HomeMy WebLinkAbout518 W Laurel St - Applications/Demolition - 08/03/2011Colorado Department
of Public Health
and Environment
861 y 5-7
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)
LJ II
Fee: $50 + $5 per 1000 ft2 of area to be demolished = $
(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, CO 80246-1530
Phone:303-692-3100
Fax: 303-782-0278
Asbestos@state.co.us
Company Name:
Building Name:
N %7
Street:
Square footage of Got y or Ftlpn of facilit to be demolished
' •
O`-�
City:
State:
Zip Code:
Street:
ekj1,
is Wi
to
Telephone #
Fax #
City:U(
tpro
Code:
3) � -33
(3o�)g 8lQ
p
ctL_LINZip
Project Manager: Cell Phone #
......�3c�3.._.. 3 _ .-�?C�1 1
Proposed StartDate ose dmpletion Date
C
I certify that the Certified Asbestos Building Inspector has informed me
F_
Method/Means of Demolition:
p
E
about any remaining asbestos -containing materials in the facility to be
demolished.
d
0
t
Wrecking El Burning ❑ Implosion El Moving [I Other, specify:
Signature:
Print Name:
Landfill Receivin4 Building Debris:
t
Burning requires additional authorization - Please call (303) 692-3100 and ask
_
to speak to the O en Burnin Permit Coordinator
General Abatement Contractor (GAC)
/ac �C
L
Own is Name:
��� Y , L
Np iC r
3
CgDgHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street:
C
0
>=
D to Rgmoval Completed
� �
Telephone #
City:
ate:
Zip Code:
Q
0) y ��
N �
m
Type(s) of Asbestos -Containing Mate 'al Removed:
I
Contact's Name:
Telephone #
a(ga�:MZ L,-
— 1
C LUJ u_'ttj
(,�b-3 )`;�SV - I bOL L
With ffiy signature below, I certify t1fat I possess current AHERA accreditation and state of Colorado certification as
o
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
Q.
asbestos by a NVL A,P-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the
c =
facility.` I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
N o
asbestos -containing material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
5 a
of ACM remaining, below: (check appropriate box(es)):
a� w.
❑ Vinyl asbestos floor tile (VAT) ❑ VAT mastic ❑ Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
t�
❑ Spray -applied tar coatings ❑ Caulking ❑ Glazing ❑ Other, specify:
V
wSignature:
(In Blue Ink)
Printed Name:
i
U
Date of Final Inspection CO Cert #
s3 l� 7_c>�1 i7io v
Expiration Date
l� 15 2Lt�
Telephone # Cell Phone #
(720)4f -Zzvo (
I verify 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
0
disposed of in accordance with 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320).
CHECK THE APPROPRIATE BOX:
mO
❑ Building Owner
ElContractor
Other C
Date:
U
Signatu e:
\
Print Name_-�
THIS Box Is FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: Approved By: ! Code: initial-310 ❑ transfer-380
Form of Payment & #: 3' �, / ( -
Permit #: Record #
Date Issued:
" Regulated asbestos -containing materials means (a) friable asbestos-conta in I i ACM that has become friable, (c)
Category I nonfriable ACM that will be or has been subjected to sanding, ad'� a II nonfriable ACM that has a high
probability of becoming or has become crumbled, pulverized, or reduced t po er by the`lorceSxeXpe�ted`�'a n 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. r
I ��
DATE_CDPHI<:-Q
Form: DNA03
Rev. 048