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HomeMy WebLinkAboutBuilding Permit #042-13 - 102 PETERS STREET 7/19/2012 NORTF/ BUILDING PERMIT °F�tL�o +b'9tio TOWN OF NORTH ANDOVER 3 APPLICATION FOR PLAN EXAMINATION Permit NO: D7 r Date Received SACHV`-'E Date Issued: WMORT—AINT: Applicant must complete all items on this page 15- �•• a 'a�Yw• � 'rte s �;. �,k• �_.�,.xa�.x•,+a�a .�. �� p.4ce r "�`�"•�y+--�+,� .:�„ 'C..r�s��gl�-,a�'+rad. ryC�' +� �, a 3}�$ �'`'r � k ���a��° �� n�M PROPERTY O{WNE-R- S r /-err .SoCt l.>~' EMAP N® _ PAR;CEL � NING DISaTRICT Q a H sto D strlctl 7,0, V�* �< TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other oI`o1Adplain' }i1rshedustricIelands � Wate � t Wykf,, DESCRIPTION OF WORK TO BE PREFORMED: b . MO LATta0 6P rIC.(Srt 14 G Dw 6 L t4 rr Identification Please Type or Print Clearly) OWNER: Name: J?ETf,0 S Pi SgW.(ATr-S (-LC- Phone: Address: P.o .G3oX 3049AN&Ucoc /4 of 810 +,,,:... xi'��+� �: �' �.�r3. a �4ygt���2e�.?.s�y.'=�ts��,.s+s•.�p�"�{ ai # "°�4<:'*.Hs�� �:`?"'v�lf`"",•�! ,a- .b ®COP; on X +. =+4+- ws +c •4 '-R +" ? zr` `•-rr- -s°5-, -'SS "r$•Vic ` Addrem77 ixC.'uP�rli d-�:;r`. ,-x.,44 --"S:t.•,2 �+ a SupervisorsConstruction License '` 5 5 Expog®ate �'�/ ola , • # �p w .=k a.k'sr''-}�a"35 MT11, r, + AR ' 'Jr � omitjR!censep m r' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. s- Total Project Cost: $ OGo FEE: $ Check No.: Receipt No.: NOTE: Persons contractin ith re is ed contractors do not have access to the guaranty fund . $i'-ature.of Agent/Ovvn Signature.of contrac Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/ ,assage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales,. Private(septic tank,etc. Permanent Dumpster on Site I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Lo 384 Osgood Street eet `*'" Gas aR� M� � ' �i�czs ^: .t g r FIR,ED,EPARTMENT Temp Dumpster,on siteyes u no a; s :Eoc M gat 124 Main,Str e•° Fire DepartmentsignatureXdate �40.x.'�+" •�J!`t',�.1�rt?1�_,.xauti....%.-' a�a� ��',...+$5�h'''L. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) f EJ I II I i Notified for pickup - Date Doc.Building Permit Revised 2008 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior. Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit j ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ® Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then.get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTM ENTMFORM07 Revised 2.2008 Location No. jQ '" �� Date e - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ w. JllFoundation Permit Fee $ *. Other Permit Fee Z)04,010 $ ' �a s TOTAL $ Check# �bb 25519 B� ing Inspector NRT#1 O own of _ 6 _n over W. No. I t . �^- h ver, Mass, /2— Coc.-CHIWtCK ��• RATED S U BOARD OF HEALTH PER IT T ILD Food/Kitchen Septic System THIS CERTIFIES THATF lsfoG�� S ' `� G BUILDING INSPECTOR ........ ....... ............ ........... . ............... ........................................................ �O Foundation has permission to erect .......................... buildings on ....... ..........................................................f........... C �v Rough to be occupied as ..................\ .. .. .°. .:!.,..rk <..1.. . ��t' ��l.r'.....1..:. �.�......... Chimney ermit shall in eve ec�onform to the terms of the appli ation provided that the person accepting this p ry res p Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ............ Service .. . rr�,.,u�................ Final BUILDING INSPECTOR GAS INSPECTOR .Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. IF SEE REVERSE SIDE Town of North Andover NORTH Building Department 0�.� 69,9ti 1600 Osgood Street Bldg20 Suite 2-36 6 North Andover MA 01845 t " Tel: 978-688-9545 Fax: 978-688-9542 DEMOLITION OF BUILDING AFFIDAVIT °4A CaCNIC0,4,441 WICK °RATEo �,PP (5 DATE V7 Iq gSSACHUS�� OWNER'S NAME &ADDRESS: fF-( s( S (9-i-2or— r A .Ssce t A-tis , LLC 0 06 7C LOCATION OF PROPERTY TO DEMOLISH 10'0 S 9r DESCRIPTION: Vl aoD f:=aA-m r-- 19 W (=C.Qju6 I)AC NI CONTRACTOR'S NAME &ADDRESS: 3 LUPI 09 (Lp, A 006Ug;4 W A 01 8!a DEPARTMENT N-OFF DEPT. OF PUBLIC WORKS -WATER: SEWER: DEPT. OF CONSERVATION HEALTH DEPT: SEPTIC WELL HISTORIC COMMISSION NA PLANNING AJ� GAS 4u OAS ELECTRIC &WA 1)60 t7o TELEPHONE e7l.3 Ll 2. CABLE aowmq -. l TAXES POLICE: (YO ) ' �-,� !e`'d FIRE: EXTERMINATOR: DUMPSTER- ON/OFF STREET O ( DIG SAFE NUMBER a D 1 d. 'a 8 0 V S'AY BUILDING INSPECTOR: I North Andover MIMAP June 27, 2012 @g-00.6 114 {$oI I G' y � w#183 024.'O ,19,'-V .R4 0W."11 ,6$ - 11 133 1, 't #487 � 1a @0=00N 00 ' {fl1P 034.0-00 4 Andover Rail Line – Wetlands Zoning Interstates t7 Exem t Lands ..Busine s 1(R-1) p ®Busine s 2(R-2) Horimnlal Datum:MA Stateplane Coordinate System,Datum NAD83, Interstate O Busine s 3(R-3) Meters Data Sources:The data for this map was produced by Merrimack —Major Roads p Busine s 4(R-4) NORTFI Valley Planning Commission(MVPC)using data provided by the Town of Roads O Genera Business(G-B) Of t au '9.�. North Andover.Additional data provided by the Executive Office of L rEasements 29 Planne Commercial Dev 00< refs 00 Environmental Affairs/MassGIS.The information depicted on this map is kR Corrido Development Dist 3• for planning purposes only.It may not be adequate for legal boundary E3 MVPC Boundary R Corrido Development Dist O -- - A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER ❑Municipal Boundary O Corrido Development Dist F p MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning O �:'.-Industri I 1(I-1) THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Overlay t 0 Industri 12(I-2) B Adult Entertainment ♦t .^, i OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT C3 Downtown Overlay District lO Industri 13(I-3) o e ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Q Historic District 0 IndustriTHIS INFORMATION Water Protection Reside ce I(R-1) �,� '�••�o'A Reside ce 2(R-2) S`SACNUS� ❑Parcels Q Ride ce 3(R-3) 0 Hydrographic Features de ce 4(R4 –Streams 1"=72 k Rede ce 5(R-5) YYY de ce B(R-8) „age esidential(VR) Q - Pest End Exterminators 15 Pelham Street WORK ORDER 375812 Methuen, MA 01844 WORK DATE: 07/02/12 (978)794-4321 FAX(978)688-8344 Monday Work Bill To: [1118606] Location: [11186061 978-687-7105 PETERS ST ASSOCIATES PETERS ST ASSOCIATES 102 PETER ST 102 PETER ST NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 WNW 6011 MRRFXMM— •• _ r • • • _ ;fax.. ? d d ,u D t M.. Lic#: 1239_8° .. I CONTACT JOE LEONE 15-20 MIN PRIOR TO 978-687-7105 HE WILL TRY TO MEET YOU.. TREAT PRIOR TO DEMO. BRING ALL PAPERWORK BACK TO THE OFFICE'. t .. DEM BAITING BEFURE RM0 CM CREDIT/MULTIPLE SERVICES 50.00 _. .. SUBTOTAL $ 150 .00 2- --- TAX �=,====0-00 t TOTAL 50. 00 , - ., •1 .1 I hereby acknowledge the satisfactory completion of all s v ces endered,and agree to pay 1 the cost of services as specified above.