HomeMy WebLinkAbout609 S COLLEGE AVE - APPLICATIONS - 5/30/2018pF C0
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1876
Colorado Department
of Pubhc 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)
�-00
Fee $50 + $5 per,1000 ft, of area to be demolished = $ S�
(See instruction #1 on reverse side)
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Colorado Dept of Publ e
Health and Environment
APCD IE B1 t C
4300 Cherry Creek Drive
South
Denver CO 80246-1530
Phone 303 692 3100
Fax 303 782 0278
Asbestos@state co us
Company Name /}� �2 /f
t t�� b f'� 1 �j l��'
Building Name
Detached Garage
De
m
Street nQ n
le- f IS
Square footage of footprint of facility or portion of facility to be demolished
—250 r
O
I
Cit
Staff
Zi Cgde
> Z L
Street 4
609 South Colleize Avenue
Demon
tion
i
t
Telephone # /
o �0 d L Z$
Fa #
City
Fort Collins
County
Lartmer
Zip Code
80524
tanager
�
lJ7V�r g/1/�
Cell Phone #[% 7
(9/0 ) JV� QLZ�
Proposed Start Date
--j i
P osed pletion Date
Cont
i
ract
O
n
rl—
I certify the the Certified Asbestos Building Inspector has informed me
Method/Means of Demolition
Or
about any remain g asbestos co aping materials in the facility to be
demolished) )
In
�{ Other specify
� ❑Implosion ❑ Moving
Sign tur{? Prl Name
_�_-.��
i
t
wrecking LJ Burning g
e
Burning requires additional authorization —Please call (303) 692 3100 and ask
_
Landfill Receiving Building Debris `
l�,f/i�,e1_ Coo,yrN% (' � L
Asbest
General Abatement Cont ctor (GAC)
But
Owner XName
G09 LVOV
os
Rem
NA
1
d
CDPHE Asbestos Permit #
Total Quantity of Asbestos Removed
Street ^ f CS�A`v�AN V�N"�
OVdI
NA
NA
Cl
pleted
Date Removal Completed
Telephone # J
City �[�t'r �L(i7J�
Statg.
(4
Zip tde
Cont
NA
NA,
Type(s) of Asbestos Containing Material Removed
NA
Contact s Name
Telephone #
ract
g
O
or
C'oL�N (/! i a
w
n
e
r
With my signature below I certify that I possess current AHERA accreditation and state of Colorado certification as
an Asbestos Building Inspector I also certify that I have thoroughly inspected the facility to be demolished as listed
Certifi
in the Demolition Site block above sampled all suspect materials had all samples analyzed for the presence of
ed
asbestos by a NVLAP accredited laboratory and have determined that no Regulated ACM exists anywhere in the
Asb
facility I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
esto
asbestos containing material allowed to stay in the facility must remain non friable during demolition Specify type(s)
s
of ACM remaining below (check appropriate box(es))
Insp
ecto
❑ Vinyl asbestos floor tile (VAT) ❑ VAT mastic ❑ Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings _
r
❑ spray applied tar coatings ❑ Caulkiri ❑ Glazin ❑ Other specify
Certi
Signature In Blue Ink)
Printed Name
icat
�
Brandon Cochran
ion
�-� �
Date of FinaWaspection
F/ u
I CO Cart #
111,116
xpira Ion —Date— —
Telephone #
(970) 482 1976 1
Cell Phone #
(970) 305 7410
I verify that all refrigerants from air conditioning/refngeration appliances have been properly recovered In accordance with AQCC Regulation No
Buildin
9
15 (for information on CFC requirements call 692 3100) 1 further verify that all luminous exit signs (containing radioactive material) have been
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)
Own
CHECK THE APPROPRIATE BOX
er or
Cont
ElBuilding Owner
Contractor
Other
Date
ract
Signature
Print Name
or
THIS BOX IS FOR CDPHE USE ONLY
Postmark or Hand Delivery Date — L /
Approved By !jr
Code initial 310 ❑ transfer 380
Form of Payment & #
P #
Recor
Date Issued
s means
Category Regulated
I nonfriable ACM that will ( l be orh s been subjected to sanding grindinga) triable asbestos ff nmaterial orit
cutting or abrading ng or (d)Category 11 nonfriable ACM that has ahigh
F — DNA08 R 01/30/08