HomeMy WebLinkAbout619 CHERRY ST - APPLICATIONS - 2/17/2016Colorado 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 spe ' otherwis
Fee: $50 4-$5 per 1000 ft2 of area to be demolished $
(See instruction #1 on reverse side)
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: ,
A e-T,N SONS EgAVA w&
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Building Name: tv
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Street:
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Square footage o tpnn facility or portion of facility to be demolished
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City:
State:
Zip Code:
Street L
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Telephone #
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Fax #
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City:
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County:
Zip Code:
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rolect Manager.
Cell Phone #
Prop
lion Date
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I certify that the Certified Asbestos Building Inspector has informed me
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about any remaining asbestos -containing materials in the facility to be
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demolished.
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J*Wrecking ❑ Burning ❑Implosion ❑Moving El Other, specify:
Name:Name:
Mr
L fill Receiving Building Debris:
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tBuming requires additional authorization - Please call (303) 692-3100 and ask
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to speak to the Open Burning Permit Coordinator
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General Abatement Contractor (GAC)
Owner's Name: AA A"L-7 o _? r GF- To
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CDPHE Asbestos Permit #
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Total Quantity of Asbestos Removed
1 `
Street
UE-TrE 1210. oAirr 8
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Date Removal Completed
9 12 20��
Telephone #
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State: Zip Code:
Cco
Type(s) of Asbestos -Containing Material Removed:
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ContacPs Name:
02rAN tiJ�S
Telephone #
}a 630-`�
00
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)):
a
aVE
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❑ Vinyl asbestos floor tile (VAT) El VAT masti Tar/asphalt impregnated roofing [I Asphaltic pipe coatings
a v
❑ Spray -applied tar coatings ❑ Caulkin Glazing ❑ Other, specify:
a)
Signature: (In Blue Ink)
Printed Name:
w
Andrew E. Dunnell
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V
Date ofFinal Inspection
GOCert#
Expiration Date/ p 1 .6
Telephone# 1 Cell Phone#
2 A
15895
teft4i2H
(970) 222-6849 i 970) 222-6849
I verify that all.sefrigerants from air conditioningtrefrigeration 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
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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 ner
❑ Contractor
❑ Other
Date: 2 IG/I6
V
Signature: Print Name:
THIS Box Is FOR CDPHE USE ONLY:
Postmark or Hand DeliveryDate: 9,1 (7 `
Approved By:
Code: initial-310 ❑ transfer-380
Form of Payment & #: CV 10l 9 �6b r 6
Per #:
Record #
ate Issued: -
• Regulated asbestos -containing materials means (a) friable asbestos -containing material, (b) Category I nonfriable AGM that has become tnable c)
CategoryI nonfriable ACM that will be or has been subjected to sanding, grinding, cutting, or abrading or (d) Category II nonfriable ACM that R ''
probability of becoming or has became crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the course arm
demolition or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vinyl and linoleum must be properly : Q_3 �T16