*Charges outstandin over 30 days from the date of service are subject to a 1 '/z%finance charge per month or annual percentage rate of 18%. Z ) 3 r ► �' 4Zt� CUSTOMER SIGNATURE PLEASE-PA FROM THIS INVOICE _' UNCLE Pest-End, Inc. 15 Peiham Street 82 Plaistow Road, Rte. 125 Methuen, MA 01844 Plaistow, NH 03865 (978)794-4321 Fax(978)688-8344 (603)382-9644 Fax(603)382-9525 pestendinc.com pestendinc.com RODENT CONTROL REPORT BAITING PRIOR TO DEMOLITION PROPERTY ADDRESS: COMMER(AAL: YES NO RESIDENTIAL: YES NO I PROPERTY TREATED WITI-I CHECK ONE OR MORE TALON G INDIVIDUAL PACKETS EPA # C 100-1057 BR()DIFACOUM CONT RAC BAITING BLUX EPA # C 12455- 79 BRO�y1ADI0LONr, INTERIOR BAITING 1/ EXTERIOI,` BURROWS DUMPSTER". PLANTER OTHER / AREA CLAN YES V NO ACTIVITY SEEN YES NO MICE RATS COMMENTS FROM TECHNICIAN TECHNICIAN NAME: SIGNATURE 2�'T LICENSE i DATE ell_ — Allstate Asbestos Abatement 55 Harvard Street Lowell, MA 01851 978-423-4723 June 19, 2012 Mr. Jeffrey Sheehy Peters Street Associates, LLC PO Box 3099 Andover, MA 01810 Re: 102 Peters Street North Andover, MA Dear Mr. Sheehy This will confirm all asbestos was removed from above referred property on May 7, 2012. The asbestosis currently being stored at my shop in Lowell awaiting shipment to the land fill. Please call me with any questions. Zak Soulong NORTHEAST ENVIRONMENTAL LABS 11 CLIFF AVE. Suite B.HAMPTON,NH.03842-3650(978)618-6064 June 5,2012 Mr. Jeffrey D. Sheehy Peters Street Assoc.LLC. P.O.Box 3099 i Andover,MA. 01810 Subject: Asbestos Air Test: 102 Peters St. North Andover MA. 01845 Dear Mr. Sheehy, Please find enclosed the final air test results taken on June 2, 2012. Northeast Environmental was contracted to perform final air clearance sampling for airborne fibers at the address cited above. All samples collected,were analyzed by Northeast Environmental Labs for the determination of an airborne fiber count. The analysis was performed in accordance with "Phase Contrast Microscopy NIOSH Method 7400". This report includes a summary of the analytical results. The analysis indicates that all fiber levels during test time were below recommended and/or established standards set by any local, state and federal agency. If you have any questions concerning your results, this report or the analytical methods employed, please feel free to call me at(978) 618-6064 Respectfully, John A. Bachand, Esq. Industrial Hygienist ASBESTOS AIR SAMPLING SHEET j PROJECT 102 PETTERS ST. Calibration:Place check mark after each test that is performed Date: 6/2/12 SITE: NORTH ANDOVER,MA.01845 Phase Rings Aligned: 1B Field Iris Centered: ID HSE/NPL test slide check: ►F Slide Certificate Number: 2698 Number of Lines Detected: 5 (Graticle Field Diameter:(um):100 Graticle Field area(mm2):0.00785) CONTRACTO ALL STATE ABATEMENT Job Number: ASA 060212-1 Cassette size: 25 mm LAB SAMPLE SAMPLE START STOP TOTAL FLOW Gross Fiber NUMBER DATE TYPE SAMPLE LOCATION TIME TIME MIN. RATE VOLUME Concentration Fibers/100 Density F/cc f/mmz ASA-1 6/2/12 PCM BASEMENT CONTAINMENT:BY 1:54 PM 3:20 PM 86 16.0 / 16.0 1376 7.0 / 100 8.9172 0 .002 NEPA UNIT ASA-2 6/2/12 PCM BASEMENT CONTAINMENT:BY 1:54 PM 3:20 PM 86 16.0 / 16.0 1376 2.0 / 100 2.5478 < .002 DECOM ENTRANCE KITCHEN CONTAINMENT:BY1:57 PM 3:23 PM 86 16.0 / 16.0 1376 5.0 / 100 6.3694 < .002 ASA-3 6/2/12 PCM HEPA UNIT ASA-3 6/2/12 PCM 2ND FLOOR BATHEROOM 2:00 PM 3:30 PM 90 16.0 / 16.0 1440 7.0 / 100 8.9172 0 .002 CONTAINMENT:BY HEPA UNIT EPA Recommended release criteria of<0.01 fibers/cubic centimeter SAMPLED BY: John A.Bachand ANALYZED BY: John A.Bachand MASS CERTIFICATE#: AM 031319 Exp.Date:11/23/2012 Analyst Signature: NORTHEAST ENVIRONMENTAL LABS 11 CLIFF AVE. Suite B. HAMPTON,NH. 