HomeMy WebLinkAbout1303 W Plum St - Applications/Demolition - 02/27/20170
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 = $ tag
(See instruction #7 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 B0246-1530
Phone: 303-69223100
Fax: 303-782-0278
Asbestos@state.co.uS
Company Name:
Buildin Name: _ - ---
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Street %
aTfoota2S0footpnrrtofWIity or portion Of Willy to be demolished
State:
Zip Code:
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Street
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Telephone 9
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Collins
County:
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I Zip Code:
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Project Manager.
Cell Phone #
Start Date
Proposed Completion Date
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3
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I certfy drat the Unified Asbestos Building Inspector has Informed me
Meth a of Demolition:
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about aremaining aslrestosontainlrr� materials In the facility to be
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demolished.
04ecking ❑ Buming? ❑ Implosion ❑ Moving ❑ Other. specify:
nature:
Print Name:
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Burning requires additional authorization -Please tail (303) 692-3100 and ask
Landfill Receiving Building Debris:
to speak to the Open Burning Permit Coordinator
Generaf Abatement Contractor (GAC)
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Owner's Name:
C
n LG
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CDPHE Asbestos Permit 6
Total Quantity of Asbestos RDenn ed
3
Street -
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y
Date R aI C pleted
Telephone 0
City
State: LD Code:
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20
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Type(s) o Asbes os-Comalning Material Removed: �,'r�J�f}�
Contact's Name.
Telephone 0
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of 1
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With my signature below, I certify -Mat 1 possess current AHERA accredilation an .state of Colorado certification as
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an Asbestos Building Inspector. I also certify that 1 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
asbestos by a NVLAPaccredited 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_-, _
asbestos -containing material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
S.o
u
of ACM remaining, below: (check appropriate box(es)):
Tar/asphalt impregnated roofing ❑ Asphaltic coatings
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vinyl asbestos floor tile (VA T),❑ VAT m�c L�J pipe
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❑ Spray -applied tar Coatings 0 CaulkingGlazing ❑ Other, specify:
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Sign ure: (In Blue Ink)
- -
Printed Name.
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co-tt" Sancie�'S
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I
CQ Cps
F�cprra ' n Da
Tdeprione C .. ..
Cell Phone a
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OData o�Final
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I verify that all refrigerants from air condrtioning/refi eration appliances have been properly recovered In accordance with AQCC Regulation No::
15 (for information on CFC requirements call 692-3100): I further verify that all luminous exit signs'(conlaining radioactive material) have been
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disposed of in accordance with 6 CCR 1007-1'subpart 3.6.4.3 (for information on luminous exit signrequirements call 303o692-3320).
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CHECK THE APPROPRIATE BOX:
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❑ Building Owner
Contracts
❑ other
: 1'1
Co;
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Signature: Print Name:
_. .
.......... _ _._. ......_._. _ ._...._._.._..........J4 1��4?p.._. _. ,.. irk__.._ :.::. .... .. ........... __ _...._._...
THIS Box I3 FOR CDPHE Use ONLY:
and Delivery Date: a ��� /
EFoay
Approved By. (�
Code: If tial-310` ❑ transfer-380
ent 8 P. cc
permit OP.
Record .
Date Issued:
Kegulatedasuestos-containing materials means ta) rrl8ow asoesios-comaming nnnenxi, tot Uerc„urr r nVmnaure..�Im urm nea wwnnc , ram/
Category I nonfriable ACM that will be or has been subjected to sanding, grinding, cutting, or abrading or (d) Category Il nonfnaMe ACM,th has a
probability of becoming or has become crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the cou e of ,4
demolition or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vin and linoleum must be properly
abated/removed prior todemolition. APO��
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