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HomeMy WebLinkAboutBuilding Permit #694 - 1160 GREAT POND ROAD 5/20/2004 TOWN of NORTH ANDOVER BUELDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE TYPE USE OR OCCUPANCY OF, OR EMOLY ANY BUILDING M OTHER THAN A ONE OR TWO FAMILY dDWELLING X Ws Sed for Official dT9 3 sr BUILDING PERMIT NUMBER: _ DATE ISSUER: SIGNATURE: o 0 Building Commissioner/Inspector of Buildin Date 0� 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1160 RCAT Pak q0 C. 6K, 103 or�T Map N muMap br Parcel Number Iia• A,Qc� MA 01r0-, ( 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot ea sf) Frontage 1.6 BU DING SETBACKS(ft) M Front Yard Side Yard Rear Yard Required I Provide Required Provided Required Provided OI mr 01' L �� 1.7 Water S ly M.G.L.C.40.§54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ Zone outside Flood Zone Municipal 1K On Site Disposal System 0 y 7a 2.1 g�wwner of Record ft5 f�GE�T- �o/e 15,2_ ,4'S S�'Cfop� // �o 61e-r47- 1-:5d4-to ,ec-t o O Name V Address for Service Si nature Telephone 2.2 Authorized Agent / �I /1 "2f �dy'ai r� /l �O G4CCA j Name Print Address for Service: g" ?LS'-G Zia 441 � Telephone M 90 3.1 Licensed Construction Supervisor Not Applicable ❑ 1L l.= Address License Number Licensed Const rvisor: C)J?9�f Expiration Date C / r Signatu Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number LZ I V t:Um Address ----------- ----- ----- ----------------- ------- --- � ,, MAY 2 0 204 Expiration Date 8 U I L D 1NDEP �j Signature Telephone 7 o VA,-N as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print e / Si tune o Owner/Agent Date Item Estimated Cost(Dollars)to be Completed by permit applicant 1. Building bzjv\x� i (a) Building Permit Fee } Multiplier 2 Electrical (b) Estimated Total Cost of Construction from(6) 3 Plumbing Building Permit fee (a) x(b) � 4 Mechanical(HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) /3 a�o Check Number ,l - X NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2 N 3ao SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFMvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE -i- 1 New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify Brief Description of Proposed Work: k ouu sK)b 7nS:;0 OF i=.XX5T1JUC, wooiI I=RAMC- S112JC; uttr ,1�)C.Los-ruL5 or- FbU.�JD�4TTD J ft�i) �rrn/(�S, M ii USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly 0 A-I 0 A-2 ❑ A-3 0 ]A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ C Educational 0 2B 0 F Factory ❑ F-1 ❑ F-2 0 2C ❑ H High Hazard 0 3A ❑ IInstitutional 0 I-1 ❑ I-2 0 I-3 0 3B ❑ M Mercantile ❑ 4 ❑ R residential 0 R-1 0 R-2 0 R-3 0 5A ❑ S Storage 0 S-1 ❑ S-2 0 5B 0 U Utility ❑ Specify: M Mixed Use 0 Specify: S Special Use 0 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height ft Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SEC'T'ION 10a Owner Authorization TO RE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUrLLDTNG PERMIT i, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Bate Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed affidavit Attached Yea No . ❑ SUWE Y S lP)lt� S11t215t7 � �3 C D�tSJfl UCTION.CO- dO:l, Sd' .. 5.1 Registered Architect: Name: Address Signature Telephone Area of Responsibility Name: Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Registration Number Address Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility ` Address Registration Number Signature Telephone Expiration Date V h �R-�..P1.A)� '�+ � � Not Applicable ❑ Com y Name: 'M PytI(. Responsible in Charge of Construction Location I I :20 a--12F7►7 pok;i� � No. (p�1�- 17c�uoL.�?i oA-) Date at NORT#1 TOWN OF NORTH ANDOVER .x,40 Certificate of Occupancy $ �'�'°' •'tom Building/Frame(Frame Permit Fee $ ss•►CHu9 sa Foundation Permit Fee $ Other Permit Fee "�(nA-U $ 13a Sy TOTAL $ 3a.So Check # �U Building Inspector x a Town of North Andover a� N°Rr" q Building Department 3� gt' N6�6�°L 27 Charles Street 0 North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 ZED 0 Building Demolition Affidavit SACHIfs���� DATE 0' OWNERS NAME &ADDRESS 'P)PCQ)C5 �C 1+o0 t- PROPERTY LOCATION Ge'LACT RSD DESCRIPTION I x r-IZ$MC. SCK UC P-K(; Q,nl F/eas-" A a4 LC CONTRACTORS NAME &ADDRESS CQV5rteUG7-,tU0 C1�'GtK/L14L� �C.Z-DDL l2 ��L�rv� ,t/rLCrCGGrA�� rv1� It DEPARTMENT DE