HomeMy WebLinkAbout612 E PITKIN ST - APPLICATIONS - 9/22/2015nF CO<' .
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Colorado Department
of Public Health
and Environment
B150(A L1q
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 = $ G67
(See instruction 91 on reverse side)
submit form to:
Permit Coordinator
Colorado Dept. of Public
Health and Environment
APCD-IE-B t
4300 Cherry Creel: Drive
South
Denver, CO 8024G-1530
Phone: 303-692-3100
Fax: 303-782-0278
Asbestos@stale=.us
Company Name:
V� (ff_p �r�r
Building Name: s ;
Residence �.
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Street: G
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Square footage of footprint of facility or po:lion of facility too bbdpderno�hcd ll
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City: State: Z p Code:
zT [Lf'u S Cep gol;ay
Telephone # Fax #
Street:
612 East Pitkin Street
City:
County:
Zip Code:
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Fort Collins
1_.arimer
80524
Proposed Start Date Proposed Comple ionfQ ate
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roject Manager: Cell Phone #
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Method/fv1ean5 of Demolition' -
I.cerlify that the Certified Asbestos Building Inspector has informed me
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abouty remaining as estos-containing materials in ute facility to be
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dem lighed.
Wrecking ElBurning' El Implosion El Moving El Other, specify:
[:JJ WreckingCD.
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Si a r / Pr fl Name:'
Landfill Re iving Building )ebris:
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Lp,, � �'C Li f� &�
t Please
I Burning requires additional authorization — I I_..se call (303) 692-3 i00 and ask
1-to-speak to the Open Burning Permit Coordinator
General Abatement C ractor (GAC)
Owner's Nam
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
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Street:
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0 m 2
to
3
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City: r _ I I State Zi Code: �[
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Dale Removal Comp eled
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Telephone #
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name',
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Tele hone
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ink>a�-(c
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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. 1 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
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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 the (VAT) ❑VAT mastic ❑Tar/asphalt impregnated roofing Asphaltic pipe coatings
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❑ Spray -applied tar coatings ❑ Caulking ❑ Glaz rig ❑ Other, specify._ .__-.._.__..5
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Signature: (In lug hikt Printed Name:
Brandon Cochran
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I Date of Final Inspection CO Cart #
8/26/15 16110
xpiration Dale Telephone # Cell Phone
1/18/16 (719) 482-1976 (970) 305-7410
I verify that all refrigerants from air conditioning/refrigeration appliances have been properly recovered in a ordance with ACCC Regulation No.
692-3100). 1 further that all luminous exit sIg (con ai ng radioactive material) have been
15 (for information on CFC requirements call verify
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rn o `p disposed of in accordance with 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous e t n r r menu call 303-692-3320).
y ca CHECK THE APPROPRIATE BOX: ..
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m ❑ Buildingner I %� C ntraclor ❑ Other —Dale: _3
U Signature: Y��/^ Print Name:
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THIS BOX IS FOR CDP_HE USE ONLY:
Postmark or Hand Delivery Date: S Approved By: Code: Initial-310 ❑ transfer-380
Form of Payment & #: �r�r C)� Permit #: Record # Date Issued:
Regulated asbestos -containing materials earis ta/ .,,.. ,a 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 thaMas 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
demolition or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vinyl and linoleum must be properly SF
abated/removed prior to demolition. k` - 'INVE D P , 22
nATE 7/d :f�SCCaPHE 'f�- /�> CDPHE �(iGL. lol;a