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Building Permit #676 - 575 OSGOOD STREET 5/16/2008
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: C 7 6 Date Received Date Issued: 3'//6/ K /o',�t�eo h IMPORTANT: Applicant must complete all items on this page LOCATION ot PROPERTY OWNERC?G�4-�rJca (n Print MAP NO: PARCEL: ZONING DISTRICT: Historic°District yes no Machine Shop Village . yes no. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Additi n Two or more family J Industrial Iteration ------,-No. of units: Commercial air re lacement Assessory Bldg Others: IVlfc Demolition Other ��KJ Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: AGS" 7-&,C4 fi ()"U -7r I-' elq ✓; r A a ,� Identification Please Type or Print Clearly) OWNER: Name:Z- _ _ ��Gc�"4/-ave �cT�✓ ►u -mss --, � AY Phone: �7� Arlrlracc• ��-S e7SGao (� ' �r'G�V Phone; CONTRACTOR Name; � ����� ��� �. Address: --7e,�z✓. ,cam /1//� Supervisor's Construction License: Exp. Date: Home Improvement License:. Exp. Date: ARCHITECT/ENGINEER���� ' ''''' Phone:_ c? 000 EJB .r T Address: O�?7 y� Re So ;rk1 .t��a�7w�� 5TF/ 12),qg. No �7b' 317 7s'dp FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OFjNE TOTA ESTIMATED COST BASED ON $125.00 PER S.F. .5 23 75" L Total Project Cost: $ FEE: $ �i°��s Check No.: �3b d' �` Receipt No.:���j NOTE: Persons contracting with unregistered contractors do not have access to the aranty 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 DEPARTMENT:BPFORM07 Revised 2.2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT �0.P r COMMENTS CONSERVATION Reviewed on Signature COMMENTS e _ HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea %4 us ooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: 1: Total square feet of floor area, based on Exterior dimensions. 44i Y� 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 ❑ Notified for pickup - Date ... .................................. ..................................... ..._........ --—.............. --....................... __............... ._........ Doc.Building Permit Revised 2008 Location -�7?-4-- OS S d od S No. % A; Date .� TOWN OF NORTH ANDOVER F ; � "Certificate of Occupancy $ • i # CMUS Building/Frame Permit Fee $.a�S Foundation Permit Fee $ Other Permit Fee $ TOTAL $ .eh Check #7 2 �t5 9 (Building Inspector J- Stvansol-('Structural, Inc. r Engineering Services conrm,enciaf residential heiny limber 7-111A6CA-W fc SGt+e W5 F(il,L SAwAJ OPTION Paul W. Swanson, P.E. 116 Forrest Strcct Fmnklin, I1',I,A 02038-2571 Pliotie 509-520-13-1.3 Pax 509-520-1334 i"auhaeiKulrsfin Sde trctearari.cam AV POJAI T .s ¢ 5�vmg ?A oecv- IA10 - � �Powri� rN S�crtvrvsi Z3� 1U!I.y SIi )N1 Ze :%S "4. J*%--' A;> (.o®S CA44+ -k-WC- otr pL.o ck 5e1-nnm 1 V'JlCuI w0010 oelvN ATS zoo l(q" a -C' C --0'v *lkvq-0S .MSF, 2x3 )•4APAICS 02 2 - tj/ �c 1I'f9 -t I ' k T imgA"/,I l,rx�.5 oto A� 0 y 1417, Cay. .lab Name. D�+A - _ _ __. _ Job Number 19,50�r CCCC ``�� � eL� tt- w EDcatio r 5 V n 7 (n V06 71� y . J vA� - AWW — Sheat 7, of Client f3y !tJ ktalaZi x W 5 uraa �nrrrtan.�1S•rrn:. crnu S ,nJfr)ar�r b££I-QZS-RIIS ��.•1 E££1'QZ��CI� auUil� 6G4z-8070 r'11 °�,i yryai 4ZOA15 IS;UO.1 911 'Td 'u()NUPA%S Al laud idauznl4 qor j% OWUN Oaf / f ,�jxgXt=I=d :).a I �l jq04 d cY1!51ki Z r0Sdvr I -;p xyqugj ,Cxnsef FnYuaMS171 ,Inraraurrrrvi ca 7r:uay r1x.eAArrl�Qtr i4?[dI1S{77J`.l%'dlurflid rx,fTdG a Engineering Sen tees commercial res denrdal heapy rirmber GDGvm SOLI c ci�1h0 8q$ N'J bxb Rav&t 4-6,. a1li'f H Paul VV. Swanson, RE. 116 Forest Street Franklin, MA 02038-2579 Phone 508-520-1333 Fax 508-520-1334 PrrULa-:Sw.ansnnsmIrcrrrI rl:cam - U.8 -I- C pts &-X P L+rV5 v L Nw- . f4 -r. 8 -i B0L.7s M 5 tfoidN T2 -ksa, 3 " ___L Jab tkme Joh Number Isw L=aflon Sheet 3 at Ment lay 6,fs Date �! loo From:JOHN PAONESSA 19789701427 05/15/2008 14:50 #264 P.002/003 CERTIFICATE OF LIABILITY INSURANCE osis//20 sl PRODUCER (978)692-3330 FAX (978) 692-0728 Appleby & Wyman Insurance Agency, Inc. 234 Littleton Road, Suite iF P.O. Box 330 Westford, MA 01886 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, INSURERS AFFORDING COVERAGE NAIC P INSURED John 7. Paonessa CO., Inc. 219 Meadowcroft Street Lowell. MA 01852 INSURERA: Acadia Insurance Co. 173 INSURERS: Construction Indus Compen Corp INSURER C' INSURER 0: INSURER E: COVERAGES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AOOREQATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER Y ffiC 10/01/2007 N 10/01/2008 LIMITS GENERAL UAMUTY CPA0129235 EACMOCCURRENCE i 11000,000 X COMMERCIAL GENERAL LIABILITY OHMAGE 70 RENTED i 300.00 CLAIMS MADE I R 1 OCCUR 1—! MED EXP (Any one mien) i 5, 00 A - PERSONAL A ADV INJURY i 11000,0 GENERAL AGGREGATE 3 2,000.00 GEN. L AGGREGATE LIMIT APPUES PER, PRODUCTS -COMP/OPAGO J 2,000.00 POLICY X j LOC AUTOMOBILE LIABILITY MAA0129236 10/01/2007 10/01/2008 X ANY AUTO COMBINED SINGLE LIMIT (E"Gi0°"II i 1,000,0031 ALL OWNED ALTOS BODILY Inuuar A SCHEDULEDAUTOS (Per person) i HIRED AUTOS BODILY INJURY NONawNED AUTOS (Per ewidom i PROPERTY DAMAGE i (Per "Cloom GARAG!LIABILITY AUTO ONLY -EA ACCIDENT i RANY AUTO OTHER THAN EA ACC i AUTO ONLY' AGO i !xcliaR/MBRlLLAuaBILRY CUA0129237 10/01/2007 10/01/2008 EACM OCCURRENCE s-16,000,000 X OCCUR rI CLAIMS MADE AGOREQATE S 10, 000, 00 A i DEDUCTIBLE f RETENTION WORKERS COMPENSATION AND WC00094SS 01/01/2008 01/01/2009 X W BTA oTM• EMPLOYERS LIABILITY E.L. EACH ACCIDENT S 500 00 $ ANY 1'ROPRIETORJPARTNER/EXECUTIVE OFFICERlMEMBEREXCLUDE07 es unow E.L. DISEASE. EA EMPLOYE ! 500,000 E.L. DISEASE • POLICY LIMN 9 500,00 SPEZIA %PROVISIONS Wow OTHER DESCRIPTION OFPERATION / LOCATIONS! VEMICLES / EXCLUSI NS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS roject: Eggewoor� Horse Barn N. Andover MA , , CERTIFICATE HOLDER CA&CELL&TION SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE IBNUINO INSURER W0.L ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAKED TO THE LEFT, Kelly Construction Co, . Inc. BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY 750 East Industrial Park Drive OF ANY KIND UPON THEINSURBR,ITS A0ENTSORREPRE9ENTA71VE0. Manchester, NH 03109 AUTHORIZED REPRESENTATIVE Robert Emerson LANDER MVVKU ca(cuuTruv) CACORD CORPORATION 1988 PDF created with pdfFactory trial version www.odffactory.com Project Advantage Group 155 N BROADWAY PO BOX 68 SALEM, NEW HAMPSHIRE 03079 Telephone (603) 898-6110 Facsimile (603) 890-1070 CONTRACT AMOUNT AFFIDAVIT BY OWNER'S PROJECT MANAGER This Affidavit is made this 15th day of May, 2008 by Trident Project Advantage Group, a New Hampshire limited liability company ("OPM"), relating to the construction of the Restoration of Horse and Maintenance Barn ("Project') by Kelly Construction Company, Inc. of Manchester, New Hampshire, and the request by the Town of North Andover, Massachusetts of the Contract Amount. 