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HomeMy WebLinkAbout040-110-018WILLADSEN, 'MELTON _NIN 1524 M E SA,-, 'R D;DURHAM _ , - (DtM J 04Y Fri r Fr �,A� 9 3-`109 040' &.1V 31 =1524t MESA, RV-DURH) m'.4 �PAG 'iEXEMPTION ALMONI AL L Y r zw _6 21 - ZIP, m Blau 110— t 018 �'�n�uay����'�i� i+ _ � Mbt?TR.�''`^' 4 T ,�`^'��s[�+n `� � �. 'X _ � �� o . �y � �- '`� Q �2� � � � �.,cr...-yywvr*-r� >M 1� , - 1 1 .9 - 3�:1810. B' LLADSEN, M 'L. EL ON '1524 MESA RD-,.,'-- 'DURHAM. (DEMO o�l COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS J 7 County Center Drive - Oroville, California 95965 - Telephone: 916.'538-7541 APPLICATION, AND PERMIT PERMIT NO. 23 - /8/9 ASSESSOR PARCEL NUMBER 040-110-018 ZONING A10 BUILDING PERMIT OWNER MILTON L. WILLADSFM TELEPHONE SQ. FT. OCC. BUILDING VALUATION OWNER'S MAILING ADDRESS 9784 LOTT RD., DURHAM, CA 95938 CONTRC�R'S NAME rA�T �O 01Y t\ r li TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER NONE UNKNOWN Total Valuation $ Filing Fee $ 15.00 LENDER'S MAILING ADDRESS Permit Fee $ ARCHITECT OR ENGINEER NONE LICENSE NO. Plan Checking Fee $ Ener Plan Checking Fee Energy g ARCHITECT OR ENGINEER'S MAILING ADDRESS Penalty $ BUILDING1524DMESA ROAD, DURHAM DRESS Permit fee $ 30.00 PLUMBING PERMIT Filing Fee 15.00 Each Trap 5.00 Solar or heat pump water heater 20.00 LOT NO.SUBDIVISION NAME PARCEL MAP Water piping 7.00 Each qas water heater or vent 7.00 USE OF STRUCTURE gy�pp-,� SF L 1 Duplex❑ Mobilehome❑ Other SPECIFY Gas piping system 1 - 5 outlets 5.00 Building sewer 15.00 Mobile Home S I G I W @ 15.00 TYPE OF WORK New: Addition _ Remodel E] Utilities❑ Installation[ Other] Describe work: DFM _ Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 15.00 Main service 600V OR LESS 200A OR LESS 18.50 Main service 200A TO IOOOAI 37.50 CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ 1 am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONST. DWELLING OCCUP.& OR ADDNS. ( ACC. LDG S. 3.60 sq.ft. I.OU NEW CONSTR.ULTI.OUTLET NON.RESID BRANCH CIRC ITS @ 5.00 POWER APPARATUS &) (SINGLE OUTLET CIR. Ex. Occup(OUTLETS OR FIXTURES 20X754 FIXED Ex. OCCUp. OUTLETS P(RESID.)LN REA.) I 3.00 Temporary service 15.00 Mobile Home Facilities 15.00 Misc. Wiring 15.00 Permit Fee $ Contractor - WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. fZ I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. MECHANICAL PERMIT Filing Fee 15.00 Heating Cooling Hood 6.50 I Ventilation permit Fee $ Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the County of Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue against said County in consequence of the granting of this permit. X ^ % Date Signature of Applicant — Owner Q Contractor ❑ Agent ❑ An OSHA permit is required for excavations over 5'0" deep and demolition or construct- ion of structures over 3 stories in height. Mobile Home Installation Fee S Energy Inspection Fee $ Occ CONST TYPE TOTAL FEE $ 30.00 HAz 1 DFEES I IMP I FLOOD I CDF I PARCEL PD HD ISS This permit is hereby issued under the sions of the -Butte County Code and/or �. ) ted which fees Ave�' / work i.�t7DIR- / F PJJBLI By ( -= J . ' /h j PER EXPIR Date applicable pro i- resolutions to do / /: / i3Ve been paid. RKS /, ,Dae /Al 143260 Receipt No. WHITE-D.P.W.. YELLOW-A5SE58a R. PINK -INSPECTOR. Col. DENROD.APPLICANT BUILDINA DIVISION COUNTY OF BUTTE - DEPANTNi T OF DEVELOPMENT SERVICES 7 COUNTY CENTER DRIVE — OROVILLE, CALIFORNIA 95965 — TELEPHONE: (916) 538-7541 AGRICULTURAL BUILDING EXEMPTION PERMIT 0 :J -•1 ; . ,, Agricultural building is defined as follows: Agricultural building is a structure designed and constructed to house farm implements, hay, grain, poultry, livestock, or other horticultural products. This structure shall not be a place of human habitation or a place of employment where agricultural products are processed, treated, or packaged, nor shall