HomeMy WebLinkAboutMaster Permit.1015 Waters Ave.0204.2019 (42).ARBK OF'COCo
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�� Submit form to:
9 Permit Coord nator
* ° DEMOLITION NOTIFICATION APPLICATION FORM Colorado Dept.of Public
Health* *.%� APPLICATION FEE MUST ACCOMPANY THIS FORM APCD IE and Environment
187 INCOMPLETE APPLICATIONS WILL BE RETURNED 4300 Cherry Creek Drive
South
Colorado Department (Notice will be mailed to the demolition contractor unless specified otherwise) Denver,CO 80246-1530
of Public Health Phone:303-692-3100
and Environment Fee: $50 + $5 per 1000 ft2 of area to be demolished = $ ( lJ Fax: 303-782-0278
(See instruction#1 on reverse side) Asbestos@state.co.us
Company Name: Building Name:
HEN OF 1(z) (,, mvcIff,� l,�v use- SF/ )
Street: Square footage of footprint of facility or portion of facility to be demolished
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+� City: State: Zip Code: Street:
al ���� CO ���i� 10/S Wa4er�s /-�vehue
oTelephon # Fax# CCity: ' County: Z
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Project Manager: Cell Phone# = Proposed Star Date- Proposed Completion Date
4 i it() !���i that the NYUCI4-SUN OP ) 1-`/-( -1.`{ o r-2-0 / It' b' 1-511 `�
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certify Certified Asbestos Building Inspector has informed me E Method/Means of Demolition:
O about any remaining asbestos-containing materials in the facility to be d
E demolished. t
y !' j Wrecking ID Burning ID Implosion ID Moving El Other,specify:
O Signature. • I Pr04/LIB /i)1/2/tl 49 w J rr
Landfill Receiving Building Debris:
IT Ir r�(� tBurning requires additional authorization—Please call(303)692-3100 and ask
f to speak to the Open Burning Permit Coordinator
Genera batemtr.
Contractor(gee) ` Owner's Name:
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p S CDPHHE Asbesto4 TotalQuantity of Asbes�e�Removed 3 Street:
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.� E C Date Rem val Co le ed Telephone# C City: State: Zip Code:
41 r2 00 7 � l9 - (c70) qz7— '/S�z a cr , � w orb it
Type(s) f Asbe os-Contalning Material Re ov d: m I Contact's Name: Telephone#
ex re on wcr//bo4rd i;tir(7 HEm41146 ('10 ) ,l14r-ov-, b
With my signature below, I certify that I possess current AHERA accreditation and state of Colorado certification as
`o an Asbestos Building Inspector. I also certify that I have thoroughly inspected the facility to be demolished, as listed
O in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of
a)
o. asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the
0 c C facility.* I also certify that I have informed the owner/operator of the facility or the demolition contractor that any
rn o asbestos-containing material allowed to stay in the facility must remain non-friable during demolition. Specify type(s)
2 of ACM remaining, below: (check appropriate box(es)):
CD F
d El Vinyl asbestos floor tile (VAT) ❑VAT mastic❑ Tar/asphalt impregnated roofin A,tp,—*Nil 4tings
< v ❑ Spray-applied tar coatings ❑ Caulking El Glazing ❑ Other, specify: , •'. tl .
a) Signature:(In Blue Ink) Printed Name:w Lila, t/64g/2019
a)
O Date of final Inspection ert# , Expiration D to Telephone# I Cell I S iJ N
I7q/f 3� / z�e1a moo )Z6o �tl�lhunInln 'r,,..t i t33�/
I veri thatitlfrigerants from air conditioning/,€frig ation appliances have been properly recovered in accordance with AQCC Regulation No.
15(for inf6rmation on CFC requirements call 692-3100).I further verify that all luminous exit signs(containing radioactive material)have been
Cp 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).
4.4
C U
:, y L CHECK THE APPROPRIATE BOX: ,
C ♦+
m3 C ❑ Building Owner . Contractor ❑ Other Date:
0 U Signature: j Print Name: /,
NOB
THIS BOX IS FOR CDPHE USE ONLY:
Postmark or Hand Delivery Date: b/S tr.( Approved By: 5:-� Code: 0 iniatiat l-310 ❑transfer-380
2.3
Form of Payment&#: c ��-tf•I_ uL-( /$'66 Permit#: Record# Date Issued:
*Regulated asbestos-containing materials means(a)friable asbestos-containing material,(b)Category I nonfriable ACM that has become friable,(c)
Category I nonfriable ACM that will be or has been subjected to sanding,grinding,cutting,or abrading or(d)Category II nonfriable ACM that has,arhigh''
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. r
Form:DNA08 / / Rev.01/30/08 - '