HomeMy WebLinkAbout624 SMITH ST - CORRESPONDENCE - 10/16/2012OF' COL
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. DEMOLITION NOTIFICATION APPLICATION FORM
* • f876' ` APPLICATION FEE MUST ACCOMPANY THIS FORM
INCOMPLETE APPLICATIONS WILL BE RETURNED
Colorado Department (Notice will be mailed to the.demolition contractor unless specified otherwise)
of Public Health
and Environment Fee: $50 + $5 per 1000 ft2 of area to be demolished = $ ,'Or 55
(See instruction #1 on reverse side)
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
Company Name: ,: rr
Building Name:
Small shed
Street:
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Square footage of footprint of facility or portion of facility to be demolished
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City:
State:
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Zip Code:.
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Street:
624 Smith_ Street
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Telephone # , . —
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- -Fax # 11
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City:. '-`-- - -
County:
Zip Code:-
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Fort Collins
Larimer
80524
Project�f�anager:, �_,_ -- -
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'Cell Phone#
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Prop sed Start Date
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Proposed Completion Date
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I certi that the Certified Asbestos Building Inspector has informed me ty 9 P
Method/Means of Demolition:
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about any remaining asbestos -containing materials in the facility to be
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demolished.
® Wrecking ❑ Burning ❑ Implosion ❑ Moving ❑ Other, specify:
tNa e:
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tBurning requires additional authorization — Please call (303) 692-3100 and ask
,Larfdfill Receiving Building Dels: (� I
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to speak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
Owners Name:
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C^DrPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street: '
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Date Removal Completed
Telephone #
City:
State:
Zip Code:
Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
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+ Jan -ere
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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
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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 (VAT) ❑ VAT mastic ® Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
❑ Spray -applied tar coatings ❑ Caulking ❑ Glazinq ❑ Other, specify:
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Signature: (In Blue Ink)
Printed Name:
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Greg Kurvink
ate of final Inspection CO Cert # Expiration Date
Telephone # Cell Phone #
10/16/12 1 11041 5/06/2013
(970) 266-8000 1 (303)332-9495
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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Building Owner
❑ Contractor
El Other
Date: O Ig 2 (3 �2
U Signatur i Print Name:
TH1s 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:
noyum,au dsuestub- untaimng matenais means ta) maoie asoestos-contai Ing material, (b) Cale cry 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.
Forth: DYA08