HomeMy WebLinkAbout2700 S Lemay Ave - Applications/Demolition - 07/09/2014ASBESTOS/DEMOLITION
NOTIFICATION and PERMIT
MODIFICATION FORM
Submit form to:
Permit Coordinator
Colorado Dept. of Public Health
and Environment
APCD-IE-Bt
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Phone: 303-692-3100
Fax: 303-782-0278
asbestos@state.co.us
an ei'�'%'Faci1it�O Facility Location: /,
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SAc l UV GAC/Consultant: Phone # Fax #
Y7 S�- 1(97o)67V- 0010 (70 )674-047
E-mail Address: Permit Number (if already issued):
i/c,c.ls t/ 99 GL Al ra7�ta.��, � a, _row W k 3 q 7 61)
Please check the appropriate box(es) in A, B and C, as applicable:
A. Upgrade to: 30-day permit ❑ 90-day permit ❑ 1-year permit
B. ❑ Request to cancel above notice/permit. (All but $80 of the application fee will be returned. If you paid by check or money
order, a state of Colorado Warrant will be mailed to the company appearing in the contractor box on the application. If you
paid by credit card, a credit will be issued to the same account used to pay for the original application fee.)
C. Change in:
❑ Supervisor:
701
0
Certification #
Certification #
❑ Project Manager: �/
/ Certification #
tart Date: —/�— Iq LJ✓ End Date: Z5 J q
❑ Work Times: ❑ Disposal Site: ❑ County:
❑ Additional Scope of work (include type of ACM, quantity, location in or on facility and work practices):
I certify that I am the person authorized to sign this modification on behalf of the General Abatement Contractor and that all
statements made in this modification are, to the best of my knowledge, correct and complete. (Note: Making false statements
on this application constitutes second-degree perjury as defined by 18-8-503 C.R.S., and is punishable by law.)
7 — 19 —�
Authorized presentative Signature Date
1.2
Printed Natud Position or Title
THIS BOX IS FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date:
Approved By:
I Code:
Form of Payment & #:
Permit #:
Record #:
Date Issued:
Form: NPM08 Rev. 01/30/08