HomeMy Public PortalAbout06-0533 Resort Inns, Inc.IQ! 41', 4110b `33. 2?'12616 SR. IL.
P
SERVICES, INC.
PACiE 0.2
Approval Number:
Expiration Date; -
ASBESTOS WASTE SHIPMENT DOCUMENT
**SEE INSTRUCTIONS FOR PROPER COWILBTION OF THIS FOAM
1. 4INERATOR
-Work site name: AC'S
kMailing sddresy.,:
[Owner's Name:
C5wner's Phone Number:
3. WASTE DISPOSAL S (WDS)
Name:
Maihns adr6s: L-1-1
• Physical site location. 4 4,
Phone Number:
2. OPERATOR/CONTRAC OR
Name:
Address: (t' 3
PhOne Number
b/ I
Phone Nutiber.
4. RESPONSIBLE AGENCY
Name:
1-Address:
S. DESC RIALS
Friable,o Non-friable Asbe. . . .MIMIlr •
Hazard Class: dentification Number:
'2,dditional neSCription•
r4S914rf
Number of Containers: TT
PaQkingOr p.
of Containits, ba
s, etc'
–1
Total uantity ca ft, cu. ds. 1b., tons). j
-;f:§I•EcIAL HANDLING INSTRUCTIONS AND ADDITIONAL INFORMATION
Handled in accordance with all EPA., NESHAP, AND OSHA Regulations
J
1-13. OPERATOR'S CtRflflCAT10N 1 hereby declare that the contents of this consignment are fldly elfgl accurately
described above by proper 3bippIng narne and are classified, packed, marked, and labeled, and ate in an reiptvts in proper
condition for tratmort by hialitvay_ao_zording to applicable international end govn1tomz.
PrintediTyped Name'
ture:
9. TRANSPORTER tAcknowIedemeut of Receipt of Materials):
Phone Number: 43,/
PnatodiTypect_Nain Cl;,)014C
S •tUre: AM: —
10. DISCREPANCY DICATION SP.AC
Lcovared by this manifest except, as not. in nun 10,
Printed/Typed' mc, t4 Titic; -
! Si nature: Date:
11. WASTE DISPOSAL SITE OWNER OR OPERATOR: certification of seceipt of asbestos attenwials
Form SW03 (2001)
10 /^6!2edE. 14:39 51231 316
elowlo
1114. ISRVICEIA, fl:d1CC
SRIL
PAGE 013
Ott\cc Use Only
A ' N �.�
Expiarauon Laaiti:
SPECIAL WASTE PROFILE
Information utilized for aonupie Lion of this fora must originate Eton) ari authorized reprosotttativ-i of the geneiator or the waste material.
The inlbnntatio n on this Ibrm must be COMPLETE. LEOIHLE, and the form must be SIGNED.
A. GENERATOR INFORMATION ,
1, Generator Num: Q4 1v
2. Address: / e
City: '1
State.
3. Site Location ifdiifferent
4. i orl uft Nam: [ '
6. Fax Number: 3 r
5. Phone Number
1 Name;
TER 1 BMA
1. game;
B. CUSTOMER/HtctLINGINEORMAn.014
1. Billing Name: `> °� rE Y rH'
2 Address, yy icz.5 0.14C,,
City: I Coniaty: _02 772_R-
3.
Stew 21p: �.
Contact name' 1 A
4. Prone Nrtrnber
5. Fax Number:
6. b there a service. attrodtdetl� ba file7-I �S'F5" [J NO
D. AGENT/CONSULTANT INF'ORMA'TION
1. Name
2 . Savo A44resa: Je 2. Street Address:
3, MOM City: Ps4 �_7.- s e: _ H . ZIP' YJ 32 City; - State; 2 ,. _.
3. Phone Numi�cr;
4. Fax NUmMT.
5, Contact Name:
6, Is the a Lefler of Atttttaxization op ".IillES NO
IL WASTE STREAM INFORMATION
C.otttnton Natter of yW asta _.8.41,1,64_,0_,_-,4.,___,__
2 Detailed 7escripti,o! of Fixes;: � ,k - -Z • • 'y/ -t l� l � L
=IC a --7 .
..Z.Lo State • mc.� C� -ox- .��
3. F6yelcal at 70'T 1�9 Solid mi. olid rid U rowder 0 Othot ,
4. or: None 0 d 9, Signuflt:axtt: (dzactabc)
5. Color: ' Tit - 6. Flash Point ° F _ 0 C
7. Reactive. NO YES with 8. pH Range: 9, Heat Generating Weste vO LJ Y)aS
10, two Liquid VI NO ❑ YES 11. Water Cwatent: o ; water
3'2. Dots the waxer contain radioactive or U. S. D.O. T. hazardous materials, PCla s air aabeetoe'l 10 21 YES
t3. Does tb: waste contain. any etiological agents or unraveled medical waste? ([NO 0 YS
14. Is the waxes propored for martage-rncnt a hazardous waists as defined by Waal or State regulations? Dg NO 0 YES
F. SUPPLEMENTAL INFORMATION
1, ,Attached Doolinsent(e): None 0 MSDS �i£ied A.vah'tical Report CZMemoriAtt 0 Rucoss knowledge.
2. If anpaJ ttical data is attec , is the data derived from Costing a representative sample in accordance with 40 CPIs 2.61 and/or odic( applicable
laws? 0YES 0 NO
G. SHIPPING INFORMATION
1, Packaging: D J3u11: Sohd5 1 Built Liquids J Drums ® [toll -Off ®,Duo,? Truck J Tank Truck ❑Cflizr. „.__,"_.
2 Eitizner ei Volume: . C] Tons Cd Cubic Yenta C) Drums 0 Gallons (0 Other
3, Shipping Frequency. per IZI One-. Time 0 Month ❑ Year' 0 Outer:
4. Designated Lxndfiths): .1;c_
5 Disposal Method; Ln Solidification 0 Hioremaiiaivu CI-Other ~ r _`___
II. Generator's Certification Sratemtnt.:
I hereby certify that the above and attached information is complete and accurate to the boat dray air:i;ty, that no deliberate information was
omitted, that all illowti and suspected hazards have been disclosed, and that the waste is trot a regulated hazardous waste by govel mew cc Loral
authority, acrd does not contnm PC'B's regulated by TSCA, or any other regulatory authority. If any of fee above information change% J agree w
aatify Republic Services prior to offering the waste far ithipmont or management.
1, 3 i 4c Tr (NAME. PLEASE PRINT) son employed by
(COMPANY NAME) and am authorized to sign this request fc
4. Fax Nua »e :
1. C'cstaact Nam D W a
COMPANY NAME 't 5 i 4� Nom- l PRINTED NAME:
DATE: la- it ‘.¢ C� \3 y SION.ATURE:
Fvr7ta SW01 (2003)
E4f 24-:' e"o6 14: 29 9129F '16
Terms and Conditions of Sp*
ILi Hi, ilr+ ayeement a t4- a palm, r'Ayfwme l far Ma 4Ntitwd r 1lpama Naga
inng mrhdat of tho Agr..neni, rtdsre to the Apre aoint or my)) a1M Npy Appaoaion. parn0 and
4pproyal fart may be applloutea tv. torah W9eq.
O AntEft Aacspfpy EI faoitby. Gtnerrtbt f4prn01ri, **Lama end aovenanb a>r tow W. i.
UtiVarad to Company et la Facility hareurredt AO b. ncot4• W1& and mil nor nankin any
.nxi:ttM►t'ae 4004J0 d neseoaranfa maw** Of wf tangy., radioactive uvWYnW 01
tutMhncea, w bbC 0000 a eubma cm, a9 ddtnad by evek bfe /.swat, al", beat o
pro' o sl Iowa or re41.4■3.1,e AM• W.gt• ..lynx ChM. hgt neat 10410 rM.tirvmallti Now 16.
netetnell.r no ref0' 64 to •• "Ur 17W4at44 Wete,l'. Tyy, altharlitra that In alt natant rotating to
,he coact*. tren6teertitioc ana *mow/ 44 onto Wash Mrarndar, (t mey 44th al ap$caAlc,
taaenf, .hate and QC I brat, mutil9or», n,tat 4.ind tvdefa r.Qard114 t* memo YM t o
`Probity" anal n4een any Ian4ta,, trawl* sbraon or odor looyttal used 'o Mats, proc.aa or
Mur.,'I" dl•fwaa 0t wail Waite,
7 IiR�e>.4 Waad PertMP.O neyraavTra, teff .onatve a that 104 1Ma.e elatirerae to
Cotlypany tearrandor (1) reel not tonoIn arty tipayiel tka+te that h not Ir:.adlee0y df.raril•44 an
arty notifio.6on obbwmaA t watt 01 W7'ICP la etreArogU.r01. approved by Me CAnog am, (If)
13111 now tt. malaflal Ooioptior• 4-6 get lo!"11 17 ory App cettr aryl pkArwla. In .'I aigrifroa9
negate wad (II,� wet not og4Jn 1.1m0C4*ap+0 wawa 7'v. payee coat irw,vpv•• 46tf9d06'
e0K Wane N NM of beta AOrMnant i paw t9 *Entry al .den IS 10 =ar1I 4ity.
Cene,ut(F'i4 alnaftded an AppYa..bo' fo! soon uVaoto one Coen:soy h*o approved aaawwt of 10
ouch Waste whit• 614 t/12220.11 acnte4le0 t, COtpany a µLoin rasp cf
approval cf t%9,cia Walt* Cfgoes. Tide to any and atI W.aa handfed or Al/vVead et by
Caltt?ahy arum bt all fahm nman wan Clen yaw and Lraaar (f a laotar b roor".dl
t;.
tl)g.IT OSAIL Ige.14b111911 The secanaor anal InspaIt oe W4440 w IA. 7404(1) 0/ a011Gban
and ehMI carnovo any and ant Unrlonglab4 Waal. Company ma ids rah to 'hats or to raJaal
roar ae..rrarro., .m• torte or Wawa, dwlxwrw to Ib Facility Watling 4g f the Gemarrn'
aiOJM t . Latarator hw kw-tad ,a 4 unmanly) let repttawftt44501s wwrnabso, co,,t+araa
or oproan a:VI netwnrkr. a a,y ualtci.bl. ft.**. Mita or 101141 1x47,, r4gukiiorla, rat..:
.Wire ever a c1yy, ponfon 0( t„Cly W•ot6 Iuiw'a ie unacoeaabl.. 11,4 Company Mal 144. 1114
%MI tc 1re201$t4 dl 64 14$!s and caballero d W,ealel mair4, hatiernp trw OierPoo Ore ',KO.