it be a place used by the public. ASSESSOR PARCEL NO. -Die -000 ZONING OWNER 02C PHONE NO. 34-s OWNER'S ADDRESS LD_kAZJ4k-., CA !9S217-98 LOCATION OF BUILDING i 145 Z4 — rP -'�V, USE OF BUILDING SIZE OF STRUCTURE X I JZl = L_015� SO. FT. TYPE OF CONSTRUCTION: WOOD FRAME . STEEL,—_X— CONCRETE OTHER (Specify) TYPE OF SIDING ROOF COVERING FLOOR TYPE a L ESTIMATED COST OF CONSTRUCTION AG Buildings shall comply with the building front, side, and rear yard requirements of the applicable County Ordinances as follows:i Si S FRONT �S SIDES REAR AG Buildings shall be a minimum of five (5) feet from any septic tank or leach fields. AG Buildings less than 1000 sq. ft. in floor area shall be located a minimum of 6 feet from a residence, 10 feet from a mobilehome, and 23 feet from a commercial building. AG Buildings greater than 1000 sq. ft. in floor area shall be located a minimum of 23 feet from a residence and a mobilehome, and 40 feetfroma commercial building. F(_0 Db ZO/1/Ci T I AG Buildings must comply with Flood Zone requirements. Finish floor elevation must be at or above elevation USGS Datum. I declare under penalty of perjury that the building will be used as stated above and the purposed use conforms with the AG Building definition. If any change in use or occupancy of the building is made, I will contact the Building Division and obtain any necessary permits, inspections, and approvals to comply with the requirements in effect at that time and before occupancy. Date Co C7 Permit Fee - $50.00 Receipt No. Signature of Owner The above described AG Building is exempt from a building permit. F_ FLOJ,)D PARC L P.�! ROOF G I ISSU I � Manager Building Division By A-0jo— Date 2 9� White — DPW, Yellow — Assessor, Pink — B. I., Goldenrod — Applicant R North Valley Ready-Mix—Agri-Systems No. 11 Three Sevens Lane—Chico, CA 95926 B TIER Telephone (916) 345-7296 BUILDER License No. 3099.74 COMPLETE CONCRETE AND BUILDING SERVICE F • ♦ .. .. ' COUNTYOF BUTTE - DEPARTMENTOFrD,_LOPMENTSERVICES -BUILDING DIVISION 7 COUNTY CENTER DRIVE - OROVILLE, CALIFORNIA 95965 -TELEPHONE (916)538-7,541 PERM ITAPPLICATION DATA SHEET OWNER Proposed Building Use Building Inspector Date r At time of per(nit application, I was advised the following data must be submitted prior to permit processing and/or issuance: , Z DATEI RECEIVED BY 1. All items have been submitted...... 2. Plot plans, 3/4 sets, signed by preparer of plans. ........... }. W . 3_ Complete plans, 3/4 sets, signed by preparer of plans . ................... a. . .4. Engineered plans and calcs, 3/4 sets, with wet signature on plans. ...:......... 5. Hazardous Material Form . ........................................... . 6. Energy Design Compliance and supporting documentation . .................. 7. Statement of Intent for Non -Heated and A/C Buildings . ...................... 8-. Engineered truss details and layout in duplicate (required prior to plan check). .... 9. Mobilehome data and manufacturer's installation instructions, 2 sets, ........... 10. Fees of $......................................... 11. Impact fees as shown on attached schedule. ............................. . 12. California Department of Forestry plan approval/fees. ....................... . 13. Flood elevation letter (100 year flood) by California Engineer . ................. . 14. Sanitation and plot plan approval Health Department . ............ 15. City of Chico plumbing permit . ......................................... 16. Plot plan and business license approval from City of Biggs/Gridley. ............. 17. Planning approval for (A) Use: (B) Parking: 18. Contact Land Development about (A) Improvements (B) Drainage. .......... . 19. Driveway permit (construction approval required prior to occupancy). . 20. Pre -inspection for required. .. t. e�i�� .I.; eao (oats) �.., 21. Contractor's license information. (No., Name Style, Classification) . .............. 