1. OPM states that the Contract Amount for the Project is set at Five Hundred Twenty Three Thousand Seven Hundred Eighty Four Dollars ($523,784.00). IN WITNESS WHEREOF this affidavit has been executed this 15th day of May, 2008. ign e) Gino J. Baroni Owner and Managing Principal State of Massachusetts ss County of Essex On this 15th day of May, 2008 before me, a notary public, appeared Gino J. Baroni known to me to be the person who executed the above instrument, and acknowledged that he/she executed the same. No ry Public;nits L. Morrill �1ill My Corr'.• �s: March 21, 2014 y 0 �r �c �. bra DEVELOPMENT CONSTRUCTION PROJECT MANAGEMENT MANAGEMENT MANAGEMENT 05/15/2008 20:02 6273460 KELLY CONSTRUCTION PAGE 02/03 111Trident Project Advantage Group 156 N BROADWAY PO BOX 88 SALEM. %Ph=e (G03) 898-61 0 FPCSIM119 (809) 890.1070 CONTRACT AMOUN P IDAVIT BY OWNER'S P OJECT MANAGER This Affidavit is made this le day of May, 2008 by Trident Project Advantage Gtoup, a New Hampshire limited liability company ("OPM"), relating to the construction of the Restoration of Horse and Maintenance Barn ("Project") by Kelly Construction Company. Inc_ of Manchester, New Hampshire, and the request by the Town of North Andover, Massachusetts of the Contract Amount. 1. OpM. states that the Contract Amount for the Project is at Five Dollars Hundred Twenty Three Thousand Seven Hundred Eighty Four ($523,784.00). IN WITNESS WHEREOF this affidavit has been executed this le day of May, 2008. i e) Gino Baroni Owner and Managing Principal State of Massachusetts ss County of E$sex On this 151h day of May, 2008 before me, a notary public, appeared Gino J. Baroni known to me to be the person who executed the above instrument, and acknowledged that he/she executed the same. r RoIbRy Public' ita L Morrill My Co es: March 21, 2014 CONSTRUCTIbN ••j, PROJECT DEVELOPMEW MANAGEMENT MANAGEMENT MANAGEMENT Board of Building Regulgtions and Standards CongtructiorrSupervisor License License: CS 96371 Birthdate. ,1/27/1953 Ezp� jot rt 1/2/2010 Tr# 96371 DAVID DUVAL 109 VASSAR STREET � it MANCHESTER, NH 03104 Commissioner 9 EXHIBIT A Edgewood Retirement Community Request for Proposal for Barn Restoration Contractor March 28, 2008 Bid Documents Item Document Date Prepared by Drawings Barn Restoration A.1.1, Al. 1, A.2.1, March 24, 2008 Dewing & Schmid Architects D.1.1, E.1.1 Specifications Horse Barn Outline 3 pages Specifications Reports Structural S page report March 21, 2008 Dewing & Schmid Architects February 19, 2008 Swanson Structural, Inc. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." ` i An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver ortrustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the.occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to, opera'te-a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for.confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents.. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is !10T required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 6.17-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 r_mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents F Office of Investigations ' d 600 Washington Street e y Boston, MA 02111 5 V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): 1\ 11y CO n3 -4-a uh 0r'1 Co . Tr) C Address: VC City/State/Zip: A41 03)6j_Phone .#: Are -you an employer? Check the appropriate box: 1. ❑ I am a ' 4. I am a general contractor and I employer with employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees..[No workers' comp. insurance required.] Type of project (required):. 6. ❑ New construction 7. ( Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I LF❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rContractors that check this box must attached an additional sheet showing -the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: TrG ✓e- If -✓S In3 Q,CCknC2 Pol_cy # or Self -ins. Lie. #:' DTKII &jH0-7 L-71-7 0 Expiration Date: door Job Site Address -S75 QSC10 d S4 • City/State/Zip: /J. t%d0yCr MA 01 NtS Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coveraue verificntinn Ido hereby certifyr_ and penalti of ry that the information provided above is true and correct m Phone #: & 03- la 7- 4 63 ` 0 cial.use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact.Person: Phone #: Exhibit C Swanson Structural, Inc. Structural Report Swanson Structural, Inc. Paul W. Swanson, P.E. 116 Forest Street Franklin, MA 02038 February 19, 2008 Jeffi-ey Dearing Dewing & Schmid Architects, Inc. 30 Monument Square, Suite 200B Concord, MA 0.1742 Subject: Edgewood Barn, 575 Osgood Street, North Andover, MA (my job 2805) Dear Jeff, On Tuesday, February 5, 2008, I met with you, Stacey from Linbeck, and Dave Mermelstein from Trident at the subject property. The purpose of the meeting was to identify the minimum structural repairs that would be suitable for a limited scope restoration of the horse barn. The objective is to have a functional horse barn as well at to leave the building in place for future generations to enjoy. As I outlined in my previous letter dated December 12, 2007, the building has foundation issues, settlement.issues, moisture and wood decay issues. The perimeter stone foundation wall is in good condition, but the individual footings on the interior and along the south wall have either settled due to being undersized, or the wood columns have rotted due to the wood being too close to the ground, or likely a combination of both. Based upon our survey in the hay loft, the settlement in three of the interior column and footing locations is sufficient to separate the timber frame and leave the roof framing without proper support. Without structural repairs, this roof framing will be damaged by heavy snow loading. In addition to those three locations that Dave