In order lo deWttt.lrn atatrer the Waite la Aate,b6te W114211 of Un►ccepldort y4.4a puretarn
k 'fora ?oroom.re .4-4 sit appNo4W. 140.1.1 o1atc anti halal taws. Mao and regub one, "1.4
Ctmoaryh Pram',.°. 01 %APP m ,awrciot n. (IQhka 'ntrammar .hra oat .page to (4414. the
,Jawato of ib raaUerulbiltioe a. 0'3410 tutor Mro Agrinma/tt. T'» (1awrata st47 Ga
nwix.,0 )4► 4-Q, and VNr se ta4afsilray 404I14 .rtr.l r4anWQ44 lILUned by So Company. 4-14 w
104141t .t Ma iinacc.pahle ''MOW end x4- 4-r rytoana dad mono,* of iklucr tatl6 144
1711 4 at tow vocally. The Canp.ny, ruby alma. in 7b oda alsoe440n, moat(' Tol asne tow 113
pro e011Y nowt the .V11O04ptlS4. Wfoo
The Aa ,roam woad** O•r.(eto, 1Yfel 9 114• 411 a arbor b4 Pacley
IV Ix>I� pt,roas4 of, and only to tho axt.,rt netea4try for, eff•keding Atoeve0l4 NAM* t4-
• 6y in 616 warner dveettd by Qom7l7 . except a an T 1p10.�yry,'Owr.r.rs�e
yr6ormel shag not Maya the 4trapac1aI tnoteb of thrair yo$444. niter eff.p.4ay the W4Mer
t*en6Totvr'o p660r0IP14M4 prom pey.644144 paelI y. Vr414( ne arewm4.+e. T404 teen «ter
or 16 ptrwnnu, ertp004 eh a.1y ace,enlyrrQ of Wb,ab of GOA, medial. at the Fo011tpr, The
Ot.n1i'i4y 4-,4-.11.14 ,J1a Nat le nut, 4,14 .Aorta 0,440111b24 nits and 00461104fli eanc.hln
1206 09arati14 et Ma ream, tta o0nd4470 d ! .4 divan. end abwrs on 6t. Peeler w•malea,
guantty.a Lae aaxeaa of Weebe. Mod wry 0041 manors n44arc.>otyt e4- OMfAW for oho bag, %01i
end a1644nt 04410teon of (tor Fa01k matu4 , Gtr: oot !Wig! t0. 6peed 11mtb 0.4 010 mode
ur10aaed by the Company, and Ihs wearing te had hots and aW, er psi** prehe;tmn'calorie
by all 1hdn1dtt* 40044 On Pt. reed* 00110&0. briar m4- gam G 04tlerm to suti, 044104
and1egtaWtap M toy may bo a.1a0W1t.Q and n1dad moan en. ea atm. (4111Mny miry
ehf30 to 400 pt Npn 4.4-11 ate malf 4404- an enr.,'1ca noarwer b, any es Q aer,aar'6 FMi 4-w' .l
wean OQ4040' 1y b4116vaa a OW ow Mltaan cis of ro0ttd ea 01hr dental aubatanaM.
rieneillo4- .tine !y adety oago0ada b, ro arny4oyara. and 44op.netalloa 4.ffeerlIn0 12,.,
060.1.0 0fra m ♦ eQ, nuIu .4w0 at dm (artjhty 4f Company.
6t:Nr4 Phy.narll Inge t,• 'bads by d.yt.0.tor uty,pl non (10) 9.y4 40412 re.a'pt
t1. tnrolat 10401 Company. M the e1en4wt.>!y htn1474 i6 onaaMu►, Ina tleePparfy may fomenters
onto¢ lagrastrart. Oanergtat agates to pay a finance Metrge &Peat to bib 101611 4011 ro.ol 4-s
94 16)44 by 100. O204(•6 "1 60 WWMt lOr 411 6)1,44, fain, or 9144 oJ04 gat ial464140 upon the
4»Pos•i of the WpM b4- federal rase moral Of twenpeaty, from
220 b) dm*, nay nm04 6k a th4y 640 simian
oaks to C.YMrater.
11. neury104. Tsen (*0(7 •bl'9o*000. repr.s nine 0, werno-Os and a044nionh wangling on
4v4,1, gateau ea wa4 461 Y elemaldrea akad toro$, arm nbt)A 01 tfaa Apraanittt. Should
Bator (rnttfiP)y patio in any it ba tl•Q6ton. h1'..arcW. Ozer GI:awry mom tnnadlee,b
»runnel. t"c Arp14en14ra end Gambia& an4) to teieie far 4b coos am! 174111440 *4001Tad try t•.
Company".