03842-3650 May 8,2012 Mr.Jeffrey Sheehy PO Box 3099 .Andover,MA 01810 Re: Pre-Demolition Asbestos Inspection: 102 Peter Street No.Andover,MA 01845 li Dear Mr. Sheehy, Y ` Enclosed are the analytical results for the samples collected by Northeastern Environmental Labs at the location cited above as requested by you.The sampling was performed on May 7,2012 in an effort to identify the accessible asbestos containing building material(ACBM)present. A total of seven (7) bulk samples were collected from the different accessible suspect ACMB and the samples were analyzed using polarized light microscopy (.PLM) to determined possible asbestos content. Table 1 below provides a summary of the sample results and the enclosed results provide a listof the suspect materials:inventories and the analytical results.Please note that although PLM is the method currently recognized in State regulations for asbestos identification in I bulk samples,some industry studies have found that PLM may not be sensitive enough to detect all of the asbestos fibers in certain materials. In the event that more definitive results are requested, than NEE Labs recommends that confirmation testing is completed using transmission electron microscopy. Any additional suspect materials, not listed in the enclosed listing of suspect material, which may be identified during demolition or renovation should be properly sampled when made accessible or assumed to be asbestos-containing and then properly handled as such. In particular, it is possible that other suspect ACMB, may be encountered with in wall or ceiling chase areas accessed during renovation or other facilities work. Use care when accessing these spaces and properly test suspect material encountered prior to any disturbance. In. accordance with current regulatory requirements ACMB that may be impacted or disturbed (such.that asbestos fiber release occurs) by renovation, demolitionor other such activity must be removed by qualified and licensed asbestos abatement firms. ACMB that will not be impacted by renovation.or demolition activity may be left in place if managed properly and materials are left in good condition. If If you have any questions or comments,please do.not hesitate to call me at(978)618-6064. I Respectfully, John A.Bachand,Esq. Industrial Hygienist AA000153 AM 031319 Al 030160 r i TABLE I SUMMARY OF ACCESSIBLE ASBESTUS CONTAINING BUILDING MATERIAL IDENTIFIED Sample Description: Results: Identification: 050712-5 Interior: Kitchen: 5% Red 12x12 Fl Chrysotile Tile 050712-7 White & Green Interior: 2 d Bath 20% Linoleum Chrysotile N/A Interior: Basement: TSI Pipe Insulation ASSUMED ASBESTOS i EMSL Analytical, Inc. EMSL Order: 131202115 7 Constitution Way,Suite 107,Wobum,MA 01801 CUStomerlD: NEEL62 Phone/Fax (781)933-8411/(781)933-8412 CustomerPO: cc/ bostonlab(a)emsi.com ProjectlD: Attn: John A. Bachand Phone. (978)618-6064 Northeast Environmental Labs Fax: (603)929-5958 11 Cliff Avenue Received: 05107/12 3:00 PM Suite B Analysis Date: 5/8/2012 Collected: 5!712012 Hampton, NH 03842-3650 Project 102 Peter St;North Andover,KA Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 and/or EPA 600/M4-82-020 Method(s) using Polarized Light Microscopy Non-Asbestos Asbestos Sample Description Appearance % Fibrous % Non-Fibrous _% Tyrue 050712-1 Ext;Roof- Black; 55% Cellulose 45% Non-fibrous(other) None Detected Asphaltic Roofing Fibrous 131202115-0001 Shingle Homogeneous 050712-2 Ext;under Siding- Brown/Black 70% Cellulose 30% Non-fibrous(other) None Detected Felt Paper Fibrous 1312021150002 Heterogeneous 050712-3 Ext;Wooden Tan 100% Non-fibrous(other) None Detected Windows-Glazing Non-Fibrous 131202115-0003 Homogeneous 050712-4 Int;Throughout- White 100% Non-fibrous(other) None Detected Skim Coat Plaster Non-Fibrous 1312021150004 Homogeneous 050712-5 Int;Kitchen-Red Red 95% Non-fibrous(other) 5% Chrysotile 12x12 FI Tile Non-Fibrous 131202115-0005 HOtTtOgeneOUS 050712-6 Int;Kitchen- Tan 100% Non-fibrous(other) None Detected Mastic on Red Non-Fibrous 1312021150006 12X12 FT Homogeneous 050712-7 Int;2nd;Bath- GrayNarious 20% Cellulose 60% Non-fibrous(other) 20% Chrysotile White&Green Fibrous 1312021150007 Linoleum Heterogeneous Analyst(s) Allison Libeskind(7) Renakfo Drakes,Laboratory Manager or other approved signatory EMSL maintains liability lim iced to cost of analysis. This report relates only to the samples reported and may not be reproduced,except in full,without written approval by EMSL. EMSL bears no responsibility for sample collection activities or analytical method limitations. Interpretation and use of test results are the responsibility of the client. This report must not be used by the client to claim j product certification,approval,or endorsement by NVLAP,NIST or any agency of the federal government. Non-friable organically bound materials present a problem matrix and therefore EMSL recommends gravmetric reduction prior to analysis. Samples received in good condition unless otherwise noted. Estimated accuracy,precision and uncertainty data available upon request.Unless requested by the client,building materials manufactured with multiple layers(i.e.linoleum,wallboard,etc.)are reported as a single sample.None Detected=<1% Samples analyzed by EMSL Analytical,Inc.Woburn,MA NVLAP Lab Code 101147.0,CT PH-0315,MA AA000188,RI AAL-10773 and VTAL357102 4 Initial report from 05108/2012`17:16:11 a I THIS IS THE LAST PAGE OF THE REPORT. Test Reoat PLM-7.16.0 Printed:5/8/2012 5:18:37 PM 1 Asbestos Chain of Custody EMSL ANALYTICAL. INC. ' 1'CONSTITUTION WAY EMSL Order Number(Lab use only): SUITE 107 EMaI ANALYTICAL.INC. 1312 0211WOBURN, M.A.01801 PHONE: (781)-933-8411 FAX: (781)-933-8412 EMSL-Bill to:❑Same ❑Different Com pany / If Bill to is Different note instructions in comments" Street: claw( Thins Party Billing re vires written authorization from third p8rfy Ci!y: State/Province: Zi /Postal Code: Coun Re ort To Name: Telephone M Email Address: ax M Purchase Order: Project Name/Number. ase Provide Results: ❑ Fax ❑Email U.S.State Samples Taken: Connecticut Samples:❑Commercial Residential T rnaround Time ATO tions"-Please Check ❑3 Hour I E]6 Hour I our I ❑48 Hour I ❑ 72 Hour I L] 96 Hour I C]1 Week 1 [12 Week *For TEM Air 3 hr through 6 hr,ple4se call ahead to schedule.*There is a premium charge for 3 Hour TEM AHERA or EPA Level 11 TAT. You will be asked to sign an authorization form forth service. Analysis com feted in accordance with EMSL's Terms and Conditions located in the Analytical Price Guide. PCM-Air ❑Check if sampl s are from NY TEM-Air ❑44.5hr TAT(AHERA only) TEM-Dust ❑ NIOSH 7400 ❑ AHERA 40 CFR,Part 763 ❑Microvac-ASTM D 5755 ❑ w/OSHA 8hr.TWA ❑ NIOSH 7402 ❑Wipe-ASTM D6480 PLM ulk reoorting limit ❑ EPA Level 11 ❑Carpet Sonication(EPA 600/J-931167) PLM EPA 600/R-93/116(< %) ❑ ISO 10312 Soil/Rock/Vermiculite ❑PLM EPA NOB(<1%) TEM-Bulk ❑ PLM CARB 435-A(0.25%sensitivity) Point Count ❑TEM EPA NOB ! ❑ PLM CARE 435-B(0.1%sensitivity) ❑400(<0.25%)❑1000(<0. %) ❑ NYS