and I identified, the frame on column line F is distorted because the post.is missing on the south wall and the next support to the north has also settled significantly. Therefore the minimum number of jacking locations for a limited scope restoration is five. All of the foundation and footing work I identified in my sketches dated October 18, 2007 is structurally .required. In order to perform the foundation work, it will be necessary to shore up the structure and remove the existing basement wood columns, most of which are partially rotted. The 10x10 native pine columns and bolsters are readily fabricated from local materials. In my opinion, it would be a missed opportunity to reduce the scope of the jacking since there is an economy of scale to do it all at once. Thank you for involving me in this project. If you have any questions, please feel free to contact me. Sincerely, Paul W. Swanson, P.E. Swanson Structural, Inc. " Swanson Structural, Inc. Paul W. Swanson, P.E. 116 Forest Street Franklin, MA 02038 December 12, 2007 Jeffrey Dearing Dewing & Schmid Architects. Inc. 30 Monuinent Square, Shite 200B Concord. MA 01742 Subject: Edgewood Barn, 575 Osgood Street, North Andover, MA (my job 2805) Dear Jeff, This letter is to summarize the structural aspects of the repairs required.at the subject project. These repairs are detailed in my structural sketches dated October 18, 2007, sheets 1 through 3. 1. Foundation Issues: The perimeter stone wall foundation is in good condition. The individual interior and exterior pier footings have settled to various degrees, and the wood support columns are in the ground in some locations. New interior and exterior piers are required to increase the size and depth of the footings, and to get the wood columns out of contact with the ground. 2. Wood Decay Issues: Wood decay is a problem at the basement ground level due to wood contact with earth. This is best remedied by replacing the piers and installing new columns. Wood decay is also a problem in the first floor framing due to chronic repeated wetting of the wood due to the horses, compounded by slow drying in the basement environment. In my remedial I" floor framing plan I outlined the minimum repair which includes replacing three 12"x12" beams, replacing a sill, framing a stud wall on a new concrete curb, and providing bolsters on top of the new 10"x 10" wood columns. The reason for the bolsters is the beams are in reasonable shape along their length but they are rotted over the columns. Using the bolsters, most of the beams do not need to be replaced. 3. Settlement Issues: Due to the settling of the wood columns in the basement level, some more than others, the superstructure has gone out of square and level. Some of the joints in the timber frame have separated. It is routine work for a barn restoration specialist to true up the frame, close up the separated joints and reinforce the joints with steel tension rods and steel bracket connectors. Please note that the horse stall walls will need to be removed to facilitate this work. 4. Moisture Issues: It is critical to the longevity of any wood structure that the wood remains dry, or it will rot. Therefore, moisture protection such as roofing, siding, and windows, and appropriate ventilation to control condensation, as well as site grading and control of vegetation can be considered to be part of the maintenance of the building's structure. If you have any questions, please feel free to contact me. Sincerely, Paul W. Swanson, P.E. Swanson Structural, Inc. Sw4n, son Structural, Inc. Paul W. Swanson, P.E. engineering Services 116 Forest Street conrnrercial Franklin, AIA 02038-2579 Phone 508-520-1333 residential Fax 508-520-1334 heavy timber Paul rr,SwansonStructr�raLcom ply c VK b _ N gw -, rm Az D Jit:. ►� J SwtzMon Structural, Inc. Paul W. Swanson, P.E. 116 Forest Street „Engineering Services Franklin, NIA 02038-2579 commercial Phone 508-520-1333 residential Fax 508-520-1334 heavy timber Pan!(DSwansonSlrectural. coin 'r�xts)r• l2 -,n AM 7,1' ��d�1.STk7L j A' 1 10 14 X 5rtM BEAM �x 8 K>v� 8iL1�5 T`/P• 10910 PDsr" At G ,vCVv T71Ij3Fn5 FvL L- 54wN A14rlvC PINE~ � t✓ XCCF - P.T. S.Y,P. lel CoNr.4LT w17" c nac ERC Horse Barn Outline Specification 3-21-08 Refer to drawings A.1.1, A.2.1, D.1.1 and E.1.1 for additional information. Typical roof treatment: a. Strip existing shingles down to sheathing (may include multiple layers and/or wood roofing). b. Replace rotted sheathing in kind and install new where required to insure proper roof installation. c. Install 15# roofing felt, white anodized aluminum drip edge, and Ice & Water (Grace or equal) according to manufacturers recommendations. d. Install 3 tab (30 Year) asphalt roofing by GAF, Certainteed or equal. Shingles shall be green, typical for all barns. 2. Windows: Window sashes to be replaced in kind or reglazed as noted on drawings. All new window sashes shall be Brosco or equivalent, single glazed true divided lights and fully pre primed, and should fit well into existing frames. North basement cellar sashes and frames to be replaced, Brosco or equivalent, single glazed true divided lights and fully pre primed. Save and reuse any existing sash locks in sound condition. Specialty windows: Full round fixed West window new sash, approx 24" dia., to be pre primed wood, single glazed, true divide, 4 light muntin pattern. GC to submit shop drawings with proposed manufacturer, size and lite pattern to architect for approval. Restoration: Existing East door transom- restore existing transom sash with epoxy consolidant and wood epoxy, and reglaze. 3.. Trim All damaged or rotted trim (soffit, fascia, frieze, corner board, bracket, etc.) shall be removed and replaced in kind. New trim shall be clear grade western red cedar, fully pre primed, except soffit and frieze boards may be clear pine, fully pre -primed. Molding profiles such as the bed molding may be replaced with a similar molding provided the new profile is nearly identical in profile and size. All remaining siding and trim to be prepped and primed. 4. Typical exterior wall treatment: a. All damaged or rotted siding shall be replaced in kind with fully pre -primed clear grade western red cedar unless otherwise noted. b. All remaining siding and trim to be prepped and primed. 