17. cottliSmtdeggar, 001100no0 r 'apnoea-104 Wr!ertb end ow•er4Ma VIM 161 40040
4,114 41.6x, 61.121. to oornpary'a facility Pavia bon tayw44 by CI mania' of the compar '0
piYrtbylon 0h *avant.. of naear1044 frbeer1.L v .aha6nnm r.d:r..Q404 n'4tWNa
sutsstan0/e, v toeif create 01 aubanrrw. 00 eat .Mr LrMooeptibh Welt. b 4a reality a(
tompuny. Ive6nO.0fta x+ 041,4048 or acrid W.eto b 4o• rwoialy, of Ma doefarol& of
..rts1a.4dotm Ante str0 etaaa1ax+a dupeufioat- r farvul1rr by oppdw4w4 Wier H. 0** a,.•
bowl taw. Latta and reg•JMon. 4014 ' pn:W W1114' ee prevltfd 1141114-1, .tat d far 14m1 d tidh
Itherree 61 14t4r Compen M 1(SI
17, ().04-04.4- llb/1 kttderrey, Wand and h.4 1140440.4 na Company and It
uglatalMea 4494144 440 genre curppyt*r4s, et ppaceb1. 0140 Asir r9.4000Ne abeam,
ot144S045, 4rtdar2. emp'0yaee, rt...Wa ran ee 4412 "game fr014 tr,a gong arty and 41 0 44mu,
NA, 144040. 14t111t4a4, taaatimenta, datn4Jar•, fm4a, ants and expo/mei, 11cfudklp 04400220
e 041448 1104 400% 140440 00.011, oat. 1..4 boot lies. rugagnane ar 44tlbtano.a, M 14441164
the cwbeot 6f the Weeset et abaft; true of or m 404040(164o '6461 any 12400 of elk; Ap6tment of
.MM➢ ees or 1410 ne994944) 044.o6vn. 21010400110ioo aid disgeee1 d Waage by 15)4Mf1m1 or
0...,M016 eflrployes, 4Q4rda, 1Ob.ontra0t7f. 10 feprt ranbel s •»(12C(, Cieftwa 04- ghat 9466
tar 0 66.41444. for I0044ted k1.pamon, t1atia4. M',# erld 4 4y014 oaf, mad* worry duo
44 f4aaoraia. Cweam. 44 ma Compeer, be 10 dH coneret d h. Weft 4440410Q oroawy a
U,w.o4DOb41 W. '4411 Ir0401ib4Fen and 4414 odip.Npm. *Wad M 9+64
Ara .14r4$04 41a t.nmwat10 4f O4 adrotMMl.
14 1f- IA*1404 Conway( .rt.1l ga.Mtn Ira hen 4rn,. ant toga Mioaeramtt tie t.mt 44 (Ana
.AgTaMnenl the b:40.004 typed d tneurmaa I' s1 '.get 604 arnae1rrw epecilltdaels.s.1
minnow's '.lmnpansaeon
041/0011 Liebd4f ;50D,006 40110We.d ,..are tom
4440444414 L1,b41h
11600.000 044480044.4'l 11 Imo
PAGE 03,•'03
vial Waste Service Agreement
Alt irra0 4'000 w44 e. by Meurer; 9uwanz,4 . d. 4,1tih.» In ma opetr M ymlo.1A. a.oaq ,r wceten. r,01
To Ceranrak r bang aflowad an rila411Y preview. Gateman •010 pTnvidr the Company atm coretiratso 0'
Araranat M 06140 0.111011Ofy ,o5* 4-04 (het .1.63) 4174,w40
Ma bolt precutml fad a In iw6i. Sei4 p.bts. d1,N nai thweifc. G. Plneelvd. b. pxltal 41 fi ■79i,41 c4-
61.14-, a be cherq/d wrevme., thlry (3p; day9 ad nines wr1t.n nO46C, to thy Cc 1640/ 09n21410r tvan0164
ohµ it 124-64 admire lha sue. rnini11l0 4moterm of 6,»4!'4012 from only No;rfyrteVM+ a Ma W 4alt tc irte
tuatara.
pAktig• Portal. Nether party INreao ease be (1.664 tot d. fallorn 10 p.rf04m naaunrfar d a to
altm1 • ttat 110 dui 3n4 twyOrxi ,b ramarmliae acnttfol, 400144404, but not inn frail en, 14 oo4 or Vat
lobar 411444.6, rl eta, rage), goal d4s6,rbM•1a a eebintag.. cmando4 to t7w. 5ray. 1112000, dorteptanoe 0412th
googol-room ,equ.ste. en-744.0na..40aenta, roestAmt Ifrok of ragar.d nee"( relbronaw or eel* eA (300
affueng et* party Mrµ,. In the avant of ony at the clhturne11000aa oro41d4d 00f in 21. *0;,ding
aravance. int idled. but 110419464416.1001418., any 4641.11, atop? or Ireae muri pr ppwmmcrtbl authoa14
Wes any elan wetteh reload () doso of re boot operwpoM .t the I' so4Pa'', (10 Limit 11e4 menet, 04 preNb't
to 3.012.. )f VyaWe 14161. Fealty. 70 (Yl■ 6140101 404 d 011=0E0202 4m1.061O1 1460 /7/211004119 W2221 to
noon f4cilly, the Oornpreny 41441 )rte the tlghl, .0 rl► opbon. 10 9Th0ay, r..e9.r•4 Or tannins. G0nrro!tr
.owed to dr. Farllhy .wn.a4t1y. 14141013t pear notlo4 ,rrl vrbh000 any .1744144-x4- 6444-0,• xmrwn o.v.
party, other 6114 tMreweti( 04401'4'0 OblO1:I610 104011MM' Norma,' Party t3 'Licat0 d F..1.10,.,la t'
Mb* any lab:. *trotffi' syaVal m °•11 aMl ls•d4mae,t.
