No preview available
HomeMy WebLinkAboutMiscellaneous - 1160 GREAT POND ROAD 4/30/2018 (44) BUILDING FILE Date.�7. . .�� .S.... .. ,°pR7M v Of 3= TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �9SSACHUSEt r This certifies that . X.. .`. . .�... . . . . . .�� . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . in the buildings of . . . �.e` .. . r. at . .�,l��. / '�'���° ` . . . . . . . .. North Andover, Mass. Fee. .3.5'. . . . Lic. No..I. �.! . . . U�`'";/ . . . . . . . . . GAS INSPECTOR Check# 6 9 2 IC MASSACHUSETTS UNIFORM APPLICATON FOR PERNUr TO DO GAS FITTING (Type or print) Date —� U NORTH ANDOVER,MASS HUSETT Dr / Building Locations Permit# � ( Z- Amount O Owner's Nam New Renovation Replacement Plans Submitted x w a o w w �a O U a H x x .-Gx z U W w H o a N F z H CZ QG F w w c oq > w N a w w > W E z C�� d d O O W :. O W F m O 3 A C7 a U a; > CA a H O SUB -BASEMEN T r� BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8.TH . FLOOR (Print or type)Nam , U � � / A I Ch one: Certificate Installing Company e Corp. 0, Address I lLo Partner. Business Telephone r - 5 ® Firm/Co. Name of Licensed Plumber or Gas Fitter C4 du I C1 INSURANCE COVERAGE Check one: I have a current liability Insuranc olicy or it's substantial equivalent. Yes No If you have checked y_es,p s indicate the type coverage by checking the appropriate box. Liability insurance policrtbat Other type of indemnity 0 Bond Owner's Insurance Waiaware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,an 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 I 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 Permit Issued for this applic tion will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gener 7 By: Signature of Lic d P1 b O as Title ❑ Plumber City/Town s Fitter lcense um er Master APPROVED(OFFICE USE ONLY) Journeyman ajjw=achusetts ' �`� D�Partrrrerzt o r f 1-R�fustrial Accfden�r :``�` f Stla Ot20t�F 600 IfrashbWMn Street_ 0'"Oft, M4 O2111 r� Workers, Cam �atioa . w`w'�Sgvv1&k Pe bsiiranee Affidavit~ Ruilders/Confractors/Eiectt icia 'mato�gtion ae/Plnmbers Please Print LeQ-bf Nie(> ncss Please Address: .CIly/ : Phtme#:. Are you as empioyert Cheelt.the a ro PP Pr irate•box. I:Q I am a entpiaym with 4. Type of pr pled( elrlplayC•5(fu•!I and/orpart-{tirrt8.* �have g=.CTtCi'SI CU�Sg�ar Hn(I I 6. ���- 2.Q 2 em.aBole.. ) d the sub-cortizactors ❑New eonstivcfion . PraPn�or pad"tner. list.—Cl M the attached ship and have no employees .I.h�` shed t 7. []Remodeling working for rare in st$s-contractors have [No workers'co worlccrs' comp.insurance, g' Q Demolition re I 9 1 CL mp,mstasnx S. Q We are a corporation and its 9• Q But7ding addition 1 3•❑ i sin$homeowner doing all work have exercised their !O.Q Eie,.tricai Tight of Cxm.n on '� °�addifions mysrl£IND-wmi='comp. ( �Pr l MSL 11.�]Plcm�bmgrap-'oracldiiions 2, §1 4''.and-we have no .=PZvY�s.[No wormers' 12.0 Roof repay *AiW.Up Mrfic ti=6 ho, mutt comp• ir:sumco squired.) aiso fiII oittth=section h;iow alrowiQg thairworkao;'cotnpaooffi�n Poi�Y ininrmafion. Fi°meowner€vuho sebmit this efridayit indicting they ere doing an Cant acrtnrs that check ttiia box mustalte an ad&iaesl r►'0z1c'end tFtOrt hiie outside connectors nnist ' new streersbowkg•lite name of the suT:.coutt j. n t�ftidnvit nomdir; ch., I csf�rt e+�pio�rer is;•omrtr�tstb:laark.•.••:,� v '`�'tri�mon. irtfvrnrafeorL ! ���n�Jor�,�plmre�; h'e�r�.�.