vinyl with mastic. Off white with blue and tan. No asbestos detected. Sample #2. Northwest bedroom 9" x 9" floor tiles with mastic. White paint on tan, gold speckled vinyl. No asbestos detected. Sample #3. Northeast bedroom 9" x 9" floor tile with mastic. White paint on peach vinyl. No asbestos detected. All asbestos containing building materials with a reading of 1% or greater is to be removed by a certified abatement contractor which follows the rules of the EPA and governed by Olympic Region Clean Air Agency During building demolition or remodeling, it is possible that additional suspect asbestos containing building material (ACBM) may be found with in a wall, floor, ceiling or other areas not accessible at the time of the survey Should such suspect material be discovered an AHERA certified inspector will have to sample and test the material to prove it is of non-asbestos. Northwest Asbestos Consultants is not responsible for identification of hidden materials that are not identifiable with reasonable diligence. Thank you, OCRO Bob Witheridge, LF.M. rl \: • / Ir ,1,. .,, � ...Ili \� ..;,�( , , ,�. ,. "':r f{It , i.,•' . �.. rl.� •�I}r It, J :: !Ii 4,,'r 1„1�u1 i(I(,l 19,) tirS.:F`,} i,:. . ,F. ,,5 nS1: "`✓ �,{� rh•�n:rr' ::,Si{J} �t�r.—�,.'1 �yrFlr r ��N(: �^I Plh »}:1}� (nnr ll/'( ,... � nr / II .� \/ I:I 7 1' y\� S of Completion F 1) 5 �1_n a --T w Irk ' n, Vr� Rs” lg i fi - c. k Bob A. W161therdge. 'I . _ a e satisfactorily complete 1 �r 4 hours of refresher training as an ® ® Old' ® � s Int- pector i i i r u + - i , �m ���� ' 4` Certificate-NUmbdr 101-8144 •Provider Cert. Number, 1085 Exam Score NA Y\ ./V. Oct 12. 2005 Instructor 0 Date(s) of Training , r CSAFETY TRAINING INDUSTRIAL H GIENE Expiration Date Oct 12, 2006 eattle, Washington. 98119 (206)285.3373 fax (206) 285;3927 •v 5'h4'1.� - -.�., \----'-++; ....--^^^---r--.-� ..m.-..--. ..:-f--T .......... A ti r >.l.\ \ .i, I ..,� n: �,.. /�. 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