4 tyaCti 71111a1,4p Tn. 4001.0.116» at arty of the f 4ked%) ,wefts anal a.a t,'on1Rtda en er..0 of 004112!
0y 1.e 9rtciato' 0447.haIl aka (A1 Company the root la trunod411*44 V4'th•r4,rn1 this A4rt4(1ern
(Ai A oataten for Norden=On 71 bon efu0my i14.d by or ayolnts 4„ W.rnnw(o,,
((1) Fedi" of Gaarata to pay •ny .100131 tk flora LOntbeirr.f .
(C) 404 lct.acn try t'krnavtor of any of 46 0642200 p1Xoutrt 6a the A94# m.ru.
0.naxor &null be Nabl4 for Ltd rind( ■ndansafy. nef.4-q 110 had h ■mdeas CompyM tram VW 160262.
01104 eg02640 01 natrape incurred by Me Mmerany se b row* of mf..,in ffon be(aund0r,
tT, efeisnAu. 13.044,110, ma4 r104 n8elsn, 04044 r ., tow*** 1+024 10. any mbar Ccoo4oM. ant4Y or 0er004,
In hyho.e ?4-'h port. +ny 04 es right, 00 obl10161003 anew Into Ayre4m4nt 1v ltata Ina 8)14• vnrtcn 00404.111 at
the Camc'eny, prwtdod, hoyrrv.4, for 15o Conlpr6 may rrifh04d any such prier 64-140 :orvaerl, s:vidn b
ripirb w#,04 abipediena W4) 64 Ayeem.ra to 1100.1444,7, or.49141. 41200001,10.
10,
ffalikestot_illliormal, Tha Ad moment de4. nee °rent 44y fights to !Rapport of Ilybau, other s,.., (r, ecac 111na4
1,4rm,v4h, The 0001 00Y nape °. the nyht to imr e0104/y tatmfnate 4ccten 10 m. Fr: "y by Gene,r1&47
and V.nertwtr'6 064)141»1 in toe want of Iraesa1 Of b40l.ac.l by Cef,efef o. o' any M ew inane of 444
Apnahnrll, 11', Oomperfe ap.rleero r141s 04- 1444-6401 po➢ci.c a 4ny hpttheeb6141ra of tigL41410116,
11, r T1w 47e0wrator hat a cola/1301g 40141•600 T Iron, 1.4 company at 4-m new
6rrperrweion, 444(Mn not 4n..rlottily olo004 4 to the .WnOany 6y 6an.fte04 44144. 4t Bey 06411 bhe
soaepttebl4b of has Waft by the Company. F4ath.e, 6'. Gar*wor 4176' ar•ypy 1002 v! Compeln9
re:0mM hw 4.64.rb, 446 Oaner $O0'4 rgrpffht.n4 oompnanea MIn (104 64-04 of the A4n,m.r0 ina,ue149 044
not pmiIod to the Tolleelnct (0 trovidtnp nwr. updabd Whi4 Pnf224 an the Waseda) 010.00 In, ir4Doest
Or, CO pltMMefnQ appropriate aereflr•J67n that 414 Wee* DaNm olferaf tar 071p0040 is arnun44143 T014045).
the .ppeopnIie or, (a; /1040/0910 the Warne at oe04104../1 exp4nt41 rya..n.bre ...Jr. 40400
At 40 Us wombat W4 4049141.140'12 of his 4,4r.eitlem a, (.a) chew ate 00043114(440 12-e0p22 11a Waal-
ae Oenaeh,r1 axeerua J rena4.40ble ua1»e aces se V ro eceop4UbilM U NKr 01114 terms of Olio AQr4yhoe,i
Of (v) all of tit above
74.
VU Tht■ Aonum9nl.hail 61 gevernrd ty Y4- l 4 et6,.a Stara 40 vrhrcn too Rdrllty 1, bcr4e4
ft)
4-le %te r ef 1 bn.oh of arty of its abhgntwn■ Coffered 40 the Poloomenl t4- ,.4I b4 106.0.9 4-n o.