NOB 198.4(non-friable-NY) ❑TEM CARB 435-B(0.1%sensitivity) Point Count w/Gravimetric ❑Chatfield SOP ❑TEM GARB 435-C(0.01%sensitivity) ❑400(<0.25%)❑ 1000(<0. %o) ❑TEM Mass Analysis-EPA 600 sec..2.5 ❑TEM Qual.via Filtration Technique NYS 198.1 (friable in NY) TEM-Water.EPA 100.2 ❑TEM Qual.via Drop-Mount Technique ❑ NYS 198.6 NOB(non-fria le-NY) Fibers>10Nm ❑Waste ❑Drinking Other: ❑ NIOSH 9002 <1% All Fiber Sizes ❑Waste ❑Drinking ' ❑ El Check For Positive Stop Clearly Identify Homogenous Group Filter Pore Size Air S les : ❑0.8pm ❑0.45pm Samplers Name:SW Samplers Signatu A t<3 Volume/Area(Air) Date/Time Sample# Sample Description HA# Bulk Sampled Cut (i (� t ? t l�► /z.x1Z �f T tt,, Client Sample#(s): - S Relinquished(Cl ie Date: -S' / - MAY U 7 T=- I Received(Lab): Date: ,.�Cs -Time: Comments/Special Instructions: commue0 Doamerd-Asbestos GDC-R5-wirtnt t Page 1 0f pages Commonwealth of Massachusetts 100148419 Ilk}` Asbestos Notification Form ANF-001 Decal Number Important: illiA. Asbestos Abatement Description When filling out r.+ computer, to the 1 a. Is this facility fee exempt-city,town district,municipal housing authority, owner-occupied oompuler,use ty P ❑ � 9 ty� only the tab key residence of four units or less? Yes D No to move your cursor-do not b,Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. f=acility Location: PETER STREET ASSOCIATES,LLC. 102 PETER ST. P.Name of Facilityb.Street Address ANDOVER MA 01810 C.City/Town d.Stale e.Zip Code L Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sectlonsorthis BASEMENT,KITCKEN,BAT form must be a.Building Name/Building Location b.Building 0 c-Vving d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑Yes 2 No DEP nouticatlon requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division or Occupational JALLSTATE ASBESTOS ABATEMENT 8� VARNEY STREET Safety(DOS) e.Name b.Address notrequirements LOWELL 018Sd 9784587466 requirements of 453 � �—..___.. CMR 6 12 c.Cil /Town d.Zip Code e.Telephone Number AC000472 g. Contract Type: ❑Written ❑Verbal f.DOS License Number . a Contact Person I.Contact Person's Title 6 ZAKARIYA SOULONG AS052339 a.Name of On-Site Supervisor/Foremen b.Supervisor/Foreman DOS Certification Number 7 GARALD LABLANC AM061397 a Name of Project Monitor D. ro act Monitor DOS Certification Number ENVIROTEST LABORATORY AA000128 8' a.Name ofAlklasto5Analylical Lab b.Asbestos Anal cal Lab DOS Certification Number _° 9 05/30/2012 05130/2012 �_ a.Project start Date mmlddl b.End Date(mnVddlyyyy) �o SAM-41RM N c.worts hours Mon-Fri. d.Work hours Sat-Sun. o 10. a.What type of project Is this? --O ED Demolition ❑Renovation F_ ❑Repair ❑Other,please specify; b.Describe 11. a. Check abatement procedures: ----0 ✓ Glove bag Encapsulation �--�oEnclosure Disposal only gwwu=LL Cleanup ❑Other, specify.- Full pecify:Full containment b.Describe �•�--Z 12. Is the job being conducted: 0 Indoors? [�Outdoors? anfOolap.doc•10/02 Aebestos Notification Form-Page 1 of 3 d i Commonwealth of Massachusetts 100148419 1` Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encs sulated� 80 100 a.Total pipesor uc�s(I near R) o. I ofal other surfaces square HT c.Boiler,breaching,duct,tank surface coatings Lin,9. S R a.Insulating cement Lin.4. S►—f►-� e.Corrugated or layered paper 80 f.Trowel/Sprayer ra g pipe insulation p yer coatin s �� ---J Lin.fl. (SC,M. Lin.R. Sq.R. g.Spray-on fireproofing ) h.Trensile board.wall board Lin,R. Sq.R. Lin. 5q.R. i.Cloths,woven fabrics 100 (Li-n—:�.