*,�tole�r.r�ielob�, Insurance Company Name: Poficy#or Ser-ins Job Site Address: •pffafion Date; Attach a copy of the workers''co Om' Tp Failure m mPensation policy declaration page(showing fie policy number and e fine coverage ss wired under Seclion 25A of]+ aL c. 152 can �P ion $45D0.00 and/or one-ym"' :is civil �to the imposition of cranitraf p }des of a of up tD$250.00 a �onm�+as Weil penalties in the form of a 57l'}P WORK O lnvmli 3 against the violator. Se advised that a copy of this statement ORDER and a fine gations of Sze DIA for insurance rx v=s p verin"cation. rorwarded to the Office of I do hereby cwVry under the pains a.d penaWw a fP ry tiro the irtfnnriader pro Svided veovc Qnd cancel S' Phone#: Date: 4Jf�eiQl resp randy. Do notwrite is fidsaftossa,m bt mp[��• 'or town.orrro[ City or Town: Issuhtg Aatho riPermit/Licease# ty(circle one): 1. Board of Fieattb L Snnilr#ing 6.Other Department 3.City/Toa Clerk q Eiectr icat IaspectAr S. Plntabiva l b nspector Contact Person: Phone#: intdrIY'1ation a Ild lI struCtions , Massachusetts General Lam chapter 1 S2 requires all empo Ioyers to provide workers' compensation fnr their employees. Pursuant to this statute,an m player is defined as"..:every person in the service of another under any contract of hire, Cyr implied,oral or wrtttm" An rmptayer is defined as"an individual pmu=hip,$ssociafion,corporation or other legal entity,or arty two armors ofthoe'famping engaged in a joint enterprise,and fimiudim-tg the legal tepn:serrtetivm of a deceased employer,or$t reztiver ortrststm•of an individual,pmtrs=ship,.assnois6c>in ar other legal entity,empioymg=Ploye •Howmthe owncir•of a dwelling house having not more than thrx apa_rtmentss and who resides therein, or the ocxupant.of the dwelling house of another who:employs persons to do miLi ttmia m,construction or repro work on.such dweliirrghouse or on the grounds or building appurtmneat thereto shall nat b=m=of r,=b ensployment be dezmed to be an smploy=." MOL chapter 152,625C(6)also states that"every slate ser-beat 6ceesing agency shalt withhold the issnanceor reoewml of a lic:em or permit to operate a baseness or tto const root boWutgs in the commonwealth for any applicant who has aot produced acceptable evidena.df eomprmce with the..iasarmnw covemp required" Additionik, MGL chapt or I5Z§25C(7)states"Nehtber I-be:commonwealth nor any of its polificw subdivisions shim enter into my contract far the perFornamce of public wade M141•aeceptible evidenm of ratnpliE6=with 81c inst==- rsgr>azrnentls.of this chapter have bean presmtted to the cntttranting authority." Appficauts Please fill out Etta workem',compensation.affidavit comptately,by decking the boxes that apply tn.your sitn6on and,if { necessary, supply subk*nt actar(s)name(A. addrMss(r.5):acid phone numbers)along with thesis can ificata(s)of t hnsitr�rcx. Limited Liability Companies (LLC)or LimiL--d Umbility.Parinmships(LLP)wifh nu employ=otherthan the r members arpartrrars,are natrrgr»redlto sang workers'ccbTnpenzation insurance. Van LLC orU P does.have employees,a policy is reQinrod Be advised thmt this afncbavitmay be submiumd to the Depariraemt of lndustriel .Accidextts for co &matian of insutatrce coverage. Also*Eye sane to sign and date the atFedavit, The affidavit dwuid be retim ed to the city or tMM that the apprication for.tbt peiait or hcdnso is baring requested,not"tiie Dq=tmMI of Industria!Acoidenta. Should you have any question regain-&V the.law or if you arc required to obtain a workzr oMpensation poHoy,plc.ase-call the Depsalme nt at the-number.listed Wow, Salt insured oomgaaies should erriar • self insrazsncx hcxmsc nurnii�oa$sc�mFsiiste iis�. ,- City or Town Offa:ialt Pie=be srse that the affidavit is cormpletr and printed lrgibiy. The Depwtnerrt his p voided a Spa=at Ire botmm of ihie affidavit for you to fill out in.the event the.Offi=Of'lnvcsti ons has to contact you regarding the applicant Please be sur to fill in the permit/license numberwhich will be used as a