Fillable Demolition Application Checklist (The Tulalip Tribes)

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Demolition Application Checklist (The Tulalip Tribes)

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Demolition Application Checklist
Submit the following documents with a signed Demolition Permit Application to: Tulalip Tribes Community
Development Department (CDD), 6406 Marine DR NW, Tulalip, WA 98271
1
Property ownership information (Property Title or Title Status Report or Land Lease).
2
If the applicant is different than the property owner, an authorization letter from the property owner is
required with the application.
3
Site plan showing which structure(s) will be demolished on the property.
4
Project location map.
5
Two photographs of the existing structure (front and side views).
6
Signed utility disconnection notification checklist.
7
Asbestos Survey Report prepared by certified asbestos inspector.
8
Application Fee: $50. Payment may be made in person by check or cash. If mailed, please provide a check
made out to: The Tulalip Tribes.
*Asbestos Notification
*If the asbestos survey report indicates the presence of more than one percent asbestos, the following
submittals are required prior to any asbestos removal.
1
Fill out and sign the U.S. EPA Notification of Demolition and Renovation form found at www.epa.gov
and provide a signed printed copy to CDD. CDD will mail the form to the U.S. EPA. The U.S. EPA will
process the form within 10 working days. No demolition may occur for asbestos projects prior to the form
being processed.
3
Ask your contactor for a copy of their Asbestos Abatement certification and provide a copy with your
application to CDD. (Note: This certification requirement does not apply to asbestos projects conducted in
an owner-occupied, single-family residence performed by the resident owner of the dwelling.)
*****Note: Applicant is responsible for submission and tracking of required documents*****
*Further details regarding Title 8.25 on Asbestos Control Standards can be found on
www.codepublishing.com/wa/tulalip or a copy of the code can be obtained through the CDD.
*Demolition Permit Execution
*The following tasks are standard for most demolition projects. There may be additional tasks for your project.
1
Asbestos projects shall be conducted in a controlled area, clearly marked by barriers and asbestos warning
signs. Access to the controlled area shall be restricted to authorized personnel only. Title 8.25.650(2)(a).
2
The disconnection of utilities must be verified prior to commencing work.
3
Traffic control signs, barricades, canopies and flagmen are provided if necessary.
4
A pre-demolition inspection is schedule with CDD to verify the first three permit execution tasks.
5
For asbestos projects, provide CDD with a copy of the stamp-received Waste Shipment Record from
certified dump site. Please refer to Title 8.25.670(2)) -Waste Tracking Requirements found on back of
page.
6
For general waste, provide CDD with a copy of a ticket or receipt from the dump site.
7
Schedule a final inspection with CDD before removing safety fencing and demolition signage.
Waste Tracking Requirements (Tulalip Tribal Codes Title 8.25.670(2)):
(1) Except as provided in subsection (3) of this section, it shall be unlawful for any person to cause or
allow the disposal of asbestos-containing waste material unless it is deposited within 10 days of removal at
a waste disposal site authorized to accept such waste.
(2) Waste Tracking Requirements. It shall be unlawful for any person to cause or allow the disposal of
asbestos-containing waste material unless the following requirements are met:
(a) Maintain waste shipment records, beginning prior to transport, using a form that includes
the following information:
(i) The name, address, and telephone number of the waste generator;
(ii) The approximate quantity in cubic meters or cubic yards;
(iii) The name and telephone number of the disposal site operator;
(iv) The name and physical site location of the disposal site;
(v) The date transported;
(vi) The name, address, and telephone number of the transporter; and
(vii) A certification that the contents of the consignment are fully and accurately
described by proper shipping name and are classified, packed, marked, and labeled, and
are in all respects in proper condition to transport by highway according to applicable
international and governmental regulations.
(b) Provide a copy of the waste shipment record to the disposal site at the same time the
asbestos-containing waste material is delivered.
