HomeMy WebLinkAbout810 E MYRTLE ST - APPLICATIONS - 12/27/2018OF,COLo
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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: $90 + $6 per 1000 ft2 of area to be demolished = $ S_
(See instruction #1 on reverse side)
Suhmit form to:
Permit Coordinator
Colorado Dept. of Public
Health and Environment
APCD-IE-B7
4300 Cherry Creek Drive
South
Denver, CO 80246.1530
Phone:303-692.3100
Fax: 303-782-0278
Aebeetoa@Male.co.ue
Company Name: ,
UD -rowid VC76(f " u t -�
Building Name:
Residence, bathroom addition to be demolished. See attached schematic.
Street:
Square footage of footprint of facility or portion of facility to be demolished
Gam ST S-(r-- C
-90
City:
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Slate:
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Zip Code:
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Street:
810 East Myrtle Street
Telephone # Fax #
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City:
Fort Collins
Larimer
County:Proposed
Zip Code:
80524
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Project Manager. ; Cell Phone #
A_ 040-44__JAI M—
Proposed Start Date
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Completion Date
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I certify that the Certified Asbestos Building Inspector has Informed me
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Method/Means of Demolition;
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about any remaining asbestos -containing materials in the facility to be
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demolished.
Cxl wrecking ❑Burning+ El Implosion [I Moving El Other, specify:
Signature:
Print Name:
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Landfill Receiving Building Debris:
tBurning requires additional authorization -Please call (303) 692.3100 and ask
to speak to the Open Burninq Permit Coordinator
General Abatement Contractor (G NA )
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Owner's Name:r r 6u�t� a
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CDPHEAsbestos Permit #
Total Quantity of Asbestos Removed
Street: �/-� �A`' sr
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NA
NA
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Date Removal Completed
Telephone 8
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04- CALL! �S
State:
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Type(s) of Asbestos -Containing Material Removed.
Contact's Name:
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
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 ❑ Asphaltic pipe coatings
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❑ Spra -applied tar coatings Caulking ❑Glazing ❑ Other, specify:
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Sign alur In lue Ink)
Printed Name:
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Brandon Cochran
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Date of Final Ins i n I Co Cart # i
11/9/2018 I 16110 j 1/26/2019
Telephone # Cell Phone #
(970) 482-1976 1 (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). 1 further verify that all luminous exit signs (containing radioactive material) have been
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disposed of In accordance wlth 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320),
to
CHECK THE APPROPRIATE BOX:
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❑ Building Owner I Contractor ❑ Other Date: Z. 18
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- -- — Print Name:
Signature:
i`�THIS BOX IS FOR CDPHE USE ONLY:
or Hand Delivery Date: O f.2Q f ) Approved By: Cade: ❑ initial-310 ❑ transfer-380
LForm
ayment & #; C( i 7� P ��
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Reco# �-I `I ) E�ate Issued:
Kagulatea asbestos-conralnmg marenats means td1 tttduto dau=atU5-�Utt.an,,,,v ,,,o.U„o,, w1 ..--.., .,,-,
Cateoory I nonfriable ACM that will be or has been subjected to sanding, grinding, cutting, or abrading or (d) Cateoory II nonfriable ACM that harp1 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#'b1
--demolitim or renovation operations regulated by this regulation. Note: Asbestos -containing sheet vinyl and linoleum must be p
rope
rly"' �_1e
ibated'Iremoved prior to demolition.