HomeMy WebLinkAbout418 Edwards St - Applications/Demolition - 10/26/2011 (2)pF C010
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Colorado Department
of Public Health
and Environment
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)
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
Getgaay Name: �</Z o EN
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Building Name: ti..
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Street:
Square footage of footprint of facility or portion of facility to be olished
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City:
State: Zip Code:
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Street:
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Telephone #
Fax #
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City: % /
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Zip Code:
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Project Manager:
Cell Phone #
Propos d Start Date
Proposed mpletion Date
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I certify that the Certified Asbestos Building Inspector has informed me
Method/Means of Demolition:
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about any remaining asbestos -containing materials in the facility to be
demolished.
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Wrecking ❑ Burning ❑ Implosion ❑ Moving ❑ Other, specify:
S' at re:
Print Name:
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Landfill Ft6teiving Building Debris:
tBurning
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requires additional authorization — Please call (303) 692-3100 and ask
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to speak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
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Owner's Name:
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Cell,
CD H Asbestos Permit #
Total Quantity of Asbes o Remwed
Street:
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Date R moval Completed
Telephone #_,
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City:
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State: Code:
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Type() of bestoq� ontaining Mate' I Removed: ``
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Contact's Name:
Telephone # —7
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With my signature Felow 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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ACM remaining, below: (check appropriate box(es)):
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Vinyl asbestos floor the (VAT) ❑ VAT mastic ❑ Tar/asphalt impregnated r ofing ❑ Asphaltic pipe coatings
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❑ Spray -applied tar coatings ❑ Caulking ❑ Glazing Other, spec
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Signature: (In Blue
Printed Name:
mJohn
David Turney
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Datg of Final In sp ct' n
CO Cart # Expiration Date
Telephone # 1 Cell Phone #
1 7 Z ��
16724 I 12/10/2011
(970) 266-8000 (970) 237-2933
1 verify that an 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
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).
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CHECK THE APPROPRIATE BOX:
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Building Owner
❑ Contractor
❑ Other
Date: - -20
Signature. Print Name:
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Afwe•-
l' THIS BOX IS FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date:
Approved By:
Code: ❑ initial-310 ❑ transfer-380
Form of Payment & #:
Permit #:
Record #
Date Issued:
Regulated asbestos -containing materials means (a) friable 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.
Forth: DNA08 2/8/2011
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ASBESTOS ABATEMENT NOTIFICATION and PERMIT APPLICATION FORM
FEE MUST ACCOMPANY THIS FORM. INCOMPLETE APPLICATIONS MALL BE RETURNED. EXit-346
Colorado Department
of Public Health
and Environment
Abatement Contractor
Abatement Site
Building Owrw
Company Larne
Building Naate
Owner Name
Excel Ermrfronmerdal Inc
UnocagAW Residential
Pally Kmesen
Sbeei Address
Spectly location in the budding where work will take place (e.g. floor,
catty.
1852 .tasper Street Unit E
room, wing, etc.) North Porch
Patty Kroesen
CltY
State
Zip code
Street Address
Street Ad�ss
Aurora
co
80041
418 Edvmrds Street
418 Edwards Street
Telephone # Fax #
803) 577--sm 677-9938
City County2tp code
Fort Collins Lackner
City State Zip code
d� died Supesor CO. Cert #
80524
Budging Contact Cell Phone #
Fort Collins co 80524
Telephone # Fax 0
Raquel Galiardo 14063
Patty Kroeum 070.207.1231
970.207.1231 NfJ0.
Project Personnel
Project Infornuftoa
3
bispasal Site
CO Project Mgc. Name
Sf�rt Date
End Date
Landfill Name
PEA
10 Z4-11 /
v
10-2A-11 t„/''�
DEnver Arapahoe Disposal Site
Cell Phone #
CO Project Designer #
Start Time
End Time
Street Address
( )
&Q0 AM PM
AM 4:00 PM
3500 South Csun Club Road
CC f royec€ Desilper Name
Check the day(s) of operagon_ Su rig Tv 1N Th F Sa
City
State
zip code
NfA
0
Aurora
I co
8011118
Cell Phone #
CO Project Designer #
Emergency?
Type of ACK-
COPHE Use only
AS 43
Trensite sidin & cauliking
Consulting Firm Name
Registration #
Linear
Square Feet f Type-55
Drums
Postmark or f3elivPry date
Appr d
CenturyEro�nmentai e, LLC
14837
—�
A.M.S.14srne
Anson
290fl'ltransfi8Form
sidingY
of Payment fi
PM req'd3Susan
WCoto
Phone #
CO A.I�E.S. Cer€ #
Permit # Record #
Date Issued:
303543.Ti18
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Please describe fQelow the work practices and procedures to be employed in conducting the abatement
of asbestos. RE
SPECIFIC- Indicate fvoetsi
of AMA to the atee to a VAT H.irmn "to r_a air- t r r�
anomer page if necessary.
Removal & disposal of appaoxrmste► 00 W of NonlIftble ACM transom siding and 50LF 41 Non Friable ACM window and door caulkhtg. %ft* YA be completed using proper PPE, wet methods, component
removal with minimum breakage within a regulated area. A lirad v+1sual inspection veil be conductxed by a certified air monfioring specialist prior to demobilization by Excel.
APPROVED
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