HomeMy WebLinkAboutFile Documents.108 Midland Ave.0264.2017 (4).ARBK .Dc
Ai, \ Subrnil form to;
hr Permit Coordinator
DEMOLITION NOTIFICATION APPLICATION FORM Calorado Dept.ofPublic
* t Health and Environment
" k APPLICATION FEE MUST ACCOMPANY THIS FORM APCD-IE-B1
''ens} INCOMPLETE APPLICATIONS WILL BE RETURNED 43oocherry creek Drive
Colorado Department (Notice will be mailed to the demolition contractor unless specified otherwise) Oenver,co 80246.1530
of Public Health Phone:303-092-3100
and Environment Fee: $50+$5 per 1000 ft2 of area to be demolished =$ 70 Fax: 303-782-0278
(See Instruction#1 on reverse side) Asbeslos@state Co us
- Company Name Bu Wing Name
0-1.lu.5 y(ta„ rove _ NSA
Street: Square footage of footprint of fecrity or portion of facility to be demolished
/ ?IV /1/t.J y I a /( 13_ _ _ 3,325.33
15 Zlty I ' State ZI CCo"de_ Street:
>° DfbOha�<e. CO 108 Midland Avenue
c -ttelephone A Fax N U) ' Cdy County Zip Code
o (97D) 3 79— 5" 1 ( CCC Pitkin 81611
U Pro) t Manager /r Cell Phone0 ' Proposed Stan Date Proposed Completion Date
O �COr-fev- SGst��M6e01 970) 777 -r5 Y.( o
I certify that the CeNGed Asbestos 8utld:ng Inspector has Informed me 1 Method/Means of Demolition.
6 about any remaining aspestos-corttakring materials in the facility to be
t prrature dC,13147
nl N J/ ElWrecking 0 Bunning? 0 Implosion ❑Moving 0 Other specify
Lanett Rece,ing Building Debrisl
t' r� •1 Coo r h 7�/ �Ltno��t C tBurning requires die authorization-Please call(303)692-3100 and ask
to speak to the n Pemdt Coordinator
General Abeiement Contractor(GAC) Owner's Name
` 108 Midland Avenue Aspen LLC
p io S CDPHE Asbestos Permit N Total Ouantlty of Asbestos Removed Street:
JiE 2 _ _ 65 E 55th St 25th FL _
C Date Remove Completed Telephone N C City State Zip Code
us co Q re u ) _ -0 New York i NY 10027
Typef s)of Asbestos-Containing Material Removed. m Contact's Name 7 Telephone N
( )
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
o i In the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of
c, asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the
c facility? I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
to .2 asbestos-containing material allowed to stay in the facility must remain non-friable during demolition. Specify type(s)
of ACM remaining, below- (check appropriate box(es))'
m ❑Vinyl asbestos floor tile(VAT ❑VAT mastic❑Tar/asphalt impregnated roofing 0 Asphaltic pipe coatings
,g t� ❑ Spray- ed tar coatin s Caulking 0 Glazing 0 Other, specify
Signature,(I Cum trnW) Printed Name
o /"_�� ___ Z/C/ Ar✓ 6v2 9 `f
. ale of Fmsueseecron CO Ce a Exp tairon Date Tee phone# Cell Phone a J
6-27- /7- 2,87( 7-2G 20/6 61c Yole, - 37/tf qi-v )6/b- 3-2/6
I verify that all refrigerants from air conditioning/refrigerabon appliances have been properly recovered in accordance with ACCC Regulation No
15(for information on CFC requirements call 692-3100) I further verify that all luminous exit signs(containing radioactive material)have been
m im o p , 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)
c '' N CHECK THE APPROPRIATE BOX.
i
CO g C ❑ Building owner ® Contractor l ❑ Other Date t c
U SignaWn: i 7 `- .>f� Print Name t
\
h fff �' Jcc�� �� YGi'Scv-i -
_ --e-
,N112:11 Fgt COPME Ifs
Postmark or Hand Delivery Date Approved By ( Code CI initial-310 ❑transfer-380
Form of Payment a#: Permit# Record I Date Issued
•Regulated asbestos-containing materials means(a)rnr.-He asbostc =gal,(b)Category I nontnabi....,,.. that has become (e)
C, nonfriable ACM that will be or has been subjected!o sanding,grinding,suiting.or abrading or(d)C4iieoory It nonfriable ACM tb
probability of becoming or has become crumbled pulverized,or reduced to powder by the forces expected to act on the material in the coil e + U
demo„ -or renov operations regulated by this regulation Note Asbestos-containing sheet vinyl and linoleum must be properly
abated/removed prior to demolition
10/16/2017
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