---� S'S n---^-r i.Other,please specify: Lin. 9 Q 7 k.Thermal,solid core pipe f I FLOOR TILE Insulation ln. Sq.R, I.z>pgray 14. Describe the decontamination systems)to be used: 3 STAGE DECONTAMINATION. 15, Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6,14(2)(g): ALL ACM TO BE DOUBLED BAGGED IN 6 MIL LABELED ASBESTOS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a.Name 0 EP omcla b.Ti le c.Date(mm/dd of-Authorization d.DEP Waver p e.Name or DOS Official fr+ciaMie N g.Date(mm/d y)of Authorization h.DOS Wa ver>r 0 17. Do prevailing wage rates as per M.G.L. C. 149, §26, 27 or 27A—F apply to this project? Q Yes❑Q No 0 B. Facility Description N o 1. Current or prior use of facility: 0 2. Is the facility owner-occupied residential with 4 units or less? 0 Yes Q No - 3 PETER STREET ASSOCIATES.LLC. a.Faclll Owner Name b.Address o c.Ci(!Town d.Zi Code e.Tela hone Number area code and extension LL 4 a.NFacdi Owners On.Slle Manage b.On-Site Manager Address Z 20�Q C.Ciry/Town d.Zip Code e.Telephone Number(area code and extension) anPo0lap.doc•10/02 Asbestos Notification Form•PaMe 2 of 3 Commonwealth of Massachusetts 100148419 i Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont. 5 ALLSTATE ASBESTOS ABATEMENT a.Name of General Contractor b.Address C.CI Rown d.Zip Code e.Tete hone Number area code and extension f.Contractor's Worker's Comp.Insurer Q.Policy Number h,Ex .Date mm/ddl 6. What Is the size of this Facility? a. b Square Feet .Number umber of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): J.O.BJ ROLL OFF,INC. Note:Transfer a.Name of Tr ns orter b.Address Stations must comply with the a City/Town d.Zips C d-1 e.Telephone Number Solid Waste p D1vlston 2. Transporter of asbestos-containing waste material from removalitem ora site to final disposal site: Regulations 310 9 p ry p CMR 19.000 a.Name of Trane orter b.Address J C.CII /Town d.Zip Code a.Telephone Number 3. a Refuse Transfer Station and Owner b.Address c.Cif /Town d.Zip Code e.Telephone Number 4. TURNKEY LANDFILL WASTE MGT NH a.Final Dls os-al Site Location Name b.Final Disposal Site Location Owner's Name 7 ROCHESTER NECK ROAD ROCHESTER gc.F'in IDls osal sits Address d Ctt rTown 03839 rt e,Slate f,Zip Code g.Telephone Number �v D. Certification N The undersigned hereby states,under the iZAKARIYASOULONG O penalties of perjury,that he/she has read the a.N m b:Authorized Si nature v Commonwealth of Massachusetts regulations 5/15/2012 for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and C.PositionRllle d Dale mn>rddi --t 310 CMR 7.15,and that the information I contained in this notification is true and correct •Telephone Number i.Re resenlin —*—�� to the best of hie/her knowledge and belief. v .Address amLL li �Z h.Ci(y/Town i.Zip Code an1o01ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 `1 eDEP - MassDEP's OnlineFiling System Page 1 of 1 MasaDEP Home I Contact I Feedback I Tour I Privacy Policy MassDEP's Online Filing System Uscmamv:ZAKSOULONG Nickname:ALLSTATE ASBESTOS ABATEMENT My eDEP Forms®r My Profile ow Help Receipt �5 sin Racelot Summary/Receipt 11.print:.re.ceipt, Your submission is complete.Thank you for using DEP's online reporting system. You can select"My eDEP" to see a list of your transactions. DEP Transaction ID: 472020 Date and Time Submitted. 