HomeMy WebLinkAboutOWNER ACKNOWLEDGEMENT FORM 850 Black Canyon Dr 2011Received Date (
Received By
_____________
TowN OF ESTES PARK
Department of Building Safety
Permit Number 13 97 ‘
OWNER’S ACKNOWLEDGEMENT FORM
If a commercial or residential project includes demolition or renovation work,the property
owner(s)must contact the Colorado Department of Public Health and Environment to obtain
either a State Demolition Permit or a State Asbestos Abatement NotificationlPermit.
The Colorado Dept.of Public Health and Environment
4300 Cherry Creek Drive South
Denver,CO 80246-1530
Phone:303-692-3100
Fax:303-782-0278
e-mail:www.cdphe.state.co.us
This form must also be completed and signed by the owner prior to issuance of a Town of Estes
Park Building Permit.
I (owner)agree to contact the Colorado Department
of Public Health and Environment to determine the state requirements for any work on my
property located at (address):S(D9e5P,L (i
((C,
I understand that I am accepting full legal responsibility for all Colorado State requirements and
liability associated with the proj t.
Signature of wner D teç 34—,-——-.
Address V
cIe6Pv 8o5/7
(970)577-3735 +P.O.Box 1200 +170 MacGregror Avenue +Estes Park,CO 80517
City State
Telephone
Zip
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