HomeMy WebLinkAbout417 N GRANT AVE - APPLICATIONS - 9/7/20160
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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)
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Fee: $50 + $5 per 1000 ft' of area to be demolished = $
(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: , � $ VL'.
Building Name:
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Street: S� ��
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Square footagQ of ootpri of facility or portion of facility to be demolished
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City.
State:
Zi Code:
Street:
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Telephone # ��
(3 e3) 577- ��
Fax 11
(3�3 ) 77- >�s'�
City:
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County:
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Zip Code:
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Projec Manag Cell Phone # _ v
Proposed tart D to
Proposed ompl io Date
MethO /Means of Demolition:
I certify that the Certified Asbestos Building Inspector has informed me
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about any emaining asbestos -containing materials in the facility to be
demojis d.
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(�(yVrecking El Burning El Implosion El Moving El Other, specify:
tBurning requires additional authorization - Please call (303) 692-3100 and ask
n fill ceivi Building Debris:
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to speak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
Owner's Name:�%
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street: f ` 17, �r /) ,e-
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Date Removal Completed
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Telephone #
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State:
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Zip Code:
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Type(s) of Asbestos -Containing Material Removed:
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Contact's Name:
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Telephone #
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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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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 demoliti type(s)
ACM remaining, below: (check appropriate box(es)):
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RECEIVED
❑ Vinyl asbestos floor tile (VAT) ❑ VAT mastic �r/asphalt impregnated roofing ❑ Asp alti(SW4 �c �i�Igs
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❑ Spray -applied tar coatin s ❑ Caulking ❑ Glazing ❑ Other, specify: Ane—
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Signature: Blue Ink)
Printed Name:
Stationary
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Sources
Date of Final In ctio CO Cert #
Expiration Date
Telephone # i Cell Phone #
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1 I $
( 9p) Vb - ( 7D) 3D � - 7311Q
I 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
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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
❑ Other
Date:
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ignature: I
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Print Name:
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THIS 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:
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
demolition or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vinyl and linoleum must be properly
abated/removed prior to demolition.