HomeMy WebLinkAboutMiscellaneous - 13 STONINGTON STREET 4/30/2018 13 Stonington Street —
I
7 4 u Date. !/1� i�.... . . ..
HORTM f/.k
3? '` TOWN OF NORTH ANDOVER '
• PERMIT FOR GAS INSTALLATIO,i�I
:. • � •
¢.
r•
This certifies that . . . . . . . . . . . . . . . . . . . . . . . ..��,%. . . . . . . . . .
has permission for gas installation . . . /I�Zf . . . . . . . . . . . . . . . . . .
in the buildings of Tr . . : . :.: . . . ... . . . . . . . . . . . . . . . . . a
at .3. . .v . . . . . . . . . . ., North Andover, Mass. ' :y
Fee. ° . Lic. No. �..lz 1. ! . , . . . . . . . . . . . . . .
GAS INSPECTOR r'j
Check#2--L; r
I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: �. ��'/� �� MA. Date: /` S �� Permit#
Building Location