HomeMy WebLinkAboutCDPHE Demo Appliation.pdfColorado 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 ft2 of area to be demolished = $ (oCO seri
(See instruction #1 on reverse side)
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Submit form to:
Permit Coordinator
Colorado Dept. of Public
Health and Environment
APCD-IE-B1
4300 Cherry Creek Drive
South
Denver, '.10 80248.1530
Phone: 103-892-3100
Fax: 303-782-0278
Asbestos@state.co.us
Demolition Contractor
Company Na -
Stitt ea<tta�I t
Demolition Site
Building Name:
fyoase 5frctofure
Street
Sic) Lob fie, ci/of
Square footage of tprl of facility or portion of facility to be demolished
/6410
City: ri—h 1„\I3
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atr:
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Street:
Telephone# `r �1F
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Cell Phone ,„„,
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Proposed SI rt
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Proposed Completion Dale
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I certify that the ertified Asbes s Building nspector has Informed me
about any remaining asbestos -containing materials In the facility to be
demolished.
,rciive_
Metho Means o Demolition.
'Wrecking
Signa
r : fr ,, (
L LC..,
t Name:
I 44-A4•TLc�•t:,t14s
0 Burningt 0 Implosion 0 Moving 0 Other, specify
Landfill eceiving ui
g Debris: so ✓ , C :yore
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Burning requires additional authorization — Please call (303) 892-3100 and ask
to speak to the Open Burning Permit Coordinator
Asbestos
Removal
Contractor
G al Abate gt Contracty� GAC /
re; �jYY t �✓I f/ rd4mr% service-
I., Building Owner
Owner's Name:
5-ri I�S9
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Total Qupnt ofA
Shone)
ti Removed
Street: cosi �� gritei n G 1
33/2
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Tel #
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I p Code:
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Types ofAsb stos ontaini g al Removed:
ee� vi y% vii
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Teleephone#
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With my signature below, I certify
an Asbestos Building Inspector.
in the Demolition Site block above,
asbestos by a NVLAP-accredited
facility.* I also certify that I have informed
asbestos -containing material allowed
of ACM remaining, below: (check
Vinyl asbestos floor tile (VAT)
14
Sera -a• •lied tar coatin•s ❑
hat
also
sampled
laboratory,
appropriate
•
Caulkin•
I possess current AHERA accreditation and state of Colorado certification as
certify that I have thoroughly inspected the facility to be demolished, as listed
all suspect materials, had all samples analyzed for the presence of
and have determined that no Regulated ACM exists anywhere in the
the owner/operator of the facility or the demolition contractor that any
to stay in the facility must remain non -friable during demolition. Specify type(s)
boz(es)):
VAT mastic ❑ Tar/asphaltim re
roofing impregnated
P g ❑Asphaltic pipe coatings
❑ Glazin ❑Other, s•ecif :
F
t
U
Signature: (In Blue In IF
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Printed Nam // /�^/ p
d�l�S �• ��S'`
Dari0a11•. r, -•I.
r�S�(l/ u 1
I CIl Ce_�
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Expiration ate /
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Telephone#
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Cell Phone #
Phone
# .tea 33''45'
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I veri that all refrigerants from air conditioning elrig anon appliances have been properly recovered in accordance with AQCC Regulation No.
15 (for information on CFC requiremen s call 692.3100). I further verify that all luminous exit signs (containing radioactive material) have been
disposed of In accordance with 6 CCR 007-1 subpart 3.6.4.3 (for inforrtltition on luminous exit sign requirements call 303-692-3320).
CHECK THE APPROPRIATE BOX:
mO G
V
❑ Building Owner I
. Contractor
❑ Other
Date: tt�ry ^�'/' z�
I ,:(9. � ri 4�✓
SignaltS\ (
Prin e: /
• Q
THIS Box is FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: Approved By:
Code: ❑ initial -310 ❑ transfer -380
Form of Payment & #: Permit #: I Record #
•
Date Issued:
Regulated asbestos -containing materials means (a) friable asbestne.containin m t
lable ACM that has become friable (c)
Cateoory I nonfrlable 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.