HomeMy WebLinkAboutFile Documents.725 Cemetery Ln.0045-2019-BRES (34) Submit form to:'
Permit Coordina
VOLITION NOTIFICATION APPLICATION FORM Colorado Dept.of(public
Health and Environment
APPLICATION FEE MUST ACCOMPANY THIS FORM APCD-IE-B1
INCOMPLETE APPLICATIONS WILL BE RETURNED 4300 Cherry Creel�ive
South �}
e will be mailed to the demolition contractor unless specified otherwise) Denver,CO 80246-1530
Phone:303-692-3100
: $50+$5 per 1000 ft2 of area to be demolished =$ 65.00 Fax: 303-782-0278
(See instruction#1 on reverse side) Asbestos@state.co.us
Company Name: Building Name:
Koru,Ltd. Cemetery Lane
Street: Square footage of footprint of facility or portion of facility to be demolished
2551 Dolores Way 2016 SF
tO City: State: Zip Code: Street:
L Carbondale CO 81623 °) 725 Cemetery Lane
C Telephone# Fax# (/) City: County: Zip Code:
o (970)963-0577 (970) 963-9389 c Aspen Pitkin 81611
Project Manager: Cell Phone# = Proposed Start Date Proposed Completion Date
o Mike Chmura (970) 618-2383 7) 8/3/2020 8/28/2020
I certify that the Certified Asbestos Building Inspector has informed me E Method/Means of Demolition:
o about any remaining asbestos-containing materials in the facility to be a)
E demolished. t
a) x Wrecking 0 Burning 0 Implosion 0 Moving 0 Other,specify:
O Signature:Mike Chmura 6 "°° Print Name:
Mike Chmura
Landfill Receiving Building Debris:
Pitkin County Landfill tBurning requires additional authorization—Please call(303)692-3100 and ask
to speak to the Open Burning Permit Coordinator
General batement Contractor(GAC) I... Owner's Name:
L (4,e7LZ-Cr i 6:11.1/'vn 1/4e446f ( CCD 725 Cemetery Lane Duplexes LLC
8 10 :O CDPHE Asbestos Permit# Total Qu ntity of Asbestos Removed 3 Street:
o L Z0 f;7_,Z2 , "4 `' ?9 426 Main Street
cm
o• E C Date Removal Complleted Telephone# 1= City: State: Zip Code:
Q• reV ,/i*N e 4.9 f-fr, Zsz2U (3Q .f6-85 4 Aspen CO 81611
•
Type(s)of sbestos7Contain Material Remov�d: m Contact's Name: Telephone#4G.b i�,'Y i-e•----e-f,
Tiffany Phipps (970) 901-7613
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
6 in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of
a 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
u) o asbestos-containing material allowed to stay in the facility must remain non-friable during demolition. Specify type(s)
Nof ACM remaining, below: (check appropriate box(es)):
a) t~
v) ❑Vinyl asbestos floor tile (VAT) ❑VAT mastic ❑Tar/asphalt impregnated roofing El Asphaltic pipe coatings
U ❑ Spr-y.-applied tar coatings ❑ Caulking ❑ Glazing II] Other, specify:
Ts a) Signatu -:(In Blue Ink) Printed Nami0i
IC
w l
14.5-6211
0 ate of Final Inspection CO Cert# E piration Date •
Telephone# Cell Phone#
��t.te Z6{pe ze /g 7/ A�<jffsf /s/ 20z0 C/70 ) 2 2y.7/3`/ (i 70) Z.%'-3/3`!
I 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 call 692-3100).I further verify that all luminous exit signs(containing radioactive material)have been
G 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).
.Ca d `' CHECK THE APPROPRIATE BOX:
CO 0 CO ❑ Building Owner X Contractor ❑ Other Date: 6/23/2020
U Signature: ngimy.y,peo-ynutrOhmura Print Name:
Mike Chmura"``,- e ;.s
pap:2020..169u,�9p Mike Chmura
THIS Box IS FOR CDPHE USE ONLY:
APPROVED
Postmark or Hand Delivery Date: 6/26/2020 Approved By: Code: ❑ initial-310 ❑transfer-380
Form of Payment&#: cc 2479 $65 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 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.
Form.DNA08 Rev.01/30/08