22. Certificate of Workmans Compensation Insurance. 23. Owner -Builder Verification (Given to owner , Mail to owner .......... . 24. Recorded copy of Agricultural Acknowledgement Statement. 25. Letter of signature authorization . ........................................ 26. Copy of recorded deed of parcel creation and 60 right of way to a public road. ..... • 27. Letter of intent on building use . ......................................... 28. Mobilehome utility clearance . .................. Documentation of legal access . ....................................... . 30.- Documentation of 50% subdivision developed or (A) Road improvements completed r and (B) Parcel meets zoning area and frontage requirements . ............... 31. Existing violations/expired permits . ...................................... 32.. Plan check list . ...................................................... 33. _ 34. When you issue the permit, process as follows: Mail to owner. Mail to contractor. Telephone and hold for pickup at office. Deliver with inspector. - . Other Parcel Creation Acreage Applicant Date Copy of Haz-Mat form sent Health Dept. Fire Dept. Air Pollution Date Copy of plans sent Health Dept. Fire Dept. Other Date By The following data must be submitted prior to permit issuance: (Circle`new item not checked above). r 1. Index permit for above items No. ' 2. Additional items required: Contractor, designer, owner, was advised of above required data by _ phone _ mail Counter by Date Contractor, designer, owner, was advised of above required data by _ phone _ mail Counter by _ Date Plans checked by Date Plans approved by Date Sets of plans on hold in File cabinet AP folder Copy - Department of Public Works rl� June 15, 1993 Butte County Department of Public Works 7 County Center Drive RE: Flood Plain Elevation Oroville, CA 95965 Willadsen Orchards Inc. Building Permit APN: 40-11-18 A cross section taken from the F.E.M.A. Flood Plain Map, through the Willadsen property indicates the elevation of the 100 year flood . plain to be 169.50 feet (U.S.G.S. Datum). There is a U.S.G.S. Datum bench mark at the Northeast corner of the concrete slab at the rear of the existing Huller Building approximately 50 feet Southeast of the proposed building site, Elevation 166.79 feet. A finish floor elevation at or above 169.50 will be adequate to protect life and property. A. C. Bruhns R.C.E.-10531 - - - o ' Exp res-. 2=1-96 061593.LTR COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS 7 County Center Drive - Oroville, California 95965 - Telephone: 916.`538-7541 APPLICATION AND PERMIT PERMIT NO. ASSESSOR PARCEL NUMBER 040-110-018 ZONING A10 BUILDING PERMIT OWNER MILTON L. WILLADSEN TELEPHONE SO. FT. OCC. BUILDING VALUATION OWNER'S MAILING ADDRESS 9784 LOTT RD., DURHAM CA 95938 CONTRACTOR'S NAME OWNER TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CONSTRUCTION LENDER NONE UNKNOWN Total Valuation Is Filing Fee $ 15.00 LENDER'S MAILING ADDRESS Permit Fee $ 15,00 ARCHITECT NONE OR ENGINEER LICENSE NO. Plan Checking Fee $ Energy g Fee Ener Plan Checking $ ARCHITECT OR ENGINEER'S MAILING ADDRESS Penalty $ BUILDING ADDRESS 1524 MESA ROAD DURHAM Permit fee $ 30.00 PLUMBING PERMIT Filing Fee 15.00 Each Trap 5.00 Solar or heat pump water heater 20.00 LOT NO. SUBDIVISION NAME PARCEL MAP Water piping 7.00 Each qas water heater or vent 7.00 USE OF STRUCTURE SF ® Duplex❑ Mobilehome❑ Other SPECIFY Gas piping system 1 - 5 outlets 5.00 Building sewer15.00 Mobile Home JSFG W @ 15.00 TYPE OF WORK New L Addition l_ I Remodel ❑ Uti lities ❑ Installation ❑ Other f] Describe work: DEMO Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 15.00 Main service 600V OR LESS 200A OR LESS 18.50 Main service 200A TO IOOOAI _ 37.50 CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ I am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License Ao. Classification I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONST. DWELLING OCCUP.g OR ADDNS. (ACC. BLDGS. ) 3.64sq.ft. NON.RESIDCONSTR BRANCH CIRCUITS @ 5.00 POWER APPARATUS b (SINGLE OUTLET CIR. Ex. Occup(OUTLETS OR FIXTURES 20 @ 7611 FIXED APPI-NS Ex. Occup. OUTLETS IRESID )REA.) I 3.00 Temporary service 15.00 Mobile Home Facilities 15.00 Misc. Wiring g '15.00 Permit Fee $ — WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. �7 I shall not employ any person in any manner so as to become subject Al to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Contractor MECHANICAL PERMIT FiIingFee 15.00 Heating Cooling g Hood 6.50 Ventilation Permit Fee $ Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue against said County in consequence he gr nting of this permit. �.� g .Date Signature of Applicant — Owner IXI Contractor ❑ Agent ❑ !!!"' An OSHA permit is required for excavations over 5'0" deep and demolition or construct- ion of structures over 3 stories in height. Mobile Home Installation Fee $ Ener Inspection Fee $ Energy P occ CONST TYPE TOTAL FEES 30.00 I HAz I DFEES I IMP FLOOD I COF PARCEL I PD I HD Iss This permit is hereby issued under the utte Count Code and/or work d a e which fe sions 144-7 O F P BL ByDa PER EXPIR Date applicable pro i- � r olutions to do a been paid. KS/Receipt e No.YJ 143260 WHITE-D.P.W.. YELLOW -ASSESSOR. PINK -INSPECTOR. GOLDENROD -APPLICANT 3 COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS PERMIT NO. 7 County Center Drive - Oroville, California 95965 - Telephone: 916 538-7541 APPLICATION- AND PERMIT ASSESSOR PARCEL NUMBE 0 - - ZON G BUILDING PERMIT OwN TELEPHONE SO. FT. OCC.1 BUILDING VALUATION OER'S MAI LIN ADD ESS P ha vii 9 CrFMCTOR•S. NrAM V1FV TELEPHONE CONTRACTOR'S MAILING ADDRESS Fireplace CON$TRUCTIOON LENDER UNKNOWN Total Valuation is LENDER'S MAILING ADDRESS Filing Fee $ 15,00 Permit Fee $ ARCH) ECT OR ENGINEER LICENSE NO. Plan Checking Fee $ Energy Plan Checking Fee $ C ITECT OR ENGINEER'S MAILING ADDRESS Penalty $ BUILD NG e,ODRESS 15d4 Ci cc ©Cc Permit fee $ D PLUMBING PERMIT Filing Fee 15.00 Each Trap 5.00 Solar or heat pump water heater 20.00 LOT NO. SUBDIVISION NAMEPARCEL MAP Water piping 7.00 Each qas water heater or vent 7.00 USE OF STRUCTURE SFX Duplex❑ Mobilehome❑ Other SPECIFY Gas piping system 1 - 5 outlets 5.00 Building sewer 15.00 Mobile Home S I G I W @ 15.00 TYPE OF WORK Utilities ❑ Installation❑ Other N New Addition _ Remoti Describe work: PY) Permit Fee $ Contractor ELECTRICAL PERMIT Filing Fee 15.00 Main service 200A OR LESS 18.50 Main service 200A TO 1000A1 37,50 CONTRACTORS LICENSE LAW I declare under penalty of perjury (check one): ❑ 1 am licensed under provisions of Chapt. 9, Div. 3 of the Business and Professions Code and my license is in full force and effect. License No. Classification jJ I, as the owner, or my employees with wages as their sole compen- sation, will do the work,and the structure is not intended or offered for sale. (Sec. 7044) ❑ I, as the owner, am exclusively contracting with licensed contract- ors. (Sec. 7044) ❑ I am exempt under Sec. , Business and Professions Code for this reason NEW CONST. ( DWELLING OCCUP. �\ DR ADDN5. l ACC. BLDGS. / 3.66 sq.ft. NEW CONSTR MULTI -OUTLET NON-RESID BRANCH CIRCUITS) @ 5.00 POWER APPARATUS e (SINGLE OUTLET cIR. ) Ex. Occup( OUTLETS OR FIXTURES 20 76d JA 64 EX. Occup. OUTLETS P(RESID )REA.) 3.001. Temporary service 15.00 Mobile Home Facilities 15.00 Misc. Wiring g 15.00 Permit Fee $ — WORKMEN'S COMPENSATION INSURANCE I declare under penalty of perjury (check one): ❑ The permit is for $100.00 (valuation) or less. ❑ I have placed on file with the County of Butte Building Department a Certificate of Workmen's Compensation Insurance or a Certificate of Consent to Self -Insure. ❑ I shall not employ any person in any manner so as to become subject to the W. C. laws of California. Notice to Applicant: If after making this statement, should you become subject to the W. C. provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Contractor MECHANICAL PERMIT FiIingFee 15.00 Heating Cooling g E6.50 Hood Ventilation Permit Fee $ Contractor I certify that I have read this application and state that the above information is correct. I agree to comply to all County Ordinances and State Laws relating to building construction, and hereby authorize representatives of the Countyot Butte to enter upon the above-mentioned property for inspection purposes. I also agree to save, indemnify and keep harmless the County of Butte against all liabilities, judgments, costs, and expenses which may in any way accrue against said County in consequence of the granting of this permit. X Date Si nature of Applicant – owner g pp ❑ Contractor ❑ Agent ❑ An OSHA Ions over S'0" deep and demolition or construct- ion of structures tover 39stories oin excavations Mobile Home Installation Fee S Energy Inspection Fee $ occ CONST TYPE TOTAL FEE $ HAz 0FE- ES IMP I FLOOD I COI PARCEL PD HO ISSUE This permit is hereby issued under the sions of the Butte County Code and/or work indicated above for which fees DIRECTOR OF PUBLIC By EXPIRES Date applicable provi- resolutions to do have been paid. WORKS DatePERMIT 1�� Receipt No. f�1 WNIT(-O.P.W.. YELLOW-A33E330K. PINK -INSPECTOR. GOLD CN ROD -APPLICANT I COUNTY OF BUTTE - Department of Public Works 7.County Center Drive, Oroville, CA 95965 Phone: 916-538-7541 OWNER -BUILDER VERIFICATION Attention -Property -Owner: An 'owner -builder" building permit has been applied for in your name and bearing your signature. Please complete and return this information at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. 1. I personally plan to provide the major labor and materials for construction of the proposed property improvement (yes or no) 2. I (have/have not) h2 t/2 signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name Address City Phone Contractors License No. 4: I plan to provide portions.of this work, .but I.have hired the following person to coordinate', supervise, and provide the major work: Name Address City Phone Contractors' License 'No. 5. I will provide some of the work but I have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed: Property Owner Social Security Number3/= Date - NOTE: This Owner -Builder Verification is sent to you as required by Sections 19831 and 19832 of the California Health and Safety Code. This verification must be completed and returned to our office before we are per- mitted to issue the permit. Demolition Permits Asbestos Notification Statement Date l 7� Pursuant to section 19827.5 of the California Health and Safety Code, all demolition permit applicants are required to fill out this form. "19827.5. A demolition permit shall not be issued by any city, county, city and county, or state and local agency which is authorized to issue demolition permits'as to any building or structure except upon the receipt from the permit applicant of a copy of each written asbestos notification regarding the building that has been required to be submitted to the United States Environmental Protection Agency or to a designated state agency, or both, pursuant to Part 61 of Title 40 of the Code of Federal Regulations, or the successor to that part. The permit may be issued without the applicant submitting a— copy of the written notification if the applicant declares that the notification is not applicable to the scheduled demolition project. The permitting agency may require the applicant to make the declaration in writing, or it may incorporate the applicant's response on the demolition permit appli cation." Attached is a copy of my written asbestos notification