HomeMy WebLinkAbout215 E Foothills Pkwy - Applications/Demolition - 05/21/2014 (2)May, 21, 2014 11:06AM Air uf�n 3�u 1
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�o�'�DEMOLITION NOTIFICATION APPLICATION FORM
APPLICATION FEE MUST ACCOMPANY•PHIS FORM
v INCOMPLETE APPLICATIONS WILL BE RETURNED
Colorado Deppartfnenr (Nollco will bo mallod to the donloUtion contractor unless specified otherwise)
of Public ?I find Envinlnmen( Fer,; y00 I• $0 per 1000 ftz of area to be demolished = $ l2 tl
(See Instruction 01 on revorso slflo)
No. 1171 P. 3
Submit form to:
Permit Coordinator
Colorado Dept. of Publia
floofllt and Environmont
APCO•IE•O1
43UU Cherry Creek'Odve
South
Ocnvcr, CO 80240.1530
Phone: 303.002.310D
Pax: 303a07•11270
Ache slnsf0l slnla.ro.us
Company Noroo:
Building Name:
Aluine f3emnlitimi
d
Plaza Shoff
Sheol;
Square loolsge of Inalptlni of factllly or Portion of facility to be dcmaliclind
5790 W. 56111 Avo.
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VCity:
SboeL•��.��et,y�e�, 'z 24 "Zz$ �tAA(�t'IFv Ci
Glala: Zip Cudu:
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Arvada l U S0002
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TelePhonefl Fa%N....•...-"-' •"•
107 47,1-37Cfi 1U:1 940-0868
Protect Cell Phone 11
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Chir Collnly: ppCode: � •
Ft.co'.uns Lc�rlrwl( t�� G
Proposed sin'Unla Compin0an oalo
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Manager;
Sabrina ivinrtin
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Prnposad
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tOLr{?m
corilry Ialm Coifed AobaoOuilding Inspector hasinamomo
means
olll_foll:eV
p
about tiny remaining atbastos•comaining materials in the facility to be
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Wroching 0 Durninal ❑ Implosion ❑ rAoving ❑ Olher, speaffy:
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Print Noma:
rltilura:
/ .
Sabrina Martin
tBurnrng aquirua aadlflonal aunwrisallon- Please call (303) 002.310D and ack
L3ndiilf itmolving Witting Molls:
UPI Towor
to speak to the 0
pert nlymn Parnell Caoggnalot
Gon `
I Abelontonl Co 1 clor (GAC)
Owner's Name-
•p
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W C
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CMIE koosfos Pflirrijif
DR (AIll
Total Ouanlll a Asbestos Removed
Sf ZCAD
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Slreel:
G�1__�L •rlris 1ye__9 ..t�%
Cilia 51110: I Zip Coda:
ILL
Onto Removal Complalad Telephonell
:
�Conlacl'a
_jy2ejs)of AAsbeslofs• onioinln Motorlal Remo+v/pd:
Name: Talcphono 0
.VOCIt 1l�'LT'J' L
With my signature below, I certify that I possess current AHERA accreditation and state of Colorado certification as
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an Asbuslot; Building inspector. I also corlify that I have thoroughly inspected the facility to be demolished, as lister!
In Ilia Deniollllon Site block above, samplod all suspect materials, had all samples analyzed for the presence of
asbestos by a NVLAI-1-accredited laboratory, and have determiner! that no Regulated ACM exists anywhdrelft the .
facility.` 1 also certify that I have Informed the owner/operator of the facility or iho domolltion contractor that any
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asbaslos•contalning material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
j� to
of ACM remaining, below. (check appropriate box(es)):
¢
❑ Vinyl asbestos floor life (VAT) ❑ VAT mastic ❑Tar/asphalt Impregnat d roofin I I Asphaltic pipe coatin s 1
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Spray.applied tar ceatin,(IIs [Cautkin�7 ❑ GlezinL El Other, specify: t
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titgnalure: (in Blue Ink) e Pr Itod^^Noo'nto:
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Dalo of Final Inspi2clion Co Carl it Explralmn Dote Telephone d Call l4iane
5.vs, zr,( tZz-• (o-zg•zot (M —t 126 (2194
I verily that all refrigemnls from air condlllonfnglrefdgarallon applioncas have boon properly reravered In as hince w1Ul ADCC Regufapon No,
15 (for infunnation on CFC fequlremenis call 692.310D). I furlher vedty that oil luminous oxlt signs (conlalnlnp tadlonctiva nintorial) liavo beall
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dlsposed of In accordance will 0 CCR 700%-1 subpart 3.0.4.3 (for Informn11 n fin hrmtnous exD sign requiremenis call 303.692.3320).
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C)IECK 1I15 ApPROPn1ATR fit))(:
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❑ eultllnp Oivnar I�..•'Contrador l,,,J Other Dale:
slu"lurd: Print Name:
n- Sabrina Martin
I
7(�IS sox Is FOR CDPHE USa ONLY:
Postmark or I lore) Dailvory Dale: 7 ��� 7Y Approved By: Coda: ff¢ aF310 ❑_ Ironsfor_300
.
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Form of Payment & If: 9.
Permitill
Record 8
Date Issural;
6.t `i f..
rwoure,ua asaaswa•wmammp materials means to rriame esnesios•comatmna malonm, to) catouory I nonulaotexclw in3i nos oecome ))labia. (a)
Caleuary I nonbiable ACM that wig be or has boon sob)eCled to sandifig, qrindbi , _ruipag, or abrading or (d) Category li nonfrlable ACM that has a Ngh
piobablllty of becoming or has baranie crumbled, ptrlverlxed, or reduced topowder by the forces expected to not on the materlaf In Iho courso of ,.
d m G j40 or fCOnvattan operations regulated by this regulalion. Nola: Aliboslos•conlalnhiy cheat vinyl and linoleum must be property I'. 1;;..1 i i �) '•
abaledfremoved prior to donlolillon. f Iv, �a i
APPROVED
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