5. Paint All painted materials scheduled to be removed shall be assumed to contain lead paint and shall be properly handled and disposed. All laborers enlisted for demolition shall be familiar with and employ approved methods of disassembling and handling. Barn shall all be painted with 2 finish coats over 1 field primed or pre -primed coat. Paint shall be Sherwin Williams "Duration" or equal. Body color to be white, doors and lower level wall panels to be dark green to match existing. I 6. Inspection and repair of sills: Refer to .Selective Demolition Floor Plan SD.1 for extent of areas for particular exploration methods for inspection sills: a. Expose sill from exterior by removing lower 12-18" of siding (simple scarf joint), along East and West ends, b. Expose sill from interior by removing 12-18" of ceiling, along South side, or c. Drill into sill ever 2-3' from interior, along North side. Repair/replace damaged sills with pressure treated material as required. Reinstall any materials removed for inspection. 7. First fl. floorboards: Inspect barn flooring boards and replace all considered structurally unsound with preservative treated material throughout first floor of barn. 8. Doors: Doors shall be replaced in kind, and painted Dark Green to match existing, see painting, #5 above. Large gable end doors: Repair existing pocket type gable end doors. Repair existing wheeled gravity type operator hardware at West door if possible. Provide new track and trolley operator hardware at East door. Replace 1x6 single bead facing in kind. New basement sliding doors: Install 3 new bi-parting doors, 1x6 single bead facing to match gable end doors, with track & trolley hardware and new track hood. Stall doors: Reuse existing stall doors and hardware, typ. Not painted. Replace grills, see item #12 below. 9. Gutters and Rain leaders: Replace existing wood gutters with 4" K -style aluminum gutters, white anodized finish, on lattice spacers with wood bed molding below. Replace existing leaders with 3" diameter aluminum, white anodized finish. Leaders shall be tied into new subsurface collection system. Coordinate with Linbeck for extent of work. 10. Typical structural repairs: Repair all damaged bent joints as required once barn is properly realigned. Basement: Jack the existing 1 st floor structure back into its proper location and provide temporary support. SEE STRUCTURAL DRAWINGS FOR NEW FOOTINGS, AND BOLSTER BEAM AND BRACING DESIGN AND NOTES. Cut the bottom of the existing wood post to its new length. Attach a square piece of pressure treated 2x12 to the bottom of the existing wood post and align the post in it's final location and brace (temp.). Drill a 6"+/- deep, 5/8" dia. hole in the center of the bottom of the wood post for #5 rebar. Form and pour a 16x 16 pier concrete pier that bears on the new footing and supports the existing wood post, typical at all interior post locations. SEE STRUCTURAL DRAWINGS FOR DETAILS. Remove the forms, bracing and support once the concrete has properly cured. Inspection and repair of sills: see item #6 above. 11. Basement floor: Remove any existing unsuitable fill material at existing basement floor. Install 12" crushed and compacted stone, top of stone at finish floor level. Price as Add Alternate: Install 5" concrete slab finish floor, with fibermesh reinforcing, over 12" crushed and compacted stone. 8" frost wall below slab at door openings. Seal slab with dust proof sealer 12. Stalls: Reuse existing aisle wall panels, and boards, typ. Replace grills with new by Classic Equine Equipment, Inc., or equivalent, Hunter green, custom sizes as needed. Reuse existing stall doors and hardware, typ. Replace grills with new by Classic Equine Equipment, Inc., or equivalent, Hunter green, custom sizes as needed. Replace damaged boards in kind or install new 2x6 T&G or shiplap SYP boards horizontally as needed, at exterior walls of all 4 stables, hay & shaving storage and tack room. New EPDM floor membrane, adhered installation, lapped up walls, to contain urine. Non -reinforced, fire rated, 60 -mil black, Johns Manville EPDM60FR or equivalent. Interlocking closed cell foam stall mats, 3/4" thick, by Frelonic or equivalent, at all 4 stables and aisle. 13. Products specified in drawings: Classic Equine Equipment, Inc.: Window grills, Hunter green Frelonic interlocking closed sell foam floor mats Johns Manville EPDM60FR EPDM membrane Crescent Stonco Roughlyte VK1 GC glass globe and cast guard fixture Crescent SWGA2321K2Y florescent fixture Bega 6325 exterior light fixture Stiebel Eltron DHC -E 10 Electric tankless water heater Swanstone Veritek Laundry Tub T&S Brass and Bronze Works B-1113 Workboard Faucet with lever handles Exhibit B Horse Barn Outline Specifications INCORPORATED SINCE 1978 KELLY750 EAST INDUSTRIAL PARK DRIVE CONSTRUCTION CO,. INC. MANCHESTER, NH 03109 Construction Management • Design/Build • General Construction Tel (603) 627-4203 • Fax (603) 627-3460 www.kellyconstruction.com Subcontractors with Employees for Edgewood Horse Barn Project Manager (Worker's Comp Coverage Required) APS Industries Dec -Tam Stan's Granite State Building Movers Piquette & Howard Electric ACORD CERTIFICATE OF LIABILITY INSURANCE DA 511512008 PRODUCER (207) 774-6257 FAX: (207) 774-2994 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Clark Associates HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2385 Congress Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 3543 Portland ME 04104 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Insurance Co. 39357 INSURER 8: Kelly Construction, Inc. INSURER C: 750 East Industrial Park Drive INSURER D: INSURER E: Manchester NH 03109 OVERAGES 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. AGGREGATE LIMITSO AY HAVE BEEN REDUCED BY PAID CLAt S. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICEFFECTIVE DATEY MM/DD/YY POLICY EXPIRATION DATE MM/D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ PREMISES (EaEoccccurrence) $ COMMERCIAL GENERAL LIABILITY MED EXP (Any oneperson) $ CLAIMS MADE [_� OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ POLICY JE LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY $ (Per person) ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN FA A $ ANY AUTO AUTO ONLY: A $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENC $ AGGREGATE $ OCCUR FICLAIMS MADE $ $ DEDUCTIBLE RETENTION A WORKERS COMPENSATION AND WC STATIJ OTH- TORY LIMIjS E E.L. EACH ACCIDENT $ 500,000 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? DTKUB4407L71707 7/1/2007 7/1/2008 E.L. DISEASE - EA EMPLOYEEI $ 500,000 E.L. DISEASE - POLICY LIMIT 500,000 If yes, describe under SPECIAL PROMSIONSel OTHER DESCRIPTION OF OPERATIONSILOCATIONSJVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS The worker's compensation policy indicated above covers employees in the state(s) of Massachusetts and New Hampshire. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE AUTHORIZED REPRESENTATIVE Lee Ramsdell/BSRK ACORD 25 (2001108) © AGUKU GUKYUKA I IUN 1V50 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) page 2 of 2 INS025 (oioa).oaa OP IDP HATE (MMIDDIYYVYI AcoRD. CERTIFICATE OF LIABILITY INSURANCE DECTA-1 01102/08 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION pRpDUCO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE THE ANY MAY POLICIES, POLICIES REOUIRLMENT, PERTAIN, FOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR DeSanctis Insurance Agcy, In;;, ABOVE FORTHE POLICY RESPECT TO WHICH TO ALL THE TERMS, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 36 Cummings Park LTR A NSR Woburn MA 01801 POLICY NUMBERQRR PROP1357991 pq PATE MM 09/01/07 Phona:781-935-8480 Fax:781-933-5645 LIMITS EACH OCCURRENCE $1,000,000 INSURERS AFFORDING COVERAGE NAIC# INSURED PERSONAL& ADV INJURY $ 1,000.000, INSURERA; Awrioan Intuan Specialty Lad GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: INSURER 8: Th* ccweo inausanee cossnnY p0C–T3tri CcrpQratiOn INSURER C: Camoesu c Inauit ins. Co. POLICY X JECT LOC 50 C ncord Street Nort� Reading MA 01864 INSURER O: B INSURER E. COVERAGES THE ANY MAY POLICIES, POLICIES REOUIRLMENT, PERTAIN, OF INSURANCE LISTED BELOW HAVE TERM OR CONDITION OF ANY THB INSURANCE AFFORDED BY THE AC(;REGATE LIMITS SHOWN MAY HAVE BEEN ISSUED TO THE INSURED NAMED CONTRACT OR OTHER DOCUMENT WITH POLICIES DESCRIBED HEREIN IS SUBJECT SEEN REDUCED BY PAID CLAIMS. ABOVE FORTHE POLICY RESPECT TO WHICH TO ALL THE TERMS, PERIOD INDICATED. THIS CERTIFICATE MAY EXCLUSIONS AND CONDITIONS NOTWITHSTANDING BE ISSUED OR OF SUCH LTR A NSR —TYPE OF INSURANCE GENERALUABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X❑ OCCUR X 'warkaito POLICY NUMBERQRR PROP1357991 pq PATE MM 09/01/07 DAM ODIYY 09/01/09 LIMITS EACH OCCURRENCE $1,000,000 PIzEMISES Ewoewbnx $ 300.000 MED EXP (Any W.M Peradi) $5,000 PERSONAL& ADV INJURY $ 1,000.000, (pollution incl. GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X JECT LOC B AUTOMOBILE LIABILITY X ANY AUTO 07mmS4017 06/21/01 06/21/08 COMBINED SINGLE LIMIT 61,000,000 (Ea8GOdenl) ALLOWNEDAUTOS X SCHEDULED AUTOS BODILY INJURY $ (Per paean) BODILY INJURY $ (Por oOrlOeni) X ' HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ I GAitAGELIABILITY AUTO ONLY - EA ACCIDENT S OTHER THAN FA ACC $ AUTO ONLY: AGO $ ANY AUTO EXCESUUMBRELLALIABILITY EACH OCCURRENCE $9 000 000 AQGREGATE S9,000,000 A T, OCCUR ❑ CLAIMS MADE $ROU3112919 09/01/07 09/01/08 Includes $ Worksite $ DEDUCTIBLE pollution S ExRETENTION 510, 000 , WORKERS COMPENSATION AND X.TORY LHATU Ulm ITS ER- E.L. EACH ACCIDENT $ 1000000 C EMPLOYERS'LtABILITY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? . WC5313154 MKINH,Ri,CT 12/28/07 12/28/08 E.L. DISEASE• EA EMPLOYEE $ 1000000 E L. DISEASE • POUCY LIMIT s1000000 Noygs, eascnba under 8PECIAL PROVISIONS bcluw OTHER A Professional Liab MP1357991 09/01/07 09/01/08 $1,000000 Limit DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ILLUSTRATION OF COVERACaE CERTIFICATE HOLDER CANCELLATION TOWHO-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, T14E ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO no SO SHALL TO WHOM IT MAY CONCERN IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ORIZED REPRESENTAT J / ACORD ZS (2001108) rACORD CORPORATION 1998 ZO•d SZ:OT 80OZ SZ 6PW ZZOZOMM:Xp3 Wdl 03Q PiquettAHoward Elect. Fax: S <'�' May 15 2008 11:05am P001/002 AC -OW. CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDffM 05 15 2008 PRODUCER (978) 886=2266 NORTH ANDOVER INSURANCE AGENCY INC.ONLY ► M.J. POSTER INSURANCE SERVICES 163 MAIN STREET NORTH ANDOVER MA 01845-2506 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AND CONFER$ NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC 0 INSURED PIQU8TTE •& HOWARD ELECTRIC SERVICE 59 AMES ST LAORRENCE MA 01891— I INSURmpm-TRAVELER$ INSURANCE CO 25658 INSURERB:GUARD INSURANCE INSURER C; IN8 INSURER E; COVP@A6FR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. im R AD 'L TYPE OF INSURANCE POLICY NUMBER OATt: M IDD LIMITS A GENIRAL LIABILITY X COMMERCIAL GENERAL LIAEILITY Cl/UM$ MADE � OCCUR 680055000J8 09/01/2007 / / / / 09/01/2008 / / •/ / EACH6000RRENCE $ 1,000,000 $ 300,000 MED EXP (Any one can $ $1000 PER®ONAL&ADVINJU $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'LAGGREGATE pLIIMIITAPPLIES PER. POLICY X JECT M LOG PRODUCTS -COMP $ 2,000,000 A AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOB SCHEDULED AUTOS HIREDAUTOS NON+OWNEDAUTOS 14&035012198 09/01/2007 / / / / 09/01/2008 / / / / COMBINEDiINGLE'LIMIT (Es soCIderd) $ 1,000-,000 BODILYINJURY (Per person) $ BODILY INJURY' (Permld►nQ $ PROPERTY DAMAGE $ (Perawdsnq . GARAGELIABILITY ANY AUTO / / / / AUTO ONLY -EA ACCIDENT $ OTHER THAN IEAACC AUTO ONLY; AGO $ A BXCESSIUMBRELLALIABILITY X OCCUR FICLAIMS MADE DEDUCTIBLE RETENTION S CW-184OY552 09/01/2007 09/01/2008 EACH13CCURRENCE $ 5,000,000 AOOR TE i 3,000,000 B $ 8 WORKER5 COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? If yea, deecrlbe un4er SPECIAL PIRCM9101419 below PINC703634 09/01/2007 / / 09/01/2008 / / X MIS ER• E.L. EACH ACCIDENT S 500,000 E.L DISEASE • EA pMPLOYE[ $ 5001000 E.L. DISEASE • POLICY LIMIT $ 500 , 000 OTHER DESCRIPTION OP OPERATIONSILOCATIDN9NBHICLE9IEXCLU&ONS ADDED BY ENOORSEMENT/SPECIAL PROVISIONS KZLLY CONSTRUCTION CO., INC. 750 EAST INUSTRIAL DARK DRIVE 9— WORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BBPORB THE WIRATION DATE THEREOF, THE IBBUING' INSURCR WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TD 00 BO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE I 0 ACORD CORPORATION 1988 IIV8YX7(oTael.oe Pape 1 of 2 Piquette&Howard Elect. Fax: May 15 2008 11:06am P002/002 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION 1S 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), DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the Certificate holder, nor does. It offlrmatively'or negatively amend, extend or alter the coverage afforded by the policies listed thereon. A%#Vf%W AD J]LYY9(Ytl) INS025(olos).o® AMS Pape2o12 05/15/2008 10:02 FAX 6033629204 granite state Z002 nviceencc TI -15 POLICIES OF INSURANCE I.I5TED BELOW HAVE BECN ISSUED '10 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPF..GT TO WHICH IHS CCRTncATE MAY BE ISSUFD OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, FXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE ksEEN REDUCED BY PAID CLAIMS. —ems I-- I POLICY NUM9ER ItlA E MM7D[) ) DA MODNY) LIMITS EACH 0( $ 1,000,000 9011 >FS ( 04/02/06 04/02%09 PREML^,ES(EeoccurEnce) ...