HomeMy WebLinkAbout1002 W Oak St - Applications/Demolition - 09/25/2009Colorado Department
of Public Health
and Environment
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DEMOLITION NOTIFICATION APPLICATION FORM
APPLICATION FEE MUST ACCOMPANY THIS FORM
INCOMPLETE APPLICATIONS WILL BE RETURNED
(Notice will be mailed to the demolition contractor unless specified otherwise)
-yr
Fee: $50 + $5 per 1000 ftZ of area to be demolished = $ 53
(See instruction #1 on reverse side)
Submit form to:
Permit Coordinator
Colorado Dept. of Public
Health and Environment
APCD-IE-B1
4300 Cherry Creek Drive
South
Denver,Rai 1939
Company Na
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Building Name: r(
Street:n
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Square footage of footprint of facility or portion of facility a demo � d
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City:
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State:
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Zip Code:_
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Street:
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Telephone # L �7 7
Fax #
City:
Co}nty:
Zip Code:
Project Manager: Cell Phone #
Propose RStart Date
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Propo ed Com letion Date
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I certify that the rtifi d b Building Inspector has informed me
about any remainin sbest s- ntaining materials in the facility to be
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Met / ea s Dem lition:
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demolished.
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j$( Wrecking [I Burning ❑ Implosion [I Moving ❑ Other, specify:
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UpdTill Receiving Buildin De ris: /
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Burning requires additional authorization — Please call (303) 692-3100 and ask
to speak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
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Owner's Name:
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
3
Street:
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Date Removal Completed
Telephone #
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City:
State:
Zip Code:
Type(s) of Asbestos -Containing Mat rial Removed:
Contact's Name:
Telephone #
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With my signature below, I certify that I possess current AHERA accreditation and state of Colorado certification as
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an Asbestos Building Inspector. I also certify that I have thoroughly inspected the facility to be demolished, as listed
in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of
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asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the
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facility." I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
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asbestos -containing material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
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of ACM remaining, below: (check appropriate box(es)):
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Vinyl asbestos floor tile (VAT) ❑ VAT mastic N Tar/asphalt impregnate roo ' ®rAsWjlj i L-APMn sG
❑ S ra -a ied tar coatings Caulkin N Glazin ❑ Other,
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Printed Name:
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Jame DAisoonn d v
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D t of F nspection
CO Cert #
Expiration Date
Telephone # Cell Phone #
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235
02/10/2010
(970) 266-8000 1 (970) 691-6285
I Vify that all refrigerants from air conditioning/refrigeration appliances have been properly recovered in accordance with AQCC Regulation No.
15 (for information on CFC requirements call 692-3100). 1 further verify that all luminous exit signs (containing radioactive material) have been
wdisposed
of in accordance with 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320).
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CHECK THE APPROPRIATE BOX:
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❑ Building Owner
Contractor
❑ Other
Date: ? yI
V Signature:--"-7;�---� Print Name:
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THIS Box is FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date:
Approved By:
Code: 9-m1iiaa -310 ❑ transfer-380
Form of Payment & #: a& 3337
Permit #: Record #
Date Issued:
Reguiatea asbestos -containing materials means (a) triable asbestos -containing material, (b) Category I nonfriable ACM that has become friable, (c)
Category I nonfriable ACM that will be or has been subjected to sanding, grinding, cutting, or abrading or (d) Category II nonfriable ACM that has a high
probability of becoming or has become crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the course of
demolition or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vinyl and linoleum must be properly
abated/removed prior to demolition.
Form: DNA08
9/21/2009