WOE'S, M Woe Rib, a0 rambtednp 141414 (4 he 4911,9 46,449940 or or ray titer abli,^,zdkm o'f 4410
Agrsam.nt
tea meal9o.son, r441, di.ahar44 14- Hah'4l M any prevIalhn n4- ob0gavon htlar9 01a1 b. 01 any
10.;12, or 4100.. unbp in y00lr'g tired by ea W tdoo to (0410 4,444ama11
(C» 4.n.tatee true treat es crnm04fe44i Imo ■:.t easalo4* to OTheft 44wln0 (0 114y6V,teJr'4' 41. M torn% cd
424 090wmant. 4lel4 4 14 b 1140.04947 10 i)4rfa114 6v. Aertatf4■. Jo to aarntaf4 �ry 1 1204 al:I fk'att4
1114 00 (99(41rmn any 94440.110 O1rc4td1n4 61041 000 1014 i1 04000 011. 443.1.4114 ed Qe144 reeeterey
11■4 C:oinperry's p144a, plypmb,l, 94411, procer444, p,adut -1, ac440, .434010411 4-r o *4.4. ftv.:',dlldn
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(0)
DATE ISSUED: 10 -10 -2006
WORK DESCRIPTION:
WORK LOCATION:
OWNER NAME
ADDRESS
CITY, ST, ZIP
CONTRACTOR NAME
ADDRESS
CITY STATE ZIP
FLOOD ZONE
BUILDING VALUATION
SQUARE FOOTAGE
OCCUPANCY TYPE
TOTAL FEE'S CHARGED
PROPERTY IDENTIFICATION #
PROJECT VALUATION
CITY OF TYBEE ISLAND
BUILDING PERMIT
DEMOLITION
18 FIFTEENTH ST A & B
RESORT INNS INC.
PO BOX 2880
TYBEE ISLAND GA 31328
SOLOMON LANDSCAPING
PO BOX 13
TYBEE ISLAND GA 31328
P
$ 200.00
$_5,000.00
PERMIT #: 060533
TOTAL BALANCE DUE: $ 200.00
It is understood that if this permit is granted the builder will at all times comply with the zoning, subdivision, flood control, building, fire,
soil and sedimentation, wetlands, marshlands protection and shore protection ordinances and codes whether local, state or federal, including
all environmental laws and regulations when applicable, subsequent owners should be informed that any alterations to the property must be
approved by the issuance of another building permit. Permit holder agrees to hold the City of Tybee Island harmless on any construction
covered by this permit.
This permit must be posted in a conspicuous location in the front of building and protected from the weather. If this permit is not posted
work will be stopped. The building contractor will replace curb paving and gutter broken during construction. This permit will be voided
unless work has begun within six months of the date of issuance.
Signature of Building Inspector or Authorized Agent:
j--a/Nev-\-AD Jb
P. 0. Box 2749 - 403 Butler Avenue, Tybee Island, Georgia 31328
(912) 786 -4573 - FAX (912) 786-5737
www.cityoftybee.org
Location:
CITY OF TYBEE ISLAND, GEORGIA
APPLICATION FOR BUILDING PERMIT
cC.erawn P (AZq 10-tc I , I S A 413 IS`I'r' S+. PIN #
NAME
ADDRES S
TEL
Owner
P.t !+r 1- I�itk, c1. .
5 q
&Soi-I' Irb-,S -1- ^c
St,- A
ILIO1 st+.� A.
�i 12 x-
71A0 -7-771
Architect
or' ngineer
/Knilding
Contractor
lu+to
t-dmetglApin.1
P. n 8 6)(
Ty 1,ct Co A-
13
313
213
(Check all that apply)
❑ Repair
❑ Renovation
❑ Minor Addition
El Substantial Addition
❑ Other
Details of Project:
❑ Residential
❑ Single Family
❑ Duplex
❑ Multi - Family
❑ Commercial
.t S� e-v►1p
❑ Footprint Changes
❑ Discovery
JW Demolition — Hoff S c
Estimated Cost of Co
Construction
(1) Wood Fr
(2) Wood &
(3) Brick Ven
Proposed use:
Remarks:
(Enter appropriate number)
4) Masonry (6) Other (please specify)
5) Steel & Masonry
ATTACH A COPY OF THE CERTIFIED ELEVATION SURVEY OF LOT and complete the
following information based on the construction drawings and site plan:
# Units # Bedroom's # Bathrooms
Lot Area
# Off - street parking spac
Trees located & listed on
Access:
Driveway (ft.) Wit. cult' With swale?
Setbacks: Front Sides (L) (R)
# Stories Height V ed from the average adjacent
grade of the building to the extreme high o �1� e� exclusive of chimneys, heating
units, ventilation ducts, air conditioning ►:, s, elevat rs -, ld similar appurtances.
During construction:
On -site restroom facilities will be provided through L4.. � a.
On -site waste and debris containers will be provided by Ze.p,, A, I u ass+ t_
Construction debris will be disposed by 2,4),6(;c, oat{ -c.by means of
I understand that I must comply with zoning, flood damage control, building, fire, shore
protections and wetlands ordinances, FEMA regulations and all applicable codes and regulations.
I understand that the lot must be staked out and that the stakes will be inspected to ensure that the
setback requirements are met. I understand also that a certified plot plan showing elevation must
be attached to this application and that an as -built elevation certification is due as soon as the
habitable floor level is established. Drainage: I realize that I must ensure the adequacy of
drainage of this property so that surrounding property is in no way adversely affected. I accept
responsibility for any corrective action that may be necessary to restore drainage impaired by this
permitted construction.