ARTMENT SIGN-OFFS s. /D.P.W./WA 1 �7 SEWER 5-1Z- ✓CTAS ELECTRIC To Ktalan2s - TELEPHONE CABLE /V& TAXES Af POLICE ✓FIRE ' EXTERMINATOR Al 18 DUMPSTER- ON/OFF STREET G!, �dZ , DIG SAFE NUMBER �w7 X600 oZO 9cr�� y-/y-oy BLDG. INSPECTOR DATE REC'D RECEIVED MAY 2 0 2004 BUILDING DEPT. Y k North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance wh the provision of MGL c 40 S 54, a condition of Building Permit Number_ is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) . Signature of Permit Applicant IJ-/1//o q Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector j�er-ta �(c,bs k� ) Ud-41 ea RECEIVED MAY 2 U 2004 BUILDING DEPTR The Commonwealth of Massachusetts w r Department of Industrial Accidents a 1 d ®Vice of Investigations ow` Boston, Mass. 02111 5ylb Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # 0 I am a homeowner performing all work myself. . I am a sole proprietor and have no one working in any capacity EyI am an employer providing workers' compensation for my employees working on this job. Company name: Address t)q� Q-Ln City 1 HCl (.� L► UIJCT cG� Phone#: O"C) Insurance Co.Co. ///gym i L' Policv# lO c o ©0 & 7 Company name: Address City Phone#: Insurance Co Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment-as_welLas_civil..penattiesin-the fnrm ofa..STOP WORK_ORDER..and.a fine.of.(.$10.0..00)_a day against-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify and he pains and penalties of perjury that the information provided above is true and correct. Signature czc Date c�//Log Print name Phone# 014,03 1,404 Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensin_q Board ❑ Selectman's Office Contact person: Phone#. ❑ Health Department ❑ Other MAY 2 0 2004 BUILDING DEPT. �.1ORTH ® of No. = 0 dover, Mass., At VZO& bemak! -O" AOR C T D�CPK�`y�t� AE -` BOARD OF HEALTH PERMIT /Kitchen C System • UILDI INSPECTO THIS CERTIFIES THAT...�...r.�.. .... ..... O. ............................... ..:....... ..G�1t� �!'� Found 'on has permission to on. �n. ..�/��... ....... .. ....... ito Rough . AA&A91! o Chimney to be occupied as... ......�......a..........��'.. �.. i1�l �r� .... . . y provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. PLUMBG INS CTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN b MONTHS UNLESS CONSTRUCTI ST S ELECTRIC SPECTOR L Rough ....................................................... ..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building G INSPE Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final RE DEPARTMENT Bur S t No. ®s s !ffIF SEE REVERSE SIDE oke Det. ' All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP ' Plaistow, NH 03865 Fax: 603-378-0610 I Close-Out Documentation Submittals for Asbestos Abatement at Old Maintenance Building 1160 Great Pond Road No. Andover, MA i� Prepared by: All State Abatement Professionals, Inc. Contact: Joseph Scott Curley 4 Wilder Drive, Suite 12 Plaistow, New Hampshire 03865 Asbestos•Masonry Cleaning •Selective Demolition•Shot/Sand Blasting m All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP ' Plaistow, NH 03865 Fax: 603-378-0610 i INDEX l Submittal # 1 Notifications Submittal # 2 Daily Sign-In LogsL' �; Submittal # 3 Daily Job Reports Submittal # 4 Employee Licenses and Medicals Submittal # 5 Asbestos Disposal Manifests I t f. a: fl I�Asbestos•Masonry Cleaning •Selective Demolition •Shot/Sand Blasting i�. All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 ' F A 1 ; i. 3 i Submittal # 1 , Notifications x 4... 1 t i i !i Asbestos •Masonry Cleaning •Selective Demolition•Shot/Sand Blasting j I Commonwealth of Massachusetts 201842 ' Please Enter Decal# I p. Asbestos Notification Form ANF-001 A. Asbestos Abatement Description )rtant: n filling out 1. Facility Location: on the )uter,use Old Maintenance Bldg 1160 Great Pond Road :he tab key Name of Facility Street Address we your No. Andover MA 01845 978-725-6280 x-do not City/Town State Zip Code Telephone he return Worksite Location: Attic, 1"floor Building name,#,wing,floor,room. 2. Is the facility occupied? ❑ Yes ® No 3. Asbestos Contractor: All State Abatement Professionals, Inc. 4 Wilder Drive, Ste 12 ' Name Address RUCTIONS Plaistow, NH 03865 (603) 378-0600 City/Town Zip Code Telephone sections of xm must be AC00031 leted in order DOS License# Contract Type: ® Written ❑ Verbal nply with J. Scott Curley President notification FacilityContact Person Contact ements ofperson's title ,MR 7.15 4 Richard Croteau AS30312 ie Division Name of On-Site Supervisor/Foreman DOS Certification# :cupational Air Testing Services AA000124 y(DOS) 5. ration Name of Project Monitor DOS Cert cation# -ements of Air Testing Services AA000124 'MR 6.12 6. Name of Asbestos Analytical Lab DOS Certification# )mit Original to: ronwealth of 08/18/03 08/18/03 achuse 7• otos Program Project Start Date End Date ox 120087 n MA In 2-0087 7.00 am - 3:30 pm Work hours Mon-Fri. Work hours Sat-Sun. { 8. What type of project is this? 1 ❑ Demolition ® Renovation ❑ Repair ❑ Other, please specify: 1 , 9. Check abatement procedures: ® Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑ Other, specify: ® Full containment 10. Is the job being conducted: ® Indoors? ❑ Outdoors? 58 Brooks.doc•2/02 Asbestos Notification Form•Page 1 of 1 � i I � Iii 201842 i. Commonwealth of Massachusetts I Please Enter Decal# Asbestos Notification Form ANF-001 A. Asbestos Abatement Description (cont.) 11. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encapsulated: 12 50 pipes or ducts(linear ft) other surfaces(square ft) Boiler,breaching,duct,tank surface / / coatings lin.ft sq.ft Insulating cement lin.ft sq.ft Corrugated or layered paper pipe insulation lin.ft sq.ft Trowel/Sprayer coatings lin.ft sq.ft Spray-on fireproofing lin.ft /sq-ft Transite board,wall board lin.ft sq.ft Cloths,woven fabrics lin.ft /sq.ft Other,please specify: F Thermal,solid core pipe insulation 12/ Tile&Mastic /50 lin.ft sq.ft lin.ft sq.ft 12. Describe the decontamination system(s)to be used: Provide an adequate decontamination unit. 13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): Double 6 mil poly 14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: Name of DEP official Title Date of Authorization Waiver# Name of DOS official Title Date of Authorization Waiver# 15. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑ Yes® No B. Facility Description 1 1. Current or prior use of facility: Maintenance Bldg 2. Is the facility owner-occupied residential with 4 units or less? ❑ Yes ® No 3 Brooks School 1160 Great Pond Road I Facility Owner Name Address I!' t: No. Andover, MA 01845 978-725-6300 City/Town Zip Code Telephone 1 John Trovage 1160.Great Pond Road 11. 4' Name of Facility Owner's On-Site Manager Address No. Andover, MA 01845 978-725-6280 City/Town Zip Code Telephone 38 Brooks.doc•2/02 Asbestos Notification Form•Page 2 of 2 i 1 is Commonwealth of Massachusetts 201842 Please Enter Decal# Asbestos Notification Form ANF-001 B. Facility Description (cont.) 5. Name of General Contractor Address City/Town Zip Code Telephone Contractor's Worker's Comp.Insurer Policy# Exp.Date 1 6. What is the size of this facility? 3,000Square Feet #of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary)to final disposal site: All State Abatement Professional$, Inc. 4 Wilder Drive, Ste 12 -ransfer Name of transporter Address s must Plaistow, NH 03865 (603) 378-0600 with the City/Town Zip Code Telephone Vaste i .tions 310 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 9.000 J.O.B./Rolloff, Inc. P.O. Box 6037 Name of transporter Address Chelsea, MA 02150 (617) 387-1495 City/Town Zip Code Telephone 3. Not Applicable Refuse transfer station and owner Address City/rown Zip Code Telephone 4. Waste Mgmt of NH-Turnkey Landfill Final Disposal Site location name Owner's Name 90 Rochester Neck Rd Rochester j Address City/rown NH 03867 (800) 847-5303 State Zip Code Telephone j { D. Certification The undersigned hereby states, under the J. Scott Curley penalties of perjury,that he/she has read Name Authorized Signature and C6te the Commonwealth of Massachusetts ontractor regulations for the Removal, Containment President/CEO All State Abatement Professionals,Inc. gn this form or Encapsulation of Asbestos, 453 CMR Posdion/T�le Representing "0tifi1O" 6.00 and 310 CMR 7.15, and that the (603) 378-0600 4 Wilder Drive, Ste 12 information contained in this notification is Telephone Address I± true and correct to the best of his/her Plaistow, NH 03865 . knowledge and belief. City/Town Zip Code Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ❑Yes ®No i 3 Brooks.doc•2/02 Asbestos Notification