reference number. In a.ddifion,an appikmit that must submit multiple permit/;icsnse appiicesaians in any given year,need only submit onaaffidavit indicW*—c =nt policy"urformation(if necessary)and under"lob Site Adtlr-ass"the appR=rIt should write"alt locations in (city or ixwvn)."A Dopy afitiie affidavit:that has bei,officially staff Aped or marked by die c by or town may be provided to the applicant as proof that a valid affiidi%it is on file for fi>m a permits or licenses. Anew affidavit must be Mrd out each year. Whtrc a hams owner or citizen k obtsi;m- g a lio m= or permit not elated to any business or commercial veatum (i.e. a dog license or permit to bum leaves eats.)said parson is NOT.required to•compietz this armdaviL The Ofrrco of investigations would Iike to thunk you in advance for your cooperation and should you have any questions, please do not.hesitates to give us s call. The Dopmtment's address,telephone and fax number. The Commonwealth of I�fassaclitisetts Dcpardtent of Industrial Accidents Office of Invesk-2fiDns 600 Washington Strict Boston, MA 02111 TeL#617-72-74900 6ct 406 or I-&77-MASSA Fax x 61 7-727-7745 R visad 5-26-45 wvvw.raass.govidia A /c, Q All State Abatement professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP Q Plaistow, NH 03865 Fax: 603-378-0610 p RECEIVED June 5, 2007 JUN - 7 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Town of North Andover Board of Health 120 Main Street North Andover, MA 01845 Phone#: (978) 688-9540 Fax#: (978) 688-9542 Re: Asbestos Abatement @ Brooks School, Thorne House 1-160-Great.Pond.R6ad-;=;N } 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: 06/25/07 End Date: 06/26/07 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. Sincerely, J. cott Curley President JSC:jab Enclosures Asbestos•Masonry Cleaning •Selective Demolition•Shot/Sand Blasting• Mold Remediation J Commonwealth of Massachusetts F} � 100056405 Asbestos Notification Form ANF-001 Decal Number Important: 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 f four units or less? ®Yes ✓®No to move your cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: BROOKS SCHOOL 1160 GREAT POND ROAD a.Name of Facility b.Street Address North Andover MA 01845 (978)725-6284 c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. .Worksite Location: 1.All sections of this THORNE HOUSE 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? LE]Yes No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division Occupational ALL STATE ABATEMENT PROFESSIONALS 4 WILDER DRIVE SUITE 12 of Safety(DOS). a.Name b.Address notification PLAISTOW 03865 16033780600 requirements of 453 CMR 6.12 c.City/Town d.Zip Code e.Telephone Number I'AC000331 � f.DOS License Number g Contract Type: [�Written Verbal - lJ.SCOTT CURLEY 1PRESIDENT h.Facility Contact Person i.Contact Person's Title JEFF VALCOURT JAS033985 6. a.Name of On-Site Supervisor/Foremanb.Supervisor/Foreman DOS Certification Number AIR TESTING SERVICES __. AA000124 7. a.Name of_Project Monitor b.Project Monitor DOS Certification Number 1At_R TESTING SERVICES IAA000124 $' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number 106/25/2007 106/26/2007 =° 9' a Project Start Date(mm/dd/yyyy) _ ib.End Date mm/dd/yyYy)_______ ° j7-3;30 IN c.Work hours Mon-Fri. d.Work hours Sat-Sun. �o 10. a. What type of project is this? —O F-1 Demolitions—✓.,..j Renovation i T ®Repair ❑Other, please specify: b.Describe 11. a. Check abatement procedures: =° 1 Glove bag I l Encapsulation o (�;Enclosure Disposal only –�-- amu_ 7_1 Cleanup ;Other, specify: 'moi Full containment b.Describe Z 12. Is the job being conducted: 17, Indoors? i Outdoors? -� L— anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 