(c) If a copy of the waste shipment record, signed by the owner or operator of the disposal
site, is not received by the waste generator within 35 calendar days of the date the waste was
accepted by the initial transporter, contact the transporter and/or the owner or operator of the
disposal site to determine the status of the waste shipment.
(d) If a copy of the waste shipment record, signed by the owner or operator of the disposal
site, is not received by the waste generator within 45 days of the date the waste was accepted by
the initial transporter, report in writing to the Control Officer. Include in the report a copy of the
waste shipment record and a cover letter signed by the waste generator explaining the efforts taken
to locate the asbestos waste shipment and the results of those efforts.
(e) Retain a copy of all waste shipment records, including a copy of the waste shipment
record signed by the owner or operator of the designated waste disposal site, for at least two years.
THE TULALIP TRIBES
DEMOLITION PERMIT APPLICATION
Property Address: ____________________________________
Property Owner Name:
Mailing Address:
Phone: ______________________(home) ___ ______(work)
Fax:
Applicant Name: ______
Applicant Mailing Address: ______
Phone: _____ (home) (work)
Fax:
Applicant's relation to property owner:
Contractor Name or Company:
Contractor Mailing Address: ______
Phone: ______(work)
Fax:
Legal Description of Property (Section, Township, Range):
Section Township Range
Property Site Acreage/SF:
Present use of the Property:
______
Total square footage of proposed building demolition: ___________________________
Demolition work plan: Use the space provided to itemize existing building materials to
be demolished, work tasks (how the structure will be demolished and equipment used),
anticipated work schedule (duration of work, start date and end date): Please provide
information on a separate sheet if additional space is needed.
______
______
What services are currently available at the site?
Public Water Individual Well Public Sewer Septic System
I hereby certify that I have prepared this application and site plan and that, to the best of
my knowledge, the information provided is complete, accurate, and a true representation
of the proposed development, I further attest that I have the authority to submit this
application and agree to comply with any and all conditions of development permit
approval. I agree to provide any additional information required and understand that if
the scope of the project is modified, a new application may be required.
Applicant’s Signature Date
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The Tulalip Tribes
Community Development Department
6406 Marine Drive, NW, Tulalip, WA 98271
(360) 716-4214, (360) 716-0189 FAX
UTILITIES DISCONNECTION CHECKLIST FOR DEMOLITION PROJECTS
This Demolition Pre-Application Checklist must be filled out completely to verify that all utilities have been
disconnected prior to demolition, including water and sewer service piping which must be properly capped or plugged.
Site Address/Location: _______________________________________________________________________
Scope of work: _____________________________________________________________________________
Allotment number if applicable:____________Section:________Township:________Range:_
________
Checklist
Applicant please check one
Not Applicable | Applicable
Notify Tulalip Tribes Utilities Department (360-716-4840) or
Snohomish County P. U. D. (425-783-1000) of impending demolition
to ensure proper disconnection.
Notify telephone and cable provider of impending demolition to
ensure proper disconnection
Septic tank removed OR septic tank pumped and filled with 5/8
minus crushed rock OR sides broken down and filled with inert
material. Pumping invoice must be available on site at the time of
inspection.
Sewer line plugged at property line with a similar material as the
stub. (PVC cap or plug, concrete plug at bell or concrete mix in
spigot end)
Water line cut and capped at property line.
Well capped in accordance with DOE standards by a certified well
contractor. Provide copy of the well decommissioning report.
I acknowledge that I have understood the contents of this form and that the information provided is true and correct:
(applicant signature)_______________________________________________x.
Note: The above utilities shall be disconnected and services performed, if applicable, prior to issuance of the demolition permit.
Inspection is required prior to backfilling. 24 HOUR NOTICE IS REQUIRED FOR ALL INSPECTIONS. Please call Tim
Nordtvedt, Pacific Rim Code Services at (425) 239-2472 or Ray Fryberg Jr (360) 716-4214 to schedule an inspection.
Building Owner
Name:________________________________
Address:______________________________
City: __________________ Zip:___________
Phone:________________________________
Signature:_____________________________
Contractor
Name:________________________________
Address:______________________________
City:__________________ Zip:___________
Phone:_______________________________
Contractor ID#:________________________
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U.S. EPA NOTIFICATION OF DEMOLITION AND RENOVATION
Page 1 of 2
Operator Project # Postmark Date Received Notification #
I. Type of Notification (check one):
Original Revised Canceled
II. Facility Description
Building Name: ____________________________________________________________________________________________
Address: _________________________________________________________________________________________________
City: __________________________________ State: __________ Zip Code: _____________ County: ______________
Site Location : _____________________________________________________________________________________________
Building Size (square feet): __________________________ # of Floors: ________________ Age in Years: __________
Present Use: _______________________________________ Prior Use: ___________________________________________
III.
Type of Operation (check one):
Demo Ordered Demo Renovation Emergency Renovation Fire Training
IV.
Is Asbestos Present? (check one):
Yes No
V. Facility Information
Owner Name: ______________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: ____________________________________________ State: _______________ Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
Removal Contractor Name: __________________________________________________________________________
Address: __________________________________________________________________________________________
City: ____________________________________________ State: _______________ Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
Other Operator (demolition/general): __________________________________________________________________
Address: ___________________________________________________________________________________________
City: ____________________________________________ State: _______________ Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
VI. Procedure, including analytical methods, employed to detect the presence of and to estimate the quantity of RACM and
Category I and Category II non-friable ACM:
VII. Approximate Amount of Asbestos Materials:
RACM to be Removed
Non-friable Asbestos Material
to be Removed
Non-friable Asbestos Material
NOT to be Removed
Category I Category II Category I Category II
Pipes (linear feet)
Surface Area (square feet)
Facility Components (cubic feet)
VIII. Scheduled Dates Demolition or Renovation:
Start: Complete:
IX. Dates for Asbestos Removal (MM/DD/YY)
Start: Complete:
Days of the Week: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours of Operation:
U.S. EPA NOTIFICATION OF DEMOLITION AND RENOVATION
Page 2 of 2
X. Description of planned Demolition or Renovation work to be performed and method(s) to be employed, including demolition
or renovation techniques to be used and description of affected facility component s:
XI. Description of work practices and engineering controls to be used to comply with the requirements, including asbestos
removal and waste handling emission control procedures:
XII. Waste Transporter #1
Name:
Address:
City: State: Zip Code:
Contact: Telephone: ( )
Waste Transporter #2
Name:
Address:
City: State: Zip Code:
Contact: Telephone:
( )
XIII. Waste Disposal
Name:
Address:
City: State: Zip Code:
Contact: Telephone: ( )
XIV. Emergency Demolition (complete Item XIV only if this project is an Emergency Demo.)
1.
Attach a copy of the Order to this notice.
2.
Name of Authority Issuing Order: Title:
3.
Authority of Order (Citation of Code):
4.
Date of Order (MM/DD/YY): Date Ordered to Begin
XV. Emergency Renovation (Attach separate sheet with the following information if project is Emergency Renovation.)
1.
Date and Hour of the Emergency:
2.
Description of the Sudden, Unexpected Event:
3.
Explanation of how the event caused unsafe conditions or equipment damage or an unreasonable financial burden.
XVI. Description of procedures to be followed in the event that unexpected RACM is found or non-friable ACM becomes
crumbled, pulverized, or reduced to powder.
I certify that an individual trained in the provisions of NESHAP (40 CFR PART 61, SUBPART M) will be on -site during the
Demolition or Renovation, and evidence that the required training has been accomplished by this person will be
available during normal business hours.
XVII.
Signature of Owner/Operator Date Type or Print Name and Title
I acknowledge the existence of laws prohibiting the submission of false or misleading statements, and I certify that facts
contained in this notification are true, accurate, and complete.
XVIII.
Signature of Owner/Operator Date Type or Print Name and Title
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Demolition Application Checklist (The Tulalip Tribes)

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Completed 20 July 2020

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