Form•Page 3 of 3 I1 li Commonwealth of Massachusetts 203384 Please Enter Decal# Asbestos Notification Form ANF-001 A. Asbestos Abatement Description ------- ant: Filling out 1. Facility Location: m the ler,use Old Maintenance Bldg 1160 Great Pond Road tab key Name of Facility Street Address your No. Andover MA 01845 978-725-6280 - not return Cityrrown State Zip Code Telephone Worksite Location: Attic, 1"floor Building name,#,wing,floor,room. 2. Is the facility occupied? ❑ Yes ® No 3. Asbestos Contractor: ! Methuen Staffing, Inc. 2 Charles Street Name Address uCTIONs Methuen, MA 01844 978-975-7474 ections of Cityfrown, Zip Code Telephone " m must be Sed in order DOS0080# Contract Type: ® Written El Verbal ply with Albania DeLeon ncation Facility Contact Person Contad person's title -meets of AR 7.15 Richard Croteau AS30312 Division 4. Name of On-Site Supervisor/Foreman DOS Certification# upatio'DOS) ' ) 5 g Air Testing Services AA000124 'Dos tion Name of Project Monitor DOS Certification# vents of Air Testing Services AA000124 AR 6.12 6. Name of Asbestos Analytical Lab DOS Certification# nit Original onweatth of 08/18/03 08/18/03 �sosProgram s 7• Project Start Date End Date Pro c 120087 MA 0087 7:00 am-3:30 pm Work hours Mon-Fri. Work hours Sat-Sun. 8. What type of project is this? ❑ Demolition ® Renovation ❑ Repair ❑ Other, please specify: 9. Check abatement procedures: ® Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ` ❑ Cleanup ❑ Other, specify: I ® Full containment 10. Is the job being conducted: ® Indoors? ❑ Outdoors? 8 Brooks-Methuen.doc•2/02 Asbestos Notification Form•Page 1 of 1 i Commonwealth of Massachusetts 203384 Please Enter Decal# I j Asbestos Notification Form ANF-001 A. Asbestos Abatement Description (cont.) 11. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encapsulated: 12 50 pipes or ducts(linear ft) other surfaces(square ft) Boiler,breaching,duct,tank surface Insulating cement / coatings lin.ft sq.ft lin.ft sq.ft Corrugated orlayered paper pipe / Trowel/Sprayer coatings insulation lin.ft sq.ft lin.ft sq.ft Spray-on fireproofing lin.ft /sq.ft Transite board,wall board lin.ft /sq.ft Cloths,woven fabrics lin.ft /sq.ft Other,please specify. Thermal,solid core pipe insulation lin. / sq.ft Tile& Mastic lin.ft /s 0ft q 12. Describe the decontamination system(s)to be used: Provide an adequate decontamination unit. 13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): Double 6 mil poly , 14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: Name of DEP official Title Date of Authorization Waiver# Name of DOS official Title Date of Authorization Waiver# f t 15. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project?❑ Yes Z No ; B. Facility Description 1. Current or prior use of facility: Maintenance Bldg 2. Is the facility owner-occupied residential with 4 units or less? ❑ Yes ® No 3 Brooks School 1160 Great Pond Road Facility Owner Name Address No. Andover, MA 01845 978-725-6300 City/Town Zip Code Telephone 4 John Trovage 1160 Great Pond Road Name of Facility Owner's On-Site Manager Address No. Andover, MA 01845 978-725-6280 Cityrrown Zip Code Telephone 58 Brooks-Methuen.doc•2/02 Asbestos Notification Form•Page 2 of 2 ' i i Commonwealth of Massachusetts 203384 Please Enter Decal# Asbestos Notification Form ANF-001 i :i B. Facility Description (cont.) 5' Name of General Contractor Address City/Town Zip Code Telephone Contractor's Worker's Comp.Insurer Policy# Exp.Date 6. What is the size of this facility? 3,000 Square Feet #of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary)to final disposal site: All State Abatement Professionals, Inc. 4 Wilder Drive, Ste 12 Transfer Name of transporter Address ns must Plaistow,'NH 03865 (603) 378-0600 y with the City/rown Zip Code Telephone Naste 3ttions 310 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 19.000F J.O.B./Rolloff, Inc. P.O. Box 6037 Name of transporter Address i Chelsea, MA 02150 (617) 387-1495 City/Town Zip Code Telephone 3. Not Applicable Refuse transfer station and owner Address Citylrown Zip Code Telephone 4. Waste Mgmt of NH-Turnkey Landfill i Final Disposal Site location name Owner's Name 90 Rochester Neck Rd Rochester Address City/Town i NH 03867 (800) 847-5303 Statef Zip Code Telephone D. Certification The undersigned hereby states, under the Albania DeLeon (�J(♦,�41,y1, 1 j J�?c�p� penalties of perjury,that he/she has read Name Authonzed Signature an Date the Commonwealth of Massachusetts ontractor regulations for the Removal, Containment Methuen Staffing 3n this form or Encapsulation of Asbestos,453 CMR Position/Title Representing notification 6.00 and 310 CMR 7.15, and that the 978-975-7474 2 Charles Street Telephone information contained in this notification is Tel eP Address true and correct to the best of his/her Methuen, MA 01844 knowledge and belief. City/Town Zip Code Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ❑Yes ®No Brooks-Mcthuen.doc•2/02 Asbestos Notification Form-Page 3 of 3 I_ All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 July 30, 2003 0 Fire Department Attn.: Fire Prevention 124 Main Street No. Andover, MA 01845 Phone# (978) 688-9590 Re: Asbestos Abatement @ Brooks School I; Old Maintenance Building 1160 Great Pond Road i'II i To whom it may concern: i :I All State Abatement Professionals,Inc. (ASAP) is scheduled to perform work for the above referenced project on the following dates: i Start Date: 08/18/03 End Date: 08/18/03 All appropriate agencies have been notified for the above referenced project. If you have any questions or need additional information, please do not hesitate to contact me. A Sincerely, i Alicott Curley President/CEO JSC jab . Enclosures i Asbestos•Masonry Cleaning •Selective Demolition •Shot/Sa.nd Blasting_ All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 i July 30, 2003 r i Town of North Andover Board of Health 27 Charles Street North Andover, MA 01845 Phone#: (978) 688-9540 Re: Asbestos Abatement @ Brooks School Old Maintenance Building 1160 Great Pond Road i To whom it may concern: All State Abatement Professionals, Inc. (ASAP) is scheduled to perform work for the above referenced project on the following dates: Start Date: 08/18/03 End Date: 08/18/03 All appropriate agencies have been notified for the above referenced project. If you have j any questions or need additional information, please do not hesitate to contact me. Sincerely, `! J. Scott Curley President JSC Jab Enclosures i i i Asbestos • Masonry Cleaning •Selective Demolition•Shot/Sand Blasting IE All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 ! 866-565-ASAP g ' Plaistow, NH 03865 Fax: 603-378-0610 it t Submittal # 2 Daily Sign-In Logs I z Asbestos•Masonry Cleaning •Selective Demolition •Shot/Sand Blasting F i i, All State Abatement Professionals, inc. 60 Railroad Street 978-975-ASAP Haverhill, MA 01835 Fax: 978-374-5336 DAILY SIGN—IN CONTAINMENT LOG Generator: Brooks School PROJECT NAME 1160 Great Pond Rd,No. Andover, MA PROJECT #: j,y DATE /3 4 3 Day of Week (Please Circle One) S & T W TH F S Name (Print) License & State Si nature In Out Ley r—n 0r4' 2 G , } i s I! 1� t �i C t I Asbestos • Masonry Cleaning • Deleading • Shot/Sand Blasting �. I All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 Submittal # 3 Daily Job Reports P F t f Asbestos•Masonry Cleaning •Selective Demolition•Shot/Sand Blasting ., All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 DAIL Y JOB REPORT JOB NAME: _ Project: Old Maint Bldg 03-058 FORK ORDER NUMBER: 07 - 0 ,5-? ADDRESS: 1160 Great Pond Rd, No. Andover, MA DATE: �/j�/O 3 Generator: Brooks School 1160 Great Pond Rd, No. Andover, MA DAY OF WEEK(circle one) Sl..'% T W TH F S JOB FOREMAN: . SAFETY MEETING: lafetv meeting will be conducted before each project and should include the topics below. Supervisor to make sure all employees ave and wear hard hats and safety glasses. If employee does not have equipment, he will not be allowed to work that day. heck Boxes After Discussion: , a SAFE WORK PRACTICES 0 HARD HATS SAFETY GLASSES [ WORK BOOTS ERMU K SAFETY DESCRIPTION OF WORK (Check Daily Work Performed) is MOBILIZATION ON SITE UNLOADED EQUIPMENT PREPARED WORK AREA/CRITICALS SET-UP SHOWER/DECONTAMINATION UNIT /_ ABATEMENT OF FLOORING AND MASTIC//4?4► v,�c�eli rve ABATEMENT OF PIPE AND FITTING INSULATION/61,.)Ve ABATEMENT OF BOILER TANK AND BREECHING ABATEMENT OF TRANSITE BOARD j ABATEMENT OF ROOFING MATERIALS DEMOLITION OF INTERIOR PARTITIONS OTHER(Describe): NUMBER OF ACM BAGS FOR THE DAY ASSIGNED PERSONNEL: NAME HOURS N AMIEHOURS l _ L i e./La r C;-4! -C'L4L 9. 10. �I✓r.? r-,� ���-r � � 11. 12. 13. 14. 