--Ls r000 100 GENERAL LIABILI Y A X X COMMERCIAL rENCRAL LIABILITY I 660-9816C526 CLAIMS MADE. a OCCUR tiENL AGGREGATE LIMIT APPLIES PER: POLICY X 22T LOC AUTOMOBILE LIABILITY A X ANY AUf0 ALL OWNED AU10H SCHEDULED AUTOS X MRED AUTOS X NON -AWNED AUTOS QARAsE LIABILITY —1 ANY AI RO EXCESSIUMBRELLA LIABILITY OCCUR D CLAIMS MARL DF.riUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYER&' LIABILITY ANY PROPRIETORIPARTNF..R/EXECUTIVE. OrrICER)MEMBEVEXCLUDED? iiTyae, doccnbo under SPECIAI. PROVISIONS below A I Cargo MED ENP {Any one person) 16 5 000 r-ERSON L B ADV INJURY $ 1,000,000 OCNERAL Ar,G12EGATE $ 2 , 000 , 000 PRMUOS-COMP/OPAG0 1$2,000,000 $ TORY LIMI IS ER _ E.L. EACH ACCIDENT $ rl, DISEASE-FAFMPIOYFF. $ E.L. DISEASE - RVI.ICY LIMIT 660-9816CS26 04/02/08 04/02/09 ACV up to 8125,000 $5,000 Ded.. aob Location: 575 osgood Street, North Andover, MA Kelly Construction Co„ Inc. is included as Additional Insured on the General Liability poliey. CERTIFICATE HOLDER CANCELLATION KW,T,LCog SHOULD ANY OF THE A90VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Kelly COnS trUctiOn CO . , Ino. DATE TMEREDF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYE WRITTEN Edgewood Retire4nent Co=unity NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUR FAILURE TO DO 80 SHALL Trido nt IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 750 E Industrial park Drive Blanchester NX 03109 R6PRE6ENTA71VE8. 25 1200110) CUMHINCD SINGLE LIMIT $500,000 RA3206C762 04/02/08 04/02/09 (E.9 nomdonl) BOnILY INJURY $ (Por person) BODILY INJURY $ (Par eccldent) PROPERTY DAMAGE $ (Par amAmd) AUTO ONLY - FA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGUE r.ACH OCCURRENCE $ AGGREGATE $ $ TORY LIMI IS ER _ E.L. EACH ACCIDENT $ rl, DISEASE-FAFMPIOYFF. $ E.L. DISEASE - RVI.ICY LIMIT 660-9816CS26 04/02/08 04/02/09 ACV up to 8125,000 $5,000 Ded.. aob Location: 575 osgood Street, North Andover, MA Kelly Construction Co„ Inc. is included as Additional Insured on the General Liability poliey. CERTIFICATE HOLDER CANCELLATION KW,T,LCog SHOULD ANY OF THE A90VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Kelly COnS trUctiOn CO . , Ino. DATE TMEREDF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYE WRITTEN Edgewood Retire4nent Co=unity NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUR FAILURE TO DO 80 SHALL Trido nt IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 750 E Industrial park Drive Blanchester NX 03109 R6PRE6ENTA71VE8. 25 1200110) 05/14/2008 17:16 FAX 6033629204 From: Sue Giribbins 600-522-7514 TO: Joanne Pads-Wildes AT, granite state Date; 5/142008 Time: 2,42:58 PM jX*: ouclig Serial A19174 1 ON RISK SERVICES, INC. OF FLORIDA 001 BRICKF-LL 13AY DRIVE, SUITE #1100 IIAMI, FL 33131-4937 HONE; 800743-8130 FAX: 800-522-7314 iRE6 ADP TOTALSOUKCE, INC. 10200 SUNSET DRIVE MIAMI, FL 33173 -ALTI!RNATF. EMPLOYER! GRANITE STATE CONSTRUCTION SVC [a00 '._. - DATE (MMIDDIYY) 05114/2008 THIS CERTIFICATE is ISSUED AS A IVFA—'tTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTr%R THE COVERAGE AFFORDED SY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COWINY NEW HAMPSHIRE INSURANCE COMPANY A f.OMPANY COMPANY C (;OMPANY D Y 'Imll.�,.�;�= 4,� -0 _17 _7 ISSUED TO tHE INSURED E, RTHEPOLiC PERIQ YF_, -*,,Z..;,,�tt,,�'ll,�.:",�,,.. C� LISTED 6ELQVV HAVE BEEN EDNAMEDASOV r THIS !TO CERTIFY THAT THE POLICIES OF ORAN CONDITION OF ANY CONTRACT OR OTHER RE,9PECT To WHICH THIS INDICATED NOTWITHSTAN DING ANY REQUIREMIENT, TERM OR POLICIES DESCRIBED HEREIN ISTUB JECT TO ALL THE TERMS, CERT TIED E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 0 Y TH EXCLUSIONS AND CONDITIONS OF SUC14 POLICIFS, LIMITS SHOWN MAY HAVE 92EN RFDUCED BY PAID CLAIMS. pOLICY EFFSC- iE- FPOL''y" X;,,A rllN LIMITS TYPE OF POLICY NUMBER LATE (MMMDIYY) DATr(I0"� _RAL �LASKJTY Ik)MMCRVAI OFNFRAELLA511.1 (,:kAIM5MADF [7 OG -11R I 1WNE17-1., & CCjN1Ir+AC.TQR`.5 , PROT 6m4smE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NUN -OWNED AUTOS AGE LiASILITY ANY AUTO EX(:E82 LIABILITY 7 UMBRELLA FORM _111WR THAN UMV�Fl I A FORM WORKER'S COMPENSATION AND F)APLOYERS'LIAMLITY 1111-1411 1 _NINC7. r -Ali NF OFFICEPSARF CXCL FxupCp,TywWAC,I;: I i; AmOO!,ILYN I pwc)Cluc I!;. COMI 10P AGC I ILRSI NAL & AIN tN,MJR'( .1 EACH OCCURH4Ncr PIF(r LTj\MA,-,[= (Any ofie brq) . . .... . ...... MFr) Fxp (Ani -o r -r-) rnMRINCE, SINOLC LIMIT f. Wdurl' RODILYft,1URY (fln racci J, IT) FxupCp,TywWAC,I;: I i; AmOO!,ILYN I C111-JERTHAN ALI -',)'Z�LY ".T .1 AGGRIEGAIL. EACH OCCURRENCE TCZIII,ATE f. WC 1106971 NH 01111120117 1 1710112008 rXJTDFY�Ifii I [EiIi. -1 ACCIETEN f -dbO R. FACI 1100o, — E El � I I mRASE - POLICY ( IMIT 1,000,060, _E 000 �_L Q10CASE -CA EMKOYL Todo, L !RIPTION dFOPERA TI NS/LOCATION rHIC1.5013PECIALITEM5 j a CO D UND THP EMLOYE ES WORKING FR THE VE NAMF_r) CL15NT COMPANY, PAID UNDER ADP TGTAL$OURCIE. NC.'5 PAYROLL, LL E VFRE ER - TFr)PPOLICY. `TNF ABOVEOAB NAMFn CL1Or-NT IS AN ALTER14ATE EMPLOYER UNDER THIS POLICY. JOB: 575IOSGOOD STRFETvv, NORTH ANDOVER. MA. ur ABOVE SHOULD ANY OP THE A80VE PeSCRISEP POLICIES BE CANCELLED BEFORE 11HP KELLY CONSTRUCTION CO., INC; FxmRA11014 DATE THEREOF, THE I88UINQ COMPANY WILL ENDEAVOR TO MAIL 750 E. INDUSTRIAL PARK DRIVE 30 DAYS WRITTEN NO'nrr TO THr CERTIF)CATE HQLbER NAMEOTO THE LEFT, MANCHESTER, NH 03109 OUT FAILURE- TO MAIL DUCI-I NOTICE $HALL IMP066 NO 05LIOATION Oft UABILtYy OF ANY KIND UPON THE COMPANY, ITS AGFNYS OR REPRESENTATIVES, AON RISK SERVICES, INC. OF FLORIDA