HomeMy WebLinkAbout4235 S College Ave - Applications/Demolition - 03/26/2018Colorado 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 = $ 55.00
(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: 303-6923t00 _`
Fax. 303782-0278 \
Asbestos@state.co.us
Company Name:
Building Name:
Hive Construction Inc.
Oregano's Pizza Bistro " D
Street:
Square footage of footprint of facility or portion oifacility to be demolished
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4701 Marion St. Suite 201
700
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City:
State:
Zip Code:
Street
Denver
CO
80216
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4235 S Colle e Ave
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Telephone #
Fax #
City:
County:
Zip Code:
0
303 292-0554
303 845-8126
IM
Fort Collins
Larimer
80525
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Project Manager:
Cell Phone #
Proposed Start -Date—
ompletion Date
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Joel Schulz
303 570-8737
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3/12/18
4/15/18
I certify that the Certified Asbestos Building Inspector has informed me
Method/Meg emolition:
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about any remaining asbestos -containing materials In the facility to be
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demolished.
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® Wrecking [I Burning [I implosion [I Moving [I Other, specify:
Signal �f
Print Name:
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Joel N. Schulz
ndfill eceiving Buildi g Debris:
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tBuming requires additional authorization —Please call (303) 892-3100 and ask
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to speak to the Open Buminq Permit Coordinator
General Abatement Contractor (GA
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Owners Name:
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National Retail Properties LP
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street
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450 S Orange Ave Suite 900
Date Removal Completed
Telephone #
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City
State:
Zip Code:
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Orlando
FL
32801
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
F4414K A. s8o<4 .Ts
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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
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 (VAT) ❑ VAT mastic ® Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
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❑ Spray -applied tar coatings ❑ Caulking ❑ Glazing ❑ Other, specify:
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Signature: (In Blue Ink)
Printed Name:
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Date of Final Inspection O Carl #
Expiration Date
Telephone # Cell Phone #
— — o/ 3324
0-1&- 02&9 1
7o7o G793 91H ?0 373 2
1 verify that all 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
pdisposed
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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3 �+
000tJ
El Building Owner
Contractor
❑ Other
Date:
Signature: Print Names L 7
THIS BOX Is FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: 7i l
Approved By:Oil
Code: initial-310 ❑ transfer-380
Form of Payment & #: JA_C,0&3)C�0 ., 5,
1 Reco
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 11 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: DNA08
V 1 8 01 584 Rev. 01/30/08