HomeMy WebLinkAbout639 S COLLEGE AVE - APPLICATIONS - 9/26/2014 (2)0OF�COCp
Aw
°
DEMOLITION NOTIFICATION APPLICATION FORM
*� �*
APPLICATION FEE MUST ACCOMPANY THIS FORM
* L876"
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 W of area to be demolished = $ S
(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 80246-1630
Phone: 303-692-3100
Fax: 303-782-0278
Asbestos@state.co.us
Company Name: A, �/�
Building Name:
Square footage of footprint of facility or po lio of faci ity to be molished
Street: 3 v
L
q
VCity
^
State:^
Zip �ad!
Street
r
c
to
0
Telephone #
g� 222
( )
Fax #
City:
County. Zipe`,
-
o
U
o
Project Manager. Cell
#99� 23zs
Proposed a
p
Proposed vmpl lio Date
O
Q�1. (e3�3)
Method Bans of olition:
I certify that the Certified Asbestos Building Inspector has informed me
E
p
about any remaining asbestos -containing materials in the facility to be
a)
E
demolished.
t
� Wrecking ❑Burning ❑ Implosion [I Moving ❑Other, specify:
ature:Name:,
DA cO s
tBurning requires additional authorization — Please call (303) 692-3100 and ask
Landfill Receiving/Building Debris: � )r In �L L
1.1f C �'�n
t1l � (/f
to s eak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
d
Owners Name:
S urs�f•I- G �39 CL.L
,
n s
G
Street: VQ4� rL
2�Z sT Moi.+VlAUr f\
L
p m w
3
CDPHE Asq�estos Permit#
`11y71
Total Quanply of Asbesto Removed
s.
N o rva
�`�LI� /�
(auto
t
m
City:St
/
�R i lD�tnl y
er
Z'P Code:
S Z
O1 L
n E
0
Date Remo af-C `lete
r'1
------�
Telephone # U
�30 p 222
Q� O
A 9
1
S
-`
Type(s) of As St=Cohtaining Material Removed:
U
m
Co tacl's Name:
'L' %14C(111uAN
�' �2 i
Telephone #
(y%�) Zr5 %u�Q
�/21aN5(?=—
With my signature below, I certify that I possess current AHERA accreditation and state of Colorado certification as
an Asbestos Building Inspector. I also certify that I have thoroughly inspected the facility to be demolished, as listed
o
in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of
a
asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the
c
facility.* I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
rn o
asbestos -containing material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
�
of ACM remaining, below: (check appropriate box(es)):
w
In r
I
❑ Vinyl asbestos floor tile (VAT) ❑ VAT mastic ❑ Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
a a
❑ S ra -a lied tar coatin Caulkin ❑ lazin ❑ OtdName: her, s eci
'a
at
Signa (In Blue Ink) Printe
i
_ I A
U
t
Date of ' ' Ins pe n CO Cert # Expiration Date Telephone # I Cell Phone #
7 % d)-7�-lif - `
from refrigeration appliances have been properly recovered in accordance with AQCC Regulation No.
Iverify that all refrig ants air conditioning
15 (for'informati on CFC requirements call 692-3100). 1 further verify that all luminous exit signs (containing radioactive material) have been
3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320).
disposed of in accordance with 6 CCR 1007-1 subpart
c o U
L =
THE APPROPRIATE BOX:
a)CHECK
p �
C ..
O LO
�Buildin Owner
❑ Contractor
❑ Other
Date: jo
m
U Signs Print Name:
THIS Box IS FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: It; I� Approved By:� Code: nitial-310 ❑ transfer-380
Form of Payment & #: i —ti
Permit #:
Record #
Date Issued:
rr,i
I nnnfrinhle ACM
that has become friable, (c)
Regulated asbestos-comaimny nmraudia a aduo tar_II nonfriable ACM that has a high
Categ� y I nonfriable ACM that will be or has been subjected to sanding, grinding, cutting,, or abrading or (d) Category
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 t 7 �,M,',
abatedlremoved prior to demolition. APPROVED
:l FI�_� ry
f91 �_lC 1�4J(.l�lr�il�f I���� fJ