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Home My WebLink AboutMiscellaneous - 116 MASSACHUSETTS AVENUE 4/30/2018 (3) Commonwealth of Massachusetts _ - 100115591 Asbestos Notification Form ANF-0f E P3U ~ 32010 TOWN OF NORTH ANDOVER 'mp°'U"t= When filling out A. Asbestos Abatement Description forms on the computer,use 1. a. Is this facility fee exempt-city,town,district, municipal housing authority, owner-occupied only the tab key residence of four units or less?[Z]Yes ❑No to move your cursor-do not b.Provide blanket decal number if applicable: use the return Blanket Decal Number key. 2. Facility Location: RESIDENTIAL 1 1116 MASSACHUSETTS AVENUE a.Name of Facility b.Street Address NORTH ANDOVER IMA 01845 __J 9786894884 —� c.Cityrrown d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this RESIDENTIAL I JEXTERIOR form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? p Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational ISENCAM INC 1145 MARSTON STREET Safety(DOS) a.Name b.Address notification LAWRENCE 1 01841 9786837767 requirements of 453 CMR 6.12 c.Ci frown d.Zip Code e.Telephone Number AC000129 f.DOS License Number g.Contract Type: ❑✓ Written' ❑Verbal KATHY O"SULLIVAN OWNER h.Facili Contact Person I.Contact Person's Title PABLO A. NUNEZ AS030514 6. a.Name of On-Site Supervisor/Foreman b.Supervisor/ rernan DOS Certification Number 7' ENVIROTEST LABORATORY I IAA000128 a.Name of Project Monitor b.Project Monitor DOS Certification Number ENVIROTEST LABORATORY IAA000128 8. a.Name of Asbestos Anal ical Lab b.Asbestos Analytical Lab DOS Certification Number =0 9 11/8/2010 11/8/2010 a.Pro ect Start Date mm/d b.E nd Date mm/dd/ �0 7AM-3PM �N c.Work hours Mon-Fri. d.Work hours Sat-Sun. =c 10. a.What type of project is this? '0 ❑ Demolition ❑✓ Renovation —r ❑ Repair ❑ Other, please specify: b.Describe 11. a. Check abatement procedures: 0 ❑Glove bag ❑ Encapsulation �o ❑Enclosure ❑ Disposal only �LL ❑Cleanup Q Other, specify: EXTERIOR-NONFRIABLE METHODS 't ❑Full containment b.Describe ; —z _ - =Q 12. Is the job being conducted: ❑ Indoors? 0 Outdoors? anf001ap.doc-10/02 Asbestos Notification Form-Page 1 of 3 3 Commonwealth of Massachusetts _ 100115591 Decal ts� Asbestos Notification Form ANF-001 A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encs sulated: 0 1306 —� a.Total pipes or ducts linear 0. 1 otal other su aces square c.Boiler,breaching,duct,tank d.Insulating cement surface coatings 9 9 Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or g layered paper pipe insulation Lin.^ft� Sq�� f.Trowel/Sprayer coatings un.ft. 4 g.Spray-on fireproofing Lin.ft. --i Sq. ft—1 h.Transite board,wall board Lin q• i.Cloths,woven fabrics j.Other,please specify: L�_� 300 Lin.ft.' S ft. Lin.ft. S .ft. k.Thermal,solid core pipe SIDING SHINGL insulation Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: WORKERS SHALL DOUBLE SUIT&HEPA VACUUM UPON EGRESS IN LIEU OF DECON UNIT 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): WASTE WETTED/DOUBLE BAGGED IN 6MIL POLY/EPA APPROVED LANDFILL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date mm/dd/yyyy of Authorization d.DEP Waiver# e.Name of DOS Official t.DOS Official—Title g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# N 0 17. 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 N =o 1. Current or prior use of facility: RESIDENTIAL o 2. Is the facility owner-occupied residential with 4 units or less? ❑✓ Yes ❑No KATHY O'SULLIVAN 116 MASSACHUSETTS AVENUE 3' a.Facility Owner Name b.Address o NORTH ANDOVER 19786894884 o c.Ci /Town d.Zp Code e.Telephone Number area code and extension amu_ 4 KATHY O'SULLIVAN 116 MASSACHUSETTS AVENUE a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address Z NORTH ANDOVER 19786894884 �Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3 Commonwealth of Massachusetts _ 100115591 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) TWOMEY&LEGARE CONTRACTING 87 BELMONT STREET 5' a.Name of General Contractor b.Address NORTH ANDOVER 01845 c.Ci /Town d.Zip Code e.Telephone Number area code an�nsion f.Contractor's Worker's Comp.Insurer E Ig.Policy Number h.Exp.Date mm/dd/ 6. What is the size of this facility? 1 2 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): SENCAM, INCORPORATED 1145 MARSTON STREET Note:Transfer a.Name of Transporter b.Address Stations must ILAWRENCE 101841 19786837767 comply with the c.Citylrown d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CnnR 19.000 ISERVICE TRANSPORT GROUP,INC. 58 PYLES LANE a.Name of Transporter b.Address NEW CASTLE �� 19721 8779999559 c.Ci /Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner b.Address c.Ci /Town d.Zip Code e.Telephone Number 4. IMINERVA ENTERPRISES INC a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 9000 MINERVA ROAD I IWAYNESBURG c.Final Dis osal Site Address d.Ci /Town OH 44688 13308663435 �CO e.State f.Zip Code g.Telephone Number �o �0 D. Certification N The undersigned hereby states,under the IPATRICK J.SENNOTT JPATRICK J.SENNOTT� o penalties of perjury,that he/she has read the a.Name b.Authorized Signature �o Commonwealth of Massachusetts regulations PRESIDENT —� 10/26/2010 —1 for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and C.Position/Title fi°n/litie d.Date(mm/dd/vvwl 310 CMR 7.15,and that the information 19786837767 1 SENCAM, INC. �o contained in this notification is true and correct e.Telephone Number f.Representing to the best of his/her knowledge and belief. 