Date: 8 .23.0 0
ignature of Applicant:
Note: A permit normally takes 7 to 10 days to process.
Vtl/ -.i
0114.► L 3 c r
The following is to be completed by City personnel:
Zoning certification NFIP Flood Zone
Approved rezoning/variance?
Street address and number: New Existing
Is it in compliance with City map?
If not, has street name and/or number been reported to MPC?
FEMA Certification attached
State Energy Code Affidavit attached
Utilities and Public Works:
Describe any unusual finding(s)
Access to building site
Distance to water main tap site
Distance to sewer stub site
Water meter size
Storm drainage
Approvals: Signature
Zoning Administrator
Code Enforcement Officer
Water /Sewer
Storm/Drainage
Inspections
City Manager
Date
FEES
Permit )
Inspections
Water Tap
Sewer Stub
Aid to Const.
TOTAL
REQUIRED FOR: Building Permits
Relocation Permits
Sign Permits
Demolition Permits
Land Clearing, Disturbance or Excavation Permits
Tree Removal Permits
Relocation Permits
Special Review Permits
Site Plan Approval
Subdivision of Land
Sketch Plan Approval
Preliminary Plan Approval
Final Plat Approval
Minor Subdivision Plat Approval
Major Subdivision Plat Approval
In addition to specific requirements for the above permits and approvals, applicants must
demonstrate that they are in compliance with the City of Tybee Island Storm Water Management
requirements as outlined in Chapter 5 -4, Code of Ordinances.
Section 5 -4 -9 Prohibition provides, in part, as follows:
(4.) It is unlawful for any person to cause or permit any storm water to flow from their
property onto the property of another person, unless such storm water naturally
flowed thereon prior to any development activity.
(5.) It is unlawful for any person to interrupt the flow of any storm water runoff from
adjacent property onto their property by any development activity.
As part of the City's approval process applicants must illustrate how these storm water
management prohibitions will be met, including a showing of how storm water naturally flowed
on the affected property (prior to any development activity), and what changes in storm water
flow have occurred or are expected to occur, as attachments to this form. The City's approval or
permit does not guarantee that the applicant's plans will result in meeting requirements. The final
product must actually meet the City Ordinance requirements.
Applicant name: Ju, T. Ce_tz-,..) a.1.4 oE., Z_
Project I.D.:
Attachments approved by: Date:
Location:
zIC
CITY OF TYBEE ISLAND, GEORGIA
APPLICATION FOR BUILDING PERMIT
l g A
NAME
ADDRESS
rc‘•
PIN #
Owner
ets.ri 1 G
L
-745- --)7-1-1
Architect
or Engineer
II
I.( M2 gdc /s
%,
/
i,
'nap - 77 7 7
Building
Contractor
OICc.no '4.2ct.
'1
If
%. .,
(Check all that apply)
Repair ❑ Res • ential
® Renovation ❑ Singl Family
❑ Minor Addition Duplex
❑ Substantial Addition ❑ Multi -F. g ily
❑ Other ❑ Commerci
Details of Project: Ik( IA.)i o•.)
d /84t 3 "5-tS s4
Estimated Cost of Construction: $ /5b0 (21=
Construction Type
(1) Wood Frame
(2) Wood & Masonry
(3) Brick Veneer
Proposed use:
Remarks:
(I J
es
❑ Footprint Changes
❑ Discovery
❑ Demolition
on .b.4.70 1...)c you �2
(Enter appropriate nu ber)
(4) Masonry
(5) Steel & Masonry
(6) Other (please specify)
ATTACH A COPY OF THE CERTIFIED ELEVATION SURVEY OF LOT and complete the
following information based on the construction drawings and site plan:
# Units
# Bedrooms °Z # Bathrooms Z
Lot Area Living space (total sq. ft) 700
# Off - street parking spaces '/e s
Trees located & listed on site/plan N/4
Access:
Driveway (ft.) With culvert? With swale?
Setbacks: Front Rear Sides (L) (R)
# Stories 1 Height 4,30 1 -, Vertical distance measured from the average adjacent
grade of the uildin to the extreme high � p oint of the buildin g, exclusive of chimneys, heating
units, ventilation ducts, air conditioning units, elevators, and similar appurtances.
During construction:
On -site restroom facilities will be provided through
On -site waste and debris containers will be provided by
Construction debris will be disposed by Coi .,sj.
>4 S
y-e s
by means of evm.lizli I- 1.)*s%e-
I understand that I must comply with zoning, flood damage control, building, fire, shore
protections and wetlands ordinances, FEMA regulations and all applicable codes and regulations.
I understand that the lot must be staked out and that the stakes will be inspected to ensure that the
setback requirements are met. I understand also that a certified plot plan showing elevation must
be attached to this application and that an as -built elevation certification is due as soon as the
habitable floor level is established. Drainage: I realize that I must ensure the adequacy of
drainage of this property so that surrounding property is in no way adversely affected. I accept
responsibility for any corrective action that may be necessary to restore drainage impaired by this
permitted construction. T -i T• Q.N,a.k of Z
--n'
Date: o • 2 • o tP Signature of Applicant: 1
EP
( J
Note: A permit normally takes 7 to 10 days to process.
