HomeMy WebLinkAbout621 SYCAMORE ST - APPLICATIONS - 6/13/2016OF .CO
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DEMOLITION NOTIFICATION APPLICATION FORM
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1876 *
APPLICATION FEE MUST ACCOMPANY THIS FORM
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 ft2 o-f 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 80246-1530
Phone: 303-692-3100
Fax: 303-782-0278
Asbestos@state.co.us
Company Name:
_DO,11 701- �7v-+
Building Name:
Residence
Street
Square footage of footprint of facility or portion of facility to be demolished
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-888 s . ft.
City: State:
Zip Code:
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Street:
621 Sycamore Street
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Telephone #
Fax #
City:
County:
Zip Code:
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Fort Collins
Larimer
80521
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Project Man r:
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Cell Phone #
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roposed Start Date
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Proposed Completion Date
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I certify that the Certified A stos Building Inspector has informed me
Method/Means of Demolition:
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about any remaining asbestos -containing materials in the facility to be
demolished.
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L�l Wrecking ❑ Burning El Implosion El Moving ❑ Other, specify:
Signature:oe
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Print Name:
Landfill Receiving B . din ris:
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Burning requires additional authorization — Please call (303) 692-3100 and ask
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to s eak to the Open Burning Permit Coordinator
General Abatement Contractor (GAC)
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Owner's Name:
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Bryan and Julie Kallenberger
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CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street:
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621 Sycamore Street
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Date Removal Completed
Telephone #
City:
State:
Zip Code:
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Fort Collins
CO
80521
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
Julie Kallenberger
(970) 420-9119
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
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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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ACM remaining, below: (check appropriate box(es)):
❑ Vinyl asbestos floor tile (VAT) VAT mastic ❑ Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
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Spray -applied tar coptings 0/C-aulRing ❑ Glazing ❑ Other, specify:
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ignature: (In Blue riR)
Printed Name:
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Paul Jaeckel
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Date of Final I�}spection CO c6ft #
Expiration Date
Telephone #
Cell Phone #
6` 1 3 —1830
07/11/2016
1 (970) 266-8000
(970) 310-4581
1 verify 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).
CHECK THE APPROPRIATE BOX:
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Q Building Owner
❑ Contractor
❑ Other
Date:
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Signat e: F
Print Name:
THIS BOx.is FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: (1 S /
Approved By:
Code: initial-310 ❑ transfer-380
Form of Payment #: 30 /
Permit #: 16LK �) G Ln I Recor
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 hi
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. G
BO64 35
Form: DNA08 16 5/20!�016 .-O