145 MARSTON STREET o .Address �LL ILAWRENCE 01841 Z h.City/Town I.Zip Code � anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 I Date 10/29/10 From the Desk of.• Patrick Sennott Dear Sir/Madam- Attached please find copy of Notification for Asbestos Removal that was filed the the Massachusetts DEP & DOS. Please let us know if you have any additional requirements • . r . 145 Marston Street, Lawrence, MA 01841 TEL: 978-683-7767/ FAX: 978-688-9998 �"+ w�* ps •;r..�YatJrkK,K�'A'�,I'�t/Fr�"'rl:,.,',TI.: .. .MASS.ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO' GASFITTING r (print or Type) Mass. Date d 1 19 ) 'Permit # ^� :I Building Location 1/6 /y7as5 t-V Owner's Name C/ I/f�� Aid, 1-1 n d over /✓l 4f Type of Ocpupane< P d e17 f ,.; New O Renovation O Replacement Plans Submitted: Yes O No FIXTURES 1 � pz ' V1 W N u ,.. W Np u m z z m W x z Wig z Ida m1A LU 0 z U. z 0 0z i x o v x 3 0 . 5 u oc o g O SUB•BSMT. BASEMENT 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR ix s},ti Sth FLOOR 6th FLOOR 7th FLOOR eth FLOOR Installing Company Name +.,t PLUMBING tM ING o I I Check one:; Certificate Address P.O. BOX 728 ;(Corporatiori . U1 b4S-- -- O Partnership, ' BusinessTelephone q7<9 27 4 2 q O Firrr/Co. Narne of Licensed Plumber or Gas Fitter Cd INSURANCE,COVERAGE: I have a curvet liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch, 142. Yes No O '.N If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy K Other type of indemnity O Bond O OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the'insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner O Agent O.. 1 I hereby certify that all of the Malls and Information I have submitted for entered)in the above application are true and accurate to the best of my knowledge and Thal all plumbing wor4 and.i Ilatiom performed under the hermit issued for this application will be in cornoLance with all penineni provisions al the MasucMnem state Gas Code and owier 142 d the Genesi Uw% .. . . .. T' of License: BY �umiser �C�"L lR1V"�. •�� 'L..J r. "-�// aaliner . Title r Master Signature of Lkensed Plumber or Gas Flit" f�journeyman CihRown License Number APPROvfD tOfFICE USE ONLY) _ ..-`>«a.�-...w'F.+l...ai-1.�N%.:+:xS�K++•y^—�'.,._,::..-�»; � _.�...:ry,�.y.=,,..�,..7...f '.rr. .� ..,.:.ciY�•-..-.�.P._a..�y6r..;.;�. ni r To #2164 Date. .... ... . ,,OFTH TOWN OF NORTH ANDOVER 3 e L A p PERMIT FOR GAS INSTALLATION 49 9 SACH ) i This certifies that.0. .,D.QA tv e- L . . . . . . . . . . . has permission for gas installation . . . .R !?. .t.. . . . . . . . . . . in the buildings of . . . i�,/4A..0? ` . . f?u- qJ . . . . . . . . . . . . . . a at . . ./1.G. ./Al/I F.s. .14q. -:� . . . . . . . . North Andover, Masi. Fee.aJ,R .. . . Lic. No./o� GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File b f., •,,......- ,. ...,..+..n..e..^R�."T'^'^'"�.`�'""*"'. T.^^'.a ...,,.: _... . ...- .; ..,. - ,. .. ., �r^rre+..�C^„�*�.�r...,r•...*.�.+.r+..�.r yam\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS (Prl t or Type) p FITTING Mass. Date Permit # a Building Location Owner's Name., -i• CL Type of Occupancy /lin/ New ❑ Renovation ❑ Replacement,W1010, Plans Submitted: Yes ❑ No ❑ N N ,p� X W 4 N N v, X 0: N cc W a N rr O O F- N x W J, N W `- V' (n h 2 S to x O u N .0 _ X' .O H w < m < U: O O N N O u! Q = !O. y O C .( W Z V W H 41 < 0: C W W i:r �% ,J z < �. a a G W W �”' X fc Y -K W J i rW. N O ? 0 h W J ��, W d W Y 1c W O 2. < ft +j( O O W O: O �IJr X X X O t� Y W O O tl J. CV (r Y O d (- O SUB—BSMT. LL BASEMENT 1ST FLOOR 2110 FLOOR 3ROFLOOR ITH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR GT" FLOOR Installing Company Name ®'DOIdP+IELL't� puam® Check one: Certificate # Address_. SALEM N A-03070 ❑ Corporation ❑�/Partnership Business Telephone — Q � t�' Firm/Co, Name of Licensed Plumber or Gas Filter_ I /ted/'V)14�� T ®II p A)/l am 4 INSURANCE COVE AGE: I have a curre t tiny Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes. please Indicate the type coverage by checking the appropriate box. A liability Insurance policy pY Other type of Indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage,required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner[] Agent ❑ I hereby certify that all of the details and Information 1 have submitted(or entered)In above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under Ilia permit Issued for this application will be in compliance with all Pertinent provision' 'of!lHe Mas"chuselb Slate Gas Code and Chapter 142 of the GeWAI Laws. T;� Gasfi(ler oTitleumber nature o ce um er or Gas rtter t-AW //��%ityRown asler License Number l, !yfTwnourneyman f•Tri----- - � BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME 3 TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFr"ER LIC No. PERMIT GRAHTED DATE 19 i • s GA3INSPECTOR