J-0200000-05 Asbestos-Compliance-Form VA.pdf

ASBESTOS AND COMPLIANCE CERTIFICATION FORM

INSPECTIONS DEPARTMENT

15 N Cameron Street

Winchester, VA 22601

Office: 540.667.1815 Fax: 540.722.3618 www.winchesterva.us

This form shall be completed by all applications for building permits to renovate or demolish a building or structure. The owner or an authorized agent of the owner must sign this form and one of the applicable boxes must be checked.

ADDRESS WHERE WORK WILL BE PERFORMED

AS OWNER OR OWNER’S AGENT OF THE ABOVE BUILDING, I CERTIFY THAT:

□ Buildings built after January 1, 1985: The building permit for the original construction of the building listed above was issued after January 1, 1985; therefore, the building is not subject to asbestos certification requirements.

□ The above building is a single-family dwelling, or is a residential building containing four or fewer dwelling units, which will not be used either as a commercial building or as a public development project, and is, therefore, exempt from asbestos inspection requirements.

□ The combined amount of regulates asbestos-containing material involved in the renovation or demolition is less than 260 linear feet on pipes, or less than 160 square feet on the other facility components, or less than 35 cubic feet off facility components where length or area could not be measured previously, and is, therefore, exempt from asbestos inspection requirements.

□ The affected portions of the above building have been inspected for the presence of asbestos by an individual licensed to perform such inspections pursuant to Virginia Uniform Statewide Building Code (VUSBC) and that no asbestos-containing materials were found. Provide Report

□ The affected portions of the above building have been inspected for the presence of asbestos by an individual licensed to perform such inspections pursuant to VUSBC and that appropriate response actions will be taken with the requirements of

NESHAPS and the asbestos worker requirements established by OSHA. Provide report and obtain asbestos permit.

□ The building permit application is only for repair or replacement of roofing, floor covering, or siding materials. The materials to be repaired or replaced are assumed to contain friable asbestos and the appropriate response actions will be accomplished by a licensed asbestos contractor or a licensed asbestos roofing, flooring, siding contractor (THIS OPTION IS NOT PERMITTED

FOR SCHOOLS PER THE VUSBC). Provide Report and obtain asbestos permit.

In addition to the above, I also certify that:

□ Any asbestos abatement area will not be occupied until all response actions have been completed and final levels for re-occupancy of the abatement area shall be 0.01 or fewer asbestos fibers per cubic centimeter if determined by Phase Contrast

Microscopy analysis (PCM) or 70 or fewer per square millimeter if determined by Transmission Electron Microscopy analysis

(TEM).

□ If the structure is to be demolished, the owner or owner’s agent has obtained a release from all utilities having service connections to the building stating that all service connections and appurtenant equipment have been removed or sealed or plugged in a safe manner. The owner or owner’s agent has given written notice to the owners of adjoining lots and to the owner of other lots affected by the temporary removal of utility wires or other facilities caused by the demolition as applicable.

Signature of Owner or Agent Date

CAUTION: While proper completion of this form satisfies VUSBC for permit issuance, notification of applicable state agencies may be required. Asbestos inspections and abatement at licensed daycare centers is further regulated by the Virginia Department of Social Services Division of Licensing. For more information, contact them at (804) 662.9743. For additional information OSHA/NESHAP regulations, contact the Virginia Department of Labor and Industry, (804) 786.0574. OSHA may require additional permits or inspections.

Excerpts from the Code of Virginia Pertaining to Asbestos Disturbance and Removal

§ 36-99.7. Asbestos inspection in buildings to be renovated or demolished; exceptions:

A. A local building department shall not issue a building permit allowing a building, for which an initial building permit was issued before January 1, 1985, to be renovated or demolished until the local building department receives certification from the owner or his agent that the affected portions of the building have been inspected for the presence of asbestos by an individual licensed to perform such inspections pursuant to § 54.1-503 and that no asbestos-containing materials were found or that appropriate response actions will be undertaken in accordance with the requirements of the Clean Air

Act National Emission Standard for the Hazardous Air Pollutant (NESHAPS) (40 CFR 61, Subpart

M), and the asbestos worker protection requirements established by the U.S. Occupational Safety and

Health Administration for construction workers (29 CFR 1926.1101). Local educational agencies that are subject to the requirements established by the Environmental Protection Agency under the

Asbestos Hazard Emergency Response Act (AHERA) shall also certify compliance with 40 CFR 763 and subsequent amendments thereto.

B. To meet the inspection requirements of subsection A, except with respect to schools, asbestos inspection of renovation projects consisting only of repair or replacement of roofing, floor covering, or siding materials may be satisfied by a statement that the materials to be repaired or replaced are assumed to contain friable asbestos and that asbestos installation, removal, or encapsulation will be accomplished by a licensed asbestos contractor.

C. The provisions of this section shall not apply to single-family dwellings or residential housing with four or fewer units, unless the renovation or demolition of such buildings is for commercial or public development purposes. The provisions of this section shall not apply if the combined amount of regulated asbestos-containing material involved in the renovation or demolition is less than 260 linear feet on pipes or less than 160 square feet on other facility components or less than 35 cubic feet off facility components where the length or area could not be measured previously.

D. An abatement area shall not be reoccupied until the building official receives certification from the owner that the response actions have been completed and final clearances have been measured. The final clearance levels for reoccupancy of the abatement area shall be 0.01 or fewer asbestos fibers per cubic centimeter if determined by Phase Contrast Microscopy analysis (PCM) or 70 or fewer structures per square millimeter if determined by Transmission Electron Microscopy analysis (TEM).

NOTICE TO ALL CONTRACTORS

Virginia Department of Labor and Industry

DOLI

Regulations for Demolition, Renovation and

Removal of Asbestos

NOTIFICATION of DEMOLITION, RENOVATION and REMOVAL of

ASBESTOS

PLEASE NOTE:

In addition to permits required by the Local Authority Having Jurisdiction for the Demolition, Renovation of a structure and the Removal of Asbestos, the VIRGINIA DEPARTMENT OF LABOR AND INDUSTRY has additional requirements for compliance with the DOLI ASBESTOS

REGULATIONS.

You may view these regulations at:

www.doli.virginia.gov or

Contact: Richard Wiggins @ (540) 562-3580 ext. 131 http://www.doli.virginia.gov/