HomeMy WebLinkAbout912 WOOD ST - APPLICATIONS - 6/15/2015OF COZO�
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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 ftz of area to be demolished = $ 60.00
(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: 303-692-3100
Fax: 303-782-0278
Asbestos@state.co.us
Company Name:
Building Name: Fole"eer.
Bellisimo, Inc.
Residence
Street:
Square footage of footprint of facility or portion of facility to be demolished
3702 Manhattan Ave. #201
1,200
City.
State:
Zip Cade:
Street:
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Fort Collins
CO
80526
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834 Wood Street
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Telephone #
Fax #
City:
County:
Zip Code:
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(970) 229-5900
(970. 229-
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Fort Collins
Lorimer
80521
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Cell Phone #
Proposed Start Dale
Proposed Completion Date
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(� 10) 5&Sr S-L
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June 015
June ]0, 2015
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I certify that the Certified Asbestos Building Inspector has informed me
Method/Means of Demolition:
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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 ❑Burning El Implosion ❑Moving ®Other, specify:
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Print Name:
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Deconstructing
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Burning requires additional authorization -Please call (303) 692-3100 and ask
Landfill Receiving Building Debris:
Larimer County Landfill
to speak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
Owner's Name:
NA
Patcros Creek Development Inc.
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street:
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NA
NA
7307 Streamside Drive
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Date Removal Completed
Telephone #
City:
State:
Zip Code:
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Fort Collins
CO
80525
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
NA
Gino Campana
(970) 229.5900
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 [I Asphaltic pipe coatings
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❑ Spray -applied tar coatings ❑_Caulkin ❑ Glazin ❑ Other, specify:
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Signature: (In Blue Ink)
Printed Name:
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Brandon Cochran
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Dale of Final Inspections /I
glycert#
Expiration Date
Telephone if f Cell Phone #
5/18/2015
16110
1/18/2016
(970) 482-1972 i (970) 305-7410
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). I further verify that all luminous exit signs (containing 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 sign requirements call 303-692-3320).
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CHECK THE APPROPRIATE BOX:
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® Building Owner
® Contractor
El Other
Date: ram, • 22• 1.5
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Print Name:
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Ralph Shields
THIS BOX IS FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: ✓C -�j�
Approved By: ,��
Code: 9-miltal-310 ❑ transfer-380
Form of Payment & #: G d® s�
Permit M
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 y
demolition or renovation operations gulated by this regulation. Note: Asbestos -containing sheet-v'ny a d•linoleum must be properly lft�,,
abated/removed pr' r to demolitio�l\ j"
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