15. TOTAL HOURS l� j Asbestos • Masonry Cleaning • Selective Demolition •Shot/Sand Blasting t r'. All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610UV , Submittal # 4 Employee Licenses and Medicals i. Asbestos•Masonry Cleaning •Selective Demolition•Shot/Sand Blasting o I ommonwealth of Massachusetts INSTITUTE FOR Division of Occupational Safety g;�,, • Robert J.Prezioso,Deputy Director ENVIRONMENTAL EDUCATION, INC. r r *Asbestos Supervisor 16 Upton Drive,Wilmington,MA 01887 {���11U11 ARD CROTEAU IEE (978)658-5272 IEE to 04/09/2003 This is to certify that Da te 04/08/2004 Richard Croteau am. 312 has completed die requisite training,and has passed an examination ;f C D N E s for reaccreditation as: 12 IIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII HVRN resher pursuant to Title Iffoofthe Toestos se Substance Coupervisor ntrol Act,15 U.S.C.2646 STATE OF NEW HAMPSHIRE February 8.2003 t:a,..on.. DEPT.OF HEALTH&HUMAN SERVICES .Lena.,, ASBESTOS MANAGEMENT d CONTROL PROGRAM February 08.2003 maemt.W Envin—.W Edoma February 08.2004 ASBESTOS SUPERVISOR e..mM.aa.o,, to Upton tatty. Wllr"kn,au orae, 'RICHARD B. CROTEAU 0351201047840 CERTIFICATE r. D.O.B.: C.mnot.H 823 M-06-60 State of Maine ISSUED: EXPIRES: W c 11-27-02 11-26-03 (� Asbestos Abatement Program Richard B. Croteau �? DIRECTOR,OFFICE OF COMMUNITY d PUBLIC HEALTH Supervisor 917E OF'IVR Cert No. AS-0263 Expiration Date, 02/28r,'004 Tm.Exp.Date 02/08!2004 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Salem Family Practice Stires Road Sarem,TAll State Abatement Professionals,inc. WJr030i9 o3o TeC 603 898 4000 fax:603 894 6591 I 978.9:5-:5 i 60 Railroad Street t Haverml.MA 01 B35 Fax:9%B-37a-S3]6 ASBESTOS PHYSICAL EXAMINATION /J LETTER OF INTERPRETATION RESPIRATOR TRAI`1NGRECORD C�fiC�� _ Company S �� — Project Name: (_4 r't n k r lob s: ving examina/�tion,tests,and procedures were performed on the above-named y 5.5. O2� Q� on /•/LY.e. 7 ZJO} _ Employee's Name: may,,-, a Q,.. '4 - Physical exam with emphasis on cardio-respiratory system Your signature on this Respirator Training Record will angst to your having received and understood the basic (✓) Pulmonary Function Test performed by a certified technician respirator training program which both ASAP and the Occupational Sarery and Health Administration(OSHA) ( ) Part I Respiratory Questionnaire require as a part of their Respiratory Protection Standard. (✓) Part II Respiratory Ouestionnaire ( ) Chest X-Ray PA view with 6-reading The basic respirator training program consists of the following items: the above examination,i find;hat this individual: An explanation of the problems involved in misusing the respirator. .� A discussion of why en_incering controls could not be used effectively,and as a result respiratory protection 14 MAY USE Respiratory and Personal protective equipment without limitation. equipment,s required. ( j MAY USE Respiratory and Personal protective equipment for six months,when a How and why this particular respirator was chosen for this specific j& repeat of the PFT and Physical; recommended. The limitations of the respirator that has been selected. j MAY NOT USE Respiratory and Personal protective equipment due to abnormal How to put on the respirator and property adjust the facepiece and tension straps. findings(see"Comments"below). How to ear the respirator. ( ) Other What w the essential points of the care and maintenance program are. • How to rceegnae and handle emergencies. Comments: How to inspect the respirator. -- • When to use an Air Purifying Respirator. RISK FACTOR NOTED When a Type C Supplied-Air Respirator is required. • The purpose of the medical valuation. ( ) Has no risk factors plic;ng the individual at greater risk for asbestos exposure. How ASAP conducts a proper-fit. (� Has the following risk factors placing the individual at greater risk from asbestos A powered Air Purifying Respirator(PAPR)is available to you upon request,as long as rt mr_s the protection exposure: factor for the ha72rd involved. (�} Smoking or recent history of smoking. Employee's Signature S.S.: O Z - SF=9992_— ( ) Restrictive lung disease or symptoms(asthma,emphysema,active allergies.etc.). RESPIRATOR TEST SUMMARY ( ) Other irations have been performed in full compliance with OSH_4 standards set forth Name of Employee: res CFR 1910.1001 and 1926.58.The above named individual has been informed of the medical Date of Testing: S A/0-1 l Tat Conducted By:-�-3 cn4I' Cc^r'�eY d recommendations.Only work-related medical findings were conveyed to the employer. . any questions,please do not hesitate to call. I Respirator Selected: Manufacturer: 1✓orTk Model: r7700Se.: r- 3I7�0 I Respirator Size:(Circle Ono)-SOL MSSHA/NIOSH Approval No.:TC-23 C— Z15) Oeste: f• TP trA 46.