Commonwealth'of Massachusetts ' 10d05B405 Asbestos Notification Form ANF-001 Deal"umber A. Asbestos Abatement'Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encapsulated: 10 450 a.Total pipes or ducts(linear ft) b.Totalo er surfaces square c.Boiler,breaching,duct,tank � L—L] surface coatings LineS .ftd.Insulating cementq• Lin � e.Corrugated or layered paper pipe insulation Lin.ft. Sqf� f.Trowel/Sprayer coatings Lln,ft. Sq.ft. g.Spray-on fireproofing t��_J h.Transite board,wall board Lin.ft. Sq.ft. Lin,ft, Sq.ft— L Cloths,woven fabrics j,Other,please specify: 450 Lin.ft. Sri ft. k.Thermal,solid core pipe TILE insulation Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: PROVIDE AN ADEQUATE DECONTAMINATION SYSTEM. 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR DOUBLE 6 MIL POLY 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/yyy).of Authorization Id.DEP Waiver* e.Name of DOS Official +f.DOS Official Tr<le —N g.Date(mm/dd/yyyy)of Authorization ! h.DOS Waiver# : 0 17. Do prevailing wage rates as per M.G.L. c. 149,§26,27 or 27A—F apply to this project? ❑Yes W1 No B. Facility Description �N o 1. Current or prior use of facility: RESIDENCE o �...� 2. Is the facility owner-occupied residential with 4 units or less? L i Yes �✓'�,No 3' BROOKS SCHOOL I '11160 GREAT POND ROAD e a.Facile Owner Name b.Address 0 1NO.ANDOVER, MA - 1 101845 i 978-725-6284 o c.C' /Town d.Zip Code e.Telephone Number(area code and extension) LL 4 ,NORMAND GRENIER 4 !1160 GREAT POND ROAD F Z a.Name of Facility Owner's On-Site Manager _ b.On-Site Manager Address INO.ANDOVER, SVA (01$45_ y! 1878-4_25-6284__ s< c.City/Town ted.Zip Code �e.Telephone Number(area code a—nd extension) anf001ap.doc 10/02 Asbestos Notification Form•Paae 2 of 3 Commonwealth of Massachusetts 100056405 Asbestos Notification Form ANF-001 Deal Number B. Facility Description (cont.) 5' F a.Name of General Contractor b.Address c.C' /Town d.Zip Code e.Telephone Number area code aextension) f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date mm/dd/ myl 6. What is the size of this facility? 2000 13 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. .Transposer of asbestos-containing material from site to temporary storage site(if necessary): ALL STATE ABATEMENT PROFESSIONALS, 4 WILDER DR,STE 12 Note:Transfer a.Name of Transporter b.Address Stations must IPLAISTOW,NH � 03865 (603)378-0600 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removai/tem ora site to final dis osal site: Regulations 310 P rY P CMR 19.000 J.O.BJROLLOFF, INC. JPU BOX 6037 a.Name of Transporter b.Address CHELSEA, MA 02150 1(617)387-1495 c.C' /Town d.ZID Code e.Tele hone Number 3. NIA a.Refuse Transfer Station and Owner b.Address c.C' /Town d.Zip Code e.Telephone Number 4. TURNKEY LANDFILL(WASTE MGT NH) Ia..Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 7 ROCHESTER NECK ROAD IROCHESTER I c.Final Dis osal Site Address d.C' /Town NH �� 03839 (800)847-5303 e.State f.Zip Code g.Telephone Number ° 0. D. Certification ••�� The undersigned hereby states, under the JUDITH BEREZANSKY �O penalties of perjury,that he/she has read the a.Name b.Authorized signature Commonwealth of Massachusetts regulations JOFFICE MANAGER 1 106/05/2007 for the Removal,Containment or /tl Encapsulation of Asbestos,453 CMR 6.00 and c.Position/Title d.Dat m dlvwvl 310 CMR 7.15,and that the information (603)378-0600� JASAP, INC. .� contained in this notification is true and correct e.Telephone Number f.Representing ° to the best of his/her knowledge and belief. 14 WILDER DR, STE 12 ° g.Address _ 'LL PLAISTOW, NH � IQ3865 Z h.City[Town i.Zip Code anf001ap.doc 10/02 Asbestos Notification Form•Page 3 of's