Vol Date: 9/28/2007 Time: 1:12 PM To: @ 6273460 Minuteman Group Page: 002 AW -RP CERTIFICATE OF LIABILITY INSURANCE 09�zs/2007 PRODUCER (603) 883--1776 FAX (603)882-1843 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Minuteman Group 90 Main Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 487 POLICY EXPIRATION LIMITS EACH OCCURRENCE $ 1,000,000 Nashua, NH 03061-0487 INSURERS AFFORDING COVERAGE NAIC # INSURED APS Industries, LLC INSURERA: Western World 05/11/2008 3 Stevens -Drive ---------- -- -- -------------- -- ------------- - -- ---- - INSURER B: Hartford Underwriters - - Hooksett, NH 03106 INSURER C' DAMAGE TO RENTED RRFN1lSf:A CE,$ 100,000 114SURER D: A INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDIL TYPE OF INSURANCE POLICY NUMBER POLICY EEFFECTIVE POLICY EXPIRATION LIMITS EACH OCCURRENCE $ 1,000,000 GENERAL LIABILITY NPPI036407 05/11/2007 05/11/2008 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FRI OCCUR DAMAGE TO RENTED RRFN1lSf:A CE,$ 100,000 _ MED EXP (Any one person) $ — 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGRFGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP ACG $ 2, 000 , 000 POLICY PR T JECT LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Pet Person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACY: $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY OCCUR a CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ $ DEDUCTIBLE $ .RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 6SOUB547OC76507 07/28/2007 07/28/2008 X& -T TU-MITS T E.L. EACH ACCIDENT $ 100,000 B ANY PRCPRIETOR!PARTNER/EXECUTIVE OFMCER!MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE.$ �,QQ,----QQQ -------------------------------- ----•--------------------- SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY F,NDORSE EVT 1 SPECIAL PROVISIONS embers are excluded on the Workers Compensation policy. Kelly Construction Co., Inc. 750 E, Industrial Park Drive Manchester, NH 03109 HVVRU A0 1jAUV11U8) g nn- \VVDJOG! -JYVV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Matthew Serodio ©ACORD CORPORATION 1988 J F NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL e 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed= of in: (Location of Facility) Signa o t Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 05/15/2008 10:30 9786490135 ALLIED WASTE SALES PAGE 01/01 DATE: May 15, 2008 FROM: Dave Languirand TO: Tom Roy/Project Manager COMPANY: Kelly Construction RE: Disposal Sites for North Andover Project FAX NUMBER: 603 627.3460 PHONE NUMBER: 603 627-4203 PAGES (including cover sheet): 1 JZZ ALLIED WASTE SERVICES FAX COYER SHEET Notes: Tom, thank you for ordering our temporary construction services for the project located at 575 Osgood St in North Andover, MA. Please find below the planned disposal sites for debris generated from this project. Mixed Construction LLBS Inc 87 Lowell Rd Salem, NH 03079 Phone: 603 894-9800 Hay BMC Corp 1079 South St Tewksbury, MA 01876 Phone: 978 667-2171 Please call me at 800 442-9006 x354 If you have any questions or need any other Information. Thank you for using our services. NOTICE OF CONFIDENTIALITY The information contained in and transmitted with this facsimile is confidential. It is intended only for the Individual or entity designated above. You are hereby notified that any dissemination, distribution, copying or use of or reliance upon the information contained in and transmitted with this facsimile by or to anyone other than the recipient designated above Is unauthorized and strictly prohibited. If you have received this facsimile In error, please notify Allied Waste by phone at (local phone number) immediately. Any facsimile erroneously transmitted to you should be immediately returned to the sender by U.S. Mail, or If the sender grants authorization, destroyed. If you have any trouble receiving this transmission, please call (local phone 385 Dunstable Rd Tyngsboro MA 01879 Phone 800 442-9006/ FAX 978 649-0135 www.disposal.com tom r From: Kim_b Sent: Wednesday, May 14, 2008 4:06 PM To: tom r Subject: FW: eDEP Submittal Confirmation [mx] -----Original Message ----- From: eDEPConfirmation@massmail.state.ma.us [mailto:eDEPConfirmation@massmail.state.ma.us] Sent: Wednesday, May 14, 2008 4:13 PM To: Kim—b Subject: eDEP Submittal Confirmation [mx] Thank you for using eDEP Online Filing from the Massachusetts Department of Environmental Protection. Your transaction is complete and has been submitted to MassDEP. This email is your receipt for the eDEP Online Filing transaction described below. Please review it and keep a copy for your records. Please do NOT reply to this message, this email address will not receive messages. For assistance with eDEP Online Filing, please email the DEP Help Desk at DEP.HELPoastate.ma.us or call 617-556-1100. MassDEP is interested in how we can serve you better. To help us make improvements to eDEP, please take a minute to complete our eDEP Online Filing Survey at http://www.mass.Pov/dep/service/compliance%edepsurv.htm. To contact MassDEP Programs, please see http://mass.gov/dep/about/contacts.htm. DEP Transaction ID: 180704 Date and Time Submitted: 5/14/2008 3:55:05 PM Form Name: BWP - Demolition Form for AQ -06 Payment Information DEP code: 31148 Date: 5/14/2008 3:54:54 PM Amount ($): 35 Payment Detail: Paul Lemire --Card -- 7068 Contractor Contractor Number Name Address Supervisor Project Monitor Lab EMAIL ID OF THE USER: kbaxter(@kellyconstruction.com CA m m m m CO) m v d 0 CD C7 Z y CCD O 'O CL. r. C. ca C O C. = y a92 :2 O M 0 v CD CD O Q CD C O CO) ac y rOco CD I � v CO) O 'vCD Z CD CD O CD 0 8 IL- ?= 4 N -4d -• N O y � =R CD m Cl) H m .