The following is to be completed by City personnel:
Zoning certification NFIP Flood Zone
Approved rezoning/variance?
Street address and number: New Existing
Is it in compliance with City map?
If not, has street name and/or number been reported to MPC?
FEMA Certification attached
State Energy Code Affidavit attached
Utilities and Public Works:
Describe any unusual finding(s)
Access to building site
Distance to water main tap site
Distance to sewer stub site
Water meter size
Storm drainage
Approvals: Signature
Zoning Administrator
Code Enforcement Officer
Water /Sewer
Storm/Drainage
Inspections
City Manager
Date
FEES
Permit
Inspections
Water Tap
Sewer Stub
Aid to Const.
TOTAL a S.
10/09/2006 15:45 9127866538
October 9, 200
TYBEE ISL HIST SOC PAGE 01
TYBEE ISLAND HISTORIC REVIEW COMMISSION
Dianne Otto
Administrative Assistant
Building and Zoning
P.O. Box 2749
Tybee Island, Georgia 31328
Dear Dianne,
1 have made a site visit to 18 A& B 15th Street and found that while the property has
architectural and historic significance it would not be cost effective to move, 1 have been
unable to find a property owner willing to commit to its relocation in a timely manner_ 1
would like to take this opportunity to commend the current owners, especially Juan
Fernandez of Ocean Plaza for extending more than reasonable amount of time to try to
find someone to relocate the structure. Please feel free to proceed with the Demo Permit
as soon as possible..
Cullen Chambers
Cl.1LLEN CHAMBERS CHAIRMAN: P.O. BOX 366 TYBEE ISLANA GEORGIA 31328
OCT -09 -2006 15 :58
9127866538 98% P.01
09/15/2006 14:35 9127866536
TYBEE ISL HIST SOC PAGE 01
TYBEE ISLAND HISTORIC REVIEW COMMISSION
P. O. BOX 366 TYBEE ISLAND, GEORGIA 31328
September 5, 2006
Diane K. Otto
Administrative Assistant
City of Tybee Island
Building Et Zoning Dept.
P.O. Box 2749
Tybee Island, Georgia 31328
Dear Diane,
I have made a site visit to the property located at 18A /18B Fifteenth Street.
The structure is historic and does have architectural significance both related
to the resort era of Tybee Island's history. As such, we have notified several
possible property owners who are interested in relocating the structure.
Any co - operation in extending the demolition time frame would be greatly
appreciated.
/ )rety,
Cullen Chambers
SEP -15 -2006 14:47
9127866538 99% P.01
* * * * * * * * * * * * * ** -COMM. 2NAL- * * * * * * * * * * * * * * * * * ** DATE SEP -01 -201 * * ** TIME 10:08 * * * * * * **
MODE = MEMORY TRANSMISSION START = SEP -01 10:07 END = SEP -01 10:08
FILE NO. =614
STN COMM. ONE- TOUCH/ STATION NAME /EMAIL ADDRESS /TELEPHONE NO. PAGES DURATION
NO. ABBR NO.
001 OK a 7866538
001/001 00 :00 :39
-CITY OF TYBEE ISL.
***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** -CITY OF TYBEE - * * * ** -
Date:
912 786 9539- * * * * * * * **
City of Tybee Island
BUILDING AND ZONING
P.O. Box 2749 - 403 Butler Avenue, Tybee Island, Georgia 31328 -2749
(912) 786 -4573 - FAX (912) 786 -9539
www.eityoftybee.org
FAX TRANSMITTAL SHEET
0q -o. o,
Number of Pages Including Cover Sheet: 1
To: Cullen Chambers
Company Name: Tybee Island Historic Review Commission
Fax Number: 786 -6538
From: Dianne K. Otto
Title: Administrative Assistant
Phone Number: 786 -4573 extension 114
Fax Number: 786 -9539
NOTICE OF APPLICATION FOR DEMOLITION
Date of Application _ (:)q - 01- 0(4,,
Name of Applicant $.���,G /."Diia hie rnoncaz.
Phone Number "1 '8 to `1 y 5vS
Location of Structure j A-1- 6 r
Date:
City of Tybee Island
BUILDING AND ZONING
P.O. Box 2749 — 403 Butler Avenue, Tybee Island, Georgia 31328 -2749
(912) 786 -4573 — FAX (912) 786 -9539
www.cityoftybee.org
FAX TRANSMITTAL SHEET
Off' -a1 -0co
Number of Pages Including Cover Sheet: 1
To: Cullen Chambers
Company Name: Tybee Island Historic Review Commission
Fax Number: 786 -6538
From: Dianne K. Otto
Title: Administrative Assistant
Phone Number: 786 -4573 extension 114
Fax Number: 786 -9539
NOTICE OF APPLICATION FOR DEMOLITION
Date of Application 0 ? - Q► -
Name of Applicant z 504 -In' - N c • / U C u a.h f e r - Q n j a z
Phone Number �1 g Co - -1 —1-11 x 5.3 S
Location of Structure I A t 6 F 11 een l-k 54