to the United States Environmental Protection Agency for the demolition project located at Signature of Applicant OR I hereby declare that a written asbestos notification to the United States Environmental Protection Agency is not applicable to this demolition project. Signature of Applicant 2/19/91 MAIL TO ASBESTOS NOTIFICATION EPA/NESHAPS Region IX 1235 Mission St. A-3-3 San Francisco, Ca. 94103 DATE: PROJECT JOB t (Please see reverse side) oa 1= Notified: ❑ Ci] ifoau a Air Roaouzsans Board ❑ ca1 ossa ❑ Buildim ��-� ..t ASBESTOS DEMOLITION/RENOVATION NOTIFICATION Please check on Renovation Demolition requiring 10 day notice Demolition requiring 20 day notice Revision of Original (Form on reverse side) IDEPLEASE READ BEFORE IIs Tw[. TAT c EPA USE ONLY DateRec Pstmrk School Del/ND ADQUTE? Code## : Doc#: rnIM r 1. OPERATOR: 3. FACILITY XAME (Contractor) ADDRESS STREET ADDRESS CITY STAVE CITY STATE -- ZIP PHONE ( ) COUNTY ZIP 2. OWNER 4. FACILITY DESCRIPTION ADDRESS AGE SIZE CITY STATF�_ ZIP PHONE( ) PRIOR USE 5. Project Start Date: Completion Date: 6. Estimate of Friable Asbestos: ON PIPE: Linear Feet SURFACE OF OTHER COMPONENTS: Square Feet Nature of Materials: 7. DESCRIBE METHODS OF REMOVAL: 8. PROCEDURES USED TO COMPLY WITH 40 CFR 61.147 a 152: 9. NAME fff LOCATION OF DISPOSAL SITE: ANY FURTHER PERTINENT INFO CAN BE INCLUDED BY ATTACHING ADDITIONAL SHEETS QUESTIONS??? FOR FURTHER INFORMATION CALL (415) 556-6415 8am/4pm M -F ?NSTRIIGTIONS FOR IIgr, ()r AgEERTOR DEMOI,TTIQN/g—vNOVATTC)N NOTTT,TC1 TON lf. �1t �1 LL IV l/ l Y RENOVATION: means altering in any way one or more facility components. NOTICE MUST BE POSTMARKED AS EARLY AS POSSIBLFBEFORR' PROJECT DEMOLITION: means the wrecking or taking out -of load -supporting structural members of a facility together with any related handling'operatiol 10 Day notice for MORE than 160 sq.ft.or 260 linear ft. asbestos 20 Day notice for LESS than 160 sq.ft.or 260 linear ft. asbestos, includes facilities which contain no asbestos. FACILITY: means any institutional, commercial -or industrial structure, installation, or building. Renovations on single family residence and apartment buildings with 4 units or fewer are exempt from notification to EPA. - PROJECT JOB a: Your OWN TN -HOUSE D for a specific jobsite. Optional, but expedites communication -concerning notifications. LOCAL AGENCY: Most areas in Region 9 have local NESHAP delegated agencies. In these areas notice must be provided to both EPA and the local agency. 1. OPERATOR/CONTRACTOR: Full information concerning person doing the work. 2. PROPERTY OWNER: Complete in full. 3. FACILITY NAME: Must have complete address OR directions to the jobsite. 4. FACILITY DESCRIPTION: Current use of building. Project location in the facility. Other descriptive information as necessary. 5. START AND COMPLETION DATE: Provide month, day and year. Must be revised if dates change. (see revision form below) 6. Estimate of amount to be removed (must be in square or linear feet). Revisions(see form below) must be made for additional amounts uncovered. 7. Examples of methods: glovebag, scrape, remove in sections, etc. 8. Examples: Adequate wetting prior to and during work, double bag, etc. DRY REMOVAL MUST RECEIVE PRIOR WRITTEN APPROVAL FROM EPA OR THE LOCAL DELEGATED AGENCY IF MORE SPACE IS NEEDED THAN PROVIDED, ADDITIONAL SHEETS SHOULD BE ATTACHED TO REVISE A NOTIFICATION ALREADY ON FILE WITH EPA, USE FORM PROVIDED BELOW PROJECT NAME PROJECT JOB 4 ORIGINAL NOTIFICATION DATE Revision Notice #1 2 3 4 please circle This is to advise that the above referenced notification presently on file has been revised. Please note the revised portion listed. CHANGES FOR THIS REVISION: PROJECT ( ) CANCELLATION 1. NEW Location 2. NEW Scope of Work 3. ADDITIONAL Quantity of Asbestos 4. -NEW Start Date 5. NEW Completion Date 6. NEW Disposal Site