= 3 y = �.o O Nco T CL m y r to 0 r� p 0�oco n CD CD -n o rL y a* C ... z o cn a 0 Z:S.0131 O d o O N, :& O CD H : n CL ,.....: CS CD N : CLte. co CIM C O m_ CCD N O G t 1 : O in T ColCOD 'C a CD C -k O CD ,� ,.. Sa. l _ CD ..i N co ... c � IF _ w . � Roo 0 CA 5 0, tw z O WN v cn d cn o w ro � :p gi -n cn n ro r to 0 r� m n x -n o rL y a* C ... z o cn a 7on x rD O d o E O C N DEC -TAM CORPORATION Specialty Contractors May 9, 2008 Mr. Thomas Roy Kelly Construction Co, Inc 750 East Industrial Park Drive Manchester, NH 03109 RECEIVED MAY 12 REC' KELLY CONSTRUCTION CO., INC 978.470.2860 fax 978.470.1017 RE: Edgewood Retirement — Vacant Barns, 575 Osgood Street, North Andover, HIAA 01845 (Barn Exteriors) Dear Mr. Roy: Please be advised that Dec -Tam Corporation will be performing an asbestos abatement projects at the above referenced location. This work is scheduled for May 27, 2008 thru May 30, 2008. All applicable local, state and federal agencies have been notified of this work. Please let me know if you have any questions. Sincerest regards, Craig Barkman Sales Estimator CS/cam Enclosure Environmental Remediation Services • Surface Preparation • Facilities Services 50 Concord Street • North Reading, MA 01864 0 www.dectam.com • solutions@dectam.com Commonwealth of Massachusetts Asbestos Notification Form ANF -001 305885 Please Enter Decal # Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q INSTRUCTIONS 1. All sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 7.15 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 2. Submit Original Form to: Commonwealth of Massachusetts Asbestos Program PO Box 120087 Boston MA 02112-0087 A. Asbestos Abatement uescription 1. Facility Location: Edgewood Retirement - Vacant Barns Name of Facility North Andover MA City/rown Worksite Location: Bam Exteriors Building name, #; wing, floor, room. State 2. is the facility occupied? ❑ Yes ® No 3. Asbestos Contractor: Dec -Tam Corporation Name N. Reading. MA 01864 City/Town Zip Code AC000035 DOS License # Craig Starkman Facility Contact Person 4 George Page Name of On -Ste Supervisor/Foreman 5' Name of Project Monitor 575 Osgood Street Street Address 01845 Zip Code Telephone 50 Concord St Address 978470-2860 Telephone Contract Type: ® Written ❑ Verbal Business Development Contact person's title AS071933 DOS Certification # DOS Certification # 6. Name of Asbestos Analytical Lab DOS Certification # 7 5/27/08 5/30/08 Project Start Date End Date 7.00am-4:00pm Work hours Mon -Fri. 8. What type of project is this? ❑ Demolition ® Renovation ❑ Repair ❑ Other, please specify: 9. Check abatement procedures: ❑ Glove bag ❑ Enclosure ❑ Cleanup ❑ Full containment ❑ Encapsulation ❑ Disposal only ® Other, specify: Work hours Sat -Sun. Wet Methods, Decon 10. Is the job being conducted: ❑ Indoors? ® Outdoors? KellyConstNAndov.doc • 9102 Asbestos Notification Form - Page 1 of 4 �y 0 ()h Commonwealth of Massachusetts 305885 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: 800 pipes or ducts (linear ft) other surfaces (square ft) Boiler, breaching, dud, tank surface / Insulating cement / coatings lin. ft sq. ft lin. It sq. It Corrugated or layered paper pipe / Trowel/Sprayer coatings / insulation lin. ft sq. ft lin. It sq. It Spray -on fireproofing lin. It / sq. It Transite board, wall board lin. It / sq. it Cloths, woven fabrics - lin. ff sq It Other, please specifyc Thermal, solid core pipe insulation lin ft / sq ft Window Glazing lin. ft / s 0 ft 12. Describe the decontamination system(s) to be used: Remote Decontamination Facility with Shower Basin 13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): Material will be wetted and placed in double bags and labeled for transporatation 14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: Name of DEP official 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 N No B. Facility Description Vacant Bam 1. Current or prior use of facility: 2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ® No 3 Edgewood Retirement Communities 25 Osgood Street Facility Owner Name Address North Andover 01845 978-725-3300 City/Town Zip Code Telephone 4 Thomas Roy 750 East Industrial Park Drive Name of Facility Owner's On -Site Manager Address Manchester 03109 603-627-4203 City/Town Zip Code Telephone KellyConstNAndov.doc - 9/02 Asbestos Notification Form • Page 2 of 4 Commonwealth of Massachusetts 305885 Please Enter Decal # Asbestos Notification Form ANF -001 4. Cityfrown Zip Code Telephone Minerva Landfill n/a Owner's Name Final Disposal Site location name 9000 Minerva Road Address OH 44688 State Zip Code D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts Note: Contractor regulations for the Removal, Containment must sign this form or Encapsulation of Asbestos, 453 CMR for Dos notification 6.00 and 310 CMR 7.15, and that the purposes information contained in this notification is true and correct to the best of his/her knowledge and belief. Waynesburg City/Town 330-866-3435 Telephone Craig Starkman Name Sales Position/Title 978-470-2860 Telephone N. Reading,MA City/Town Authorized ig ature and Date Dec -Tam Representing 50 Concord St Address 01864 Zip Code Fee exempt (city, Town, district, municipal housing authority, owner -occupied residential of four units or less?) ❑ Yes ® No KellyConstNAndov.doc - 9102 Asbestos Notification Form - Page 3 of 4 B. Facility Description (cont.) Kelly Construction Co., Inc. 750 East Industrial Park Drive 5 Name of General Contractor Address Manchester 03109 603-6274203 CityFrown Zip Code Telephone AIG WC5311226 12/28/08 Contractor's Worker's Comp. Insurer Policy # Exp. Date 6. What is the size of this facility? 25,000 1 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: Note: Transfer Name of transporter Address Stations must comply with the Cityfrown Zip Code Telephone Solid Waste Division 2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 Service Transportation Group 58 Pyles Lane Name of transporter Address New Castle, DE 19720 302-778-5930 Cityfrown Zip Code Telephone 3. Refuse transfer station and owner Address 4. Cityfrown Zip Code Telephone Minerva Landfill n/a Owner's Name Final Disposal Site location name 9000 Minerva Road Address OH 44688 State Zip Code D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts Note: Contractor regulations for the Removal, Containment must sign this form or Encapsulation of Asbestos, 453 CMR for Dos notification 6.00 and 310 CMR 7.15, and that the purposes information contained in this notification is true and correct to the best of his/her knowledge and belief. Waynesburg City/Town 330-866-3435 Telephone Craig Starkman Name Sales Position/Title 978-470-2860 Telephone N. Reading,MA City/Town Authorized ig ature and Date Dec -Tam Representing 50 Concord St Address 01864 Zip Code Fee exempt (city, Town, district, municipal housing authority, owner -occupied residential of four units or less?) ❑ Yes ® No KellyConstNAndov.doc - 9102 Asbestos Notification Form - Page 3 of 4