5116/2012 8:25'02 PM Other Email : Form Name:AQ 04 -Asbestos Removal Notification Form ANF-001 Payment Information DEP code: 65937 Date: 5/15/2012 7:39:30 PM Amount($): 85 Billing Into: SOULONG ZAKARIYA—AccountType--AccountNumber*"'"2917 Confirmation Number: Contractor Contractor Number:AC000472 Name: ALLSTATE ASBESTOS ABATEMENT Address: 28 VARNEY STREET, LOWELL, MA 01854 978-458-7466 Supervisor ZAKARIYA SOULONG Project Monitor Lab Location BASEMENT, KITCKEN,BAT Project Start Date 5/30/2012 My eDEP MessDEP Home ! Contact I Feedback I Tour I Privacy Policy MassDEP's Online Filing System ver 11.5.7.00 2011 MassDEP https:Hedep.dep.mass-gov/pages/PrintReceipt.aspx 5/16/2012 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 0 S Sr is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined b MGL c 11, S 150 A. y Also, note Permits are required under Fire Prevention laws Chapter 148 Section l OA. The debris will be disposed of in: (Location of Facility) - I nature of Permit Applicant Date A i 14� i /1 S Iv SS 3 -�f N428e 4 �ee OP ID:SS ACORD" DATE(MM/DD/YYYY) `.� CERTIFICATE OF LIABILITY INSURANCE 07/18/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 978-688-7000 CONTACT Durso&Jankowski Ins Agcy LLC NAME: FAX 198 Massachusetts Avenue 978.688-7001 PHONE A/c No Ext): A/c No): North Andover,MA 01845 E-MAIL Durso&Jankowski Ins.Agcy. ADDRESS: PRODUCER GHEND-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED G Henderson CO Inc. INSURER A:Travelers Ins.Co. 19038 36 Lupine Road INSURER 8:MSA Group 14788 Andover,MA 01810 INSURER C: INSURER D: INSURER E: INSURER F: - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE IADDL B POLICY NUMBER MM/DDY EFF MMILDDPOLIEXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY MPT3579C 10/06/11 10/06/12 O Ea occurrence $ 300,00 PREMISES Ea CLAIMS-MADE OCCUR MED EXP(Any one person) $_ PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1+000,00 A ANY AUTO BA2542N26512SEL 02/06/12 02/06/13 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ .. I X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS - (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONX WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER _ B ANY PROPRIETOR/PARTNER/EXECUTIVE WCT3579C 03/12/12 03/12/13 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 fes ,describe under DCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Peters Street Associates LLC/ principal and affiliates are additional insured for geneneral liability per contractors extension endorsement when required by written contract. CERTIFICATE HOLDER CANCELLATION PETERSS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Peters Street Associates LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 3099 ACCORDANCE WITH THE POLICY PROVISIONS. Andover,MA 01810 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The C.6.mmonwealth of Massachusetts Department of Fire Services Office of the State Fire Marshal P.0.Box 1025 State pRoad, rStow,MA 01775 PERMIT Date: North Andover rermitNo Dig SafeNnm er (City of Town) (If Applicable) In accordance with the provisions of M G-LI 4$.Chapwr_J_Q_as provided in section 5 7 Z/f MR 34 Stmt Date This Permit is granted to: �itS c r%/2f.G' 057c.f, C. r6 Full name of person,Firm or Corporation Pemussionto locate dumpster for construction/renovation/demolition of building. Comments: dumpster must be . 251 from structure if unable to place with required Restrictions:clearance dumps-ter must be covered with plywood or tarp end of work -day at (Give location by street and no.,or desc such manner-as t provied adequate identification of location) FeePaids 50.00 Fire Chief - --- e_ -1 This Permit will expire (S ignatur rcal witting perrmt) Ofcal granting permit (Titre)