HomeMy WebLinkAbout424 E STUART ST - APPLICATIONS - 5/9/2019rQ P19
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PxCIDEMOLITION NOTIFICATION APPLICATION FORM
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
andEnvironment Fee: $50 + $5 per 1000 ft2 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:
Building Name:
Lam_ —
Single Family Residence
Street: ,
Square footage of footprint of facility or portion of facility to be demolished
1329 3
City: State:
Co
de: ode:
Street:
424 E. Stuart St.
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Telephone#
Fax#
City:
County:
Zip Code:
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Fort Collins
Lorimer
80525
Project Manager.
Cell Phone#
Proposed tart D to
Proposed Co pletio Date
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I certify that the Certified Asbestos Building Inspector has informed me
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Me odl ans emolition:
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about any remaining asbestos -containing materials in the facility to be
GIUIrmcking
demolished.
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❑ Burning ❑ Implosion ❑ Moving ❑ Other, specify: -
Signature:
Print Name:
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Landfill Receiving Building Debris:
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Burning requires additional authorization — Please call (303) 692.3100 and ask
to speak to the Open Buminq Permit Coordinator
General Abatement Contractor (GAG)
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Owner's Name:
Risk Removal
Chris Serbousek
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CDPHE Asbestos Permit#
Total Quantity of Asbestos Removed
Street:
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19LR1912A
1764 sgft
of
7174 CR 74
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Date Removal Completed
04/26/2019
Telephone #
221-9121
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City:
Windsor
State:
CO
Zip Code:
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(970)
80550
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Type(s) of Asbestos -Containing Material Removed:
Contact's Name:
Telephone #
Drywall texture / Sheet vinyl flooring
Chris Serbousek
(303) 419-6781
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
-containing material allowed to stay in the facility must remain non -friable during demolition. Specify type(s)
w2asbestos
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of ACM remaining, below: (check appropriate box(es)):
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❑ Vinyl asbestos floor tile (VAT) ❑ VAT mastic M Tar/asphalt impregnated roofing ❑ Asphaltic pipe coatings
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❑ spray -applied tar coatings ❑ Caulking Glazin ❑ Other, specify:
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Signature: (In BI inl
Printed Name:
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Andrew E. Dunnell
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Date of Final Inspection
CO Cert #
Expiration Date
Telephone # Cell Phone #
04/26/2019
15895
10/07/2019
970 222-6849 970 222-6849
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 Gall 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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❑ Building Owner
Contractor
❑ Other
Date:
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Signatu : Print Name:
THIS Box is FOR CDPHE USE ONLY:
or Hand Delivery Date: I' r� )2
EFormnn
Approved By:
Code: 1nitial-310 ❑transfer-380
ayment &#: p t�l
Permit #:
Record #
Date Issued: