HomeMy WebLinkAboutFile Documents.1112 Waters Ave.0089.2017 (20).ARBK ASBESTOS ABATEMENT NOTIFICATION and PERMIT APPLICATION FORM
FEE MUST ACCOMPANY THIS FORM. INCOMPLETE APPLICATIONS WILL BE RETURNED.
°F CO<o Single FamilyResidential Dwelling(SFRD) Public and Commercial Building, School,and Sin le-Famil
,�ti _ �p 9' 9� 9 Y Submit form to:
Q ; 9� >50 LF or 32 SF or a 55 gal.drum,but<_260 LF or 160 SF or a 55 gallon drum Residential Dwelling:>260 LF or 160 SF or a 55 gallon drum Permit Coordinator
�� O Colorado Dept.of Public Health
[code 200]❑ $0 Courtesy Notice [code 100]0 $0 Courtesy Notice
�c and Environment
* ^�� ; * [code 205]❑ $60 Non-Public Access Notice(Opt Out) [code 105]❑ $80 Non-Public Access Notice APCD-IE=-E31
�ig;6 [code 210]0 $60 Notice [code 110]0 $80 Notice 4300 Cherry Creek Drive South
[code 230]0 $180 30-Day Permit [code 130/232]® $400 30-Day P&C/SFRD Permit Denver,CO 80246-1530
Colorado Department [code 290]0 $300 90-Day Permit [code 190/292]❑ $800 90-Day P&C/SFRD Permit Phone:303-692-3100
PFax: 303-782-0278
of Public Health
[code 265]0 $420 365-Day Permit [code 165/267]0 $1200 365-Day P&C/SFRD Permit asbestos state.co.us
[code 180/280]0 $55 Notice or Permit Transfer [code 177]❑ $80 Phase of Multiple
and Environment Phase Permit#
Abatement Contractor Abatement Site Building Owner
Company Name Building Name Owner Name
Prestige Environmental Services, Inc. Single Family Residence 1112 Waters Ave,LP
Street Address Specify location in the building where work will take place(e.g.floor,room,wing,etc.) Contact
4515 Dillon St. Roof Rob Cairncross
City State Zip code Street Address Street Address
Denver CO 80239 1112 Waters Ave. 0133 Prospector Road,Ste 4102
Telephone# Fax# City County Zip code City State Zip code
(720) 280-4565 ( ) Aspen Pitkin 81611 Aspen CO 81611
Project Supervisor CO.Cert# Building Contact Cell Phone# Telephone# Fax#
Paul Radford 1740 Rob Cairncross (970) 618-6722 (970) 925-9817 (970-) 920-6905
Project Personnel Project Information Disposal Site
CO Project Mgr. Name Start Date End Date Landfill Name
9/18/17 9/23/17 BFI Landfill
Cell Phone# CO Project Designer# Start Time End Time Street Address
( ) 8 AM PM AM 8 PM 8480 Tower Road
CO Project Designer Name Check the day(s)of operation: Su M Tu W Th F Sa City State Zip code
❑ ® ® ® ® ® ® Commerce City CO 80222
Cell Phone# CO Project Designer# Emergency? Type of ACM:TSI,Texture,VAT,etc. CDPHE Use Only
( ) YE N® Roofing Tars/Felts
Consulting Firm Name Registration# Linear Feet/Type Square Feet/Type 55 gal. Drums Postmark or Delivery date Approved by:
DS Consulting 14912
A.M.S. Name Form of Payment&# PM req'd?
David Sinkbell 1800 Y N W
Cell Phone# CO A.M.S.Cert# rPermit# Record# Date Issued:
(720) 201-6611 13015
Please describe below the work practices and procedures to be employed in conducting the abatement of asbestos. BE SPECIFIC. Indicate type(s)of ACBM to be abated (e.g.VAT,
ceiling tile,TSI, etc.). Use another page if necessary.
Received
Form:AANPA08 5/45/4 7