$ ,�9 Type(s)of Test Conducted: Mwrse•..H earml•ow.M•OAsKtl•w.v,bnT.•cwM4a,•Ier wnWT+•cr,.eanWMNler w•a,r,0 C� t ,..w•1•.«w•..•,o••osw ..,�..r,..,....+au.a wtw.•+•..�..«.,..+.,-...ac.•... Testing Agent(.1i Used SFP902 Asbestos•Masonry Cleaning•Deleadmg•ShoVSand Blasting — e METHUEN STAFFING INC FAX N0, 31 arltirNl/�l�urr�a+u+ NI IY/pJJdbULIJa:��J /•1 :::<, •--Division,of Occu oo c,� }� METHUENsrr�FFINC INC Rabon J PraiJoso, p i ale �. 2 ChaAes Strcat..lethuen.IIIA 0174 .� � :• • _ ,OBPtIfY Il6rh7/'•. TeivTe•rls-wet ..Asbestos Worker flYTEST AVD VRFSPH1AT011 TRAININ(•!•ur-CK.ARO ORTiZ.: . .. The f dowia s a d e:WuT w ut x euu.pk d fer cad)enlplo.ec Irgn ayI to woo a Data .09104=2 Negative Pre sure=2I`"tor cxry si%lossnhs this tons u required on all ASu GStY)S job.;,,,. -4 Date 09403/2003 I CrATIFY TTL TOM T1111 DA11:111:1.0w I WA 1TTgLen1)IN 1711!nt'.'I1NARil:'ll'1'Ii nN1)M1ttJIJI.I.UMf.0 nNU 3'Wt�,� THAT'W,\3 L;VLY T7AINN[;lt1:GNt1)INU ITS1 or-1.11:AN n ANUJn NANcr 11N L;:l a:l:rJ .l.l7 1 INRTIICR CL nSLry THAT I UNDI:NYrANU'Ilik rlwNlMu 11tU VlntlJ 1U Mt.\NII KNI IlV TINT 1'I II:IL L OV A efCCME.i RPJTIftATOit JNn"R MNOMONS CON'fRARY'n)'lllu'L'It;IrUNI!nx AI1•I;tn•aIA ITi:N IIII: �•J7 I TRAWMt FPTTYSrSUSSIONNAY NOT PR Jul:ADIIJUAT'r.Pall'lW.tnlN II��I� IIINNI''rr Employee/!Jbcontractur Signature: ������I���II��u� HAV•REN Qualified Pt•sun Signature � . 'e _ - -- Datc: i, -•_ 1. Chalien:e substance:(Circle one fTllanl JIIf<)' Ball:lll::Ud,;Illti Sal'Olarlll 2. Fit(heck Procedures: A Negative Pressure Check r1raZ1 F:jI B Positive Pressure Check I°ad J. Test ag Procedure: I(ca ion: A Normal Brushing = B Deep Br-thing C Turn bud from side to side D Nod head up and down E Talking and/or wunting backwards rrolu 100 --- F Jogging in place -' --' G B.,A over and touch toes , FI Grinutce and frown --- t 1 Repeat ftinbow Passage — — J Breathe normally 4. Overall:valuarior '+�. /Fail 5. Rcspirat r Approvrds' Manufacture Approval.0 IYVc' �i2; I-^k RENCE tk n.,;jq,?,IF.DICAL CEN-ER h:p. 1 'i E �:u Jo (,r178,r'(rK233 L(3 m cd k o v titi4t���YF'`�pIAYERnnSflf OS CLL�t�N�+LZITER �Y[• ul1a 6 U ` j'`da[ [a alDae:i W.s lie strove ladivid /c� W I Z! IP= ' .. <;W o fuaesioa toy a ( r119wd a mmpl�Cls�' Tae ie uied`°')sD:+nm 1•W the CSI 'TWO ll� PhYpcalqucu°^a'i¢.a I •� h h H I�Ck'i3TCp� ,BlRP1.DlNORES)r( T: N,;ayt ✓ •aFLtmy„ry 'tv v � � .StLI:.GRY F i JTI A F folio O� Imo`.. �y \ E "'aa+coc�GtiowrctcW.+liLolwW"s lea �7J ' ` C jE. ` ci�aP�ts. t Y Pl.c<Wia cmp4r.c)c at Locsx_ai:A yr t ..3 . ''`CIAic7xAyylttr As GaladQ4a ois pr"ahsoa.l Proleecc ve IT"W;cat isaY4WGLdtowaj?e,, py i ciwsaL•.,'... � � ,�• llutiV:,lltr" uicmcat kJ t J o!their ztlts of the r t y ai o; c; C ) taki. o({,�yagt ual t� lcondliob.7lccmp Gloat uth�iutsyadW. %O;s., ncc WIW b:=mm\i+a itld aOM,L%tef�a+smokin fa'"dob t"bma i[ d �t� � ` sta- L`��ALv is c�wlr t ma uc,ivc410 t cSCsc!e:Puatra�ta.y trA Ea i L°n"anlcC W Il{cnp Tk d°°r_ saPy,a' •t7a a mPY Gf that IFisi.:a IA . Y « c c z T6.4ky,,,tar ,.p tY a 'i4i,iodi ,.• .� z J rq. vidr.l • •H opzo ei.'� � `—ri,f• �. lr �.c° '. �I t 1 e� v� `: H o Phyctdu ,,--{—�_ ::�-L •/1(. I/lG;ir.(� f. R.Lir- WVAP.,-,T1yP.M, a LAWIVIUWXxM1J V Y q;/,da,N S2HE_R ,y LAN 1EfacE FAA oT taD. n All State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Plaistow, NH 03865 Fax: 603-378-0610 ; t Submittal # 5 i Asbestos Disposal Manifests i i Asbestos•Masonry Cleaning •Selective Demolition•Shot/Sand Blasting • ASBESTOS WASTE SHIPMENT RECORD BUILDING NAME: Old Maintenance Bldg JOB# 03-058 GENERATING LOCATION: 1160 Great Pond Road No. Andover, MA 01845 GPHONE: 978-725-6300 ADDRESS CITY STATE ZP E OWNER: Brooks School N OWNER ADDRESS: 1160 Great Pond Road No.Andover, MA 01845 PHONE: 978-725-6300 ADDRESS CITY STATE z? E ASBESTOS CONTRACTOR: All State Abatement Professionals,Inc. R CONTRACTOR ADDRESS: 4 Wilder Drive, Ste 12, Plaistow,NH 03865 APHONE: 603-378-0600 ADDRESS CITY STATE Z? T QUANTITY cu ds CONTAINER TYPE #OF CONTAINERS � � I O i R UTIIORIZE OMER SIGNATURE: C C SI TRANSPORTER I: All State Abatement Professionals, Inc. T ADDRESS: 4 Wilder Drive, Ste 12, Plaistow,NH 03865 RPHONE: 603-378-0600 ADDRESS crrY STATE z1P A VEHICLE TYPE: 5 d ��-74V rL LIC#: /�3 3 N ODEL STATE/PLATE S SIGNATURE: DATE OF TRANSPORT:�PIIl D2 TEMPORARY STORAGE LOCATION: All State Abatement Professionals, Inc. P ADDRESS: 4 Wilder Drive, Ste 12, Plaistow,NH 03865 OPHONE: 603-378-0600 ADDRESS CITY STATE z8 R SIGNATURE: to-12�4DATE OF RECEIPT: T TRANSPORTER 2: J.O.B./Rolloff, Inc. E ADDRESS: P.O. Box 6037 Chelsea, MA 02150 PHONE: (617)387-1495 ADDRESS CITY STATE ZIP R VEHICLE TYPE: LIC#: (s) MAKEIMODEL STATE/PLATE SIGNATURE: DATE OF TRANSPORT: D COMPANY: Turnkey Landfill I ADDRESS: 90 Rochester Neck Road Rochester,NH 03867 S S PHONE: (800)847-5303 ADDRESS crry STATE ZIP P I OPERATOR: Waste Mgmt of New Hampshire T DISCREPANCY(IF ANY): O E S A L SIGNATURE: DATE OF RECEIPT: 3. / ROLLOFF, INC. 102.18 ' gto;s Waste Transport & Disposal NON-HAZARDOUS WASTE 6037, Chelsea, MA 02150 RQ,ASBESTOS, 9, NA2212, PG III (617) 387-1495 ROLL-OFF CONTAINERS 2�2 $ 10.1520-3040 YARDS Asbestos ASBESTOS DISPOSAL & DOCUMENTATION FORM dumber 03-058 P.O.# GENERATOR/BUILDING OWNER -actor All State Abatement Professionals, Inc. Name Brooks School :ss 4 Wilder Drive, Suite 12 Address 1160 Great Pond Road Plaistow State NH Zip 03865 city No. Andover State MA zip 01845 )hone Number (603) 378-0600 Phone Number 978-725-6300 Container Del. Date of Pickup_ GENERATING LOCATION of Container 40 yd closed Name Old Maintenance Bldg Address 1160 Great Pond Road 'le;K Non-Friable 5( No. Andover city state NIA zip 01845 Drum Box Other Phone Number E.P.A. AGENCY by certify that the above named material does not contain free liquid as 1 by 40 CFR part 260.10 or any applicable state law, is not a hazardous CT,MA,RI,VT,NH,ME as defined by 40 CFR part 261 or any applicable state law, has been GENERATORS rly described, classified and packaged, and is in proper condition for U.S.EPA-Region I ortation according to applicable regulations. Air Management-JFK Building Boston,MA 02203 )rized Signature Dae d (617)565-3265 th sporter 1: J.O.B./ROLLOFF, INC. • P.O. BOX 6037, CHELSEA, MA 02150 • (617) 387-1495 1 hereby certify that the above named material was picked up at the generator site listed above,and,if applicable delivered to the temporary storage/transfer location or final landfill destination. r: �-✓� L-� Registration#: td 0 3.IL Date: to ti 0;5 Signature State/# PORARY STORAGE/TRANSFER FACILITY: WASTE MANAGEMENT OF CONNECTICUT, INC. 203 PICKERING STREET, PORTLAND,CT 06480 PHONE: (860)342-0667 PERMIT#SW 1130223 ,ived By: Date: I hereby certify that the above named material has been accepted at the above named facility. sporter 2:, WASTE MANAGEMENT OF CT, INC., P.O. BOX 144, PORTLAND, CT 06480(860)342-0667 I hereby certify that the above named material was delivered without incident to me destination listed below. Registration#: Date: Signature State/# 'fill Name: Waste Mgmt of NH - Turnkey Landfill Phone No: (800)847-5303 .tion: 90 Rochester Neck Rd, Rochester, NH 03867 Permit#: DES-SW-SP-95-001 oximate Volume of Asbestos Received: A a` repancy If Any: , I hereby--certify that the above nam material has be acceptted�an to the best of my knowledge the information provided is ue and accurate. jived by: Date:. Y r COPY,I-GENERATOR 1- _ - - . . I �.1ORTly Town of Andover p No. - so dover, Mass., 0 LAKE I)cMDUMD" �� COCMICKE WICK ADRATED p`P�\ -`y BOARD OF HEALTH PERMIT /Kitchen Se 'c System � o \,UI1 DING INSPECTOTHIS CERTIFIES THAT. ... ........ a 8061 ... ��� � "'Aw ............ . .... .............. ....:........... .' ""' "" Foun 'on has permission to on. ..QN1WAW ... Rough to be occupied as �al... '' 'f � - �.. / AT +! �„ Chimney • provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. PLUMBG INS CT'OR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rom Final PERMIT EXPIRES IN 6 MONTHSELECTRIC SPECTOR UNLESS CONSTRUCTST S Rough ..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building G INSPE Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final RE DEPARTMENT i Bur s S tNo. • ®is is 1TV SEE REVERSE SIDE oke Det. - - -_-