HomeMy WebLinkAbout810 W Mountain Ave - Applications/Demolition - 06/08/2016o Cow
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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
ny Name:
Building Name:
I Residence
Square footage of footprint of facility or portion of facility to be demolished
State:
Zip Code:
I Street:
810 W. Mountain Ave
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one #
Fax #
City: County: Zip Code:
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Collins Larimer 80521
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t Manager. Cell Phone #
Proposed Start Date Proposed Completion Date
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that the Certified Asbestos Building Inspector has informed me
EMethod/Means
of Demolition:
any remaining asbestos -containing materials in the facility to be
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demolished.
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❑ Wrecking ❑ Burning ❑ Implosion ❑ Moving ❑ Other, specify:
Signature:
Print Name:
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Burning requires additional authorization —Please call (303) 692-3100 and ask
Landfill Receiving Building Debris:
to speak to the Open BurningPermit Coordinator
General Abatement Contractor (GAC)
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I Owner's Name:
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David and Stephanie Thompson
Total Asbestos Removed
Street:
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CDPHE Asbestos Permit #
Quantity of
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810 W. Mountain Ave
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Date Removal Completed
Telephone #
City:
State:
Zip Code:
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Fort Collins
CO
80521
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
Dick Jefferies
(970) 481-2924
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 (V ❑ VAT mastic ❑ Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
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❑ Spray -applied tar coatings ulkin ❑ Glazin ❑ Other, specify:
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Sig :(in BI e I k) Printed Name:
PaulJaeckel
as
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Date of Final Inspection CO ert # Expiration Date Telephone # Cell Phone #
_ - 830 07/11/2016 (970) 266-8000 (970) 310-4581
1 verify that all refrigerants from air conditioning/refrigeration appliances have been properly recovered in accordance with AQCC Regulation No.
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15 (for information on CFC requirements call 692-3100). 1 further verify that all luminous exit signs (containing radioactive material) have been
I 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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I CHECK THE APPROPRIATE BOX:
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E]Building Owner i ❑ Contractor
❑ Other
Date:
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Signature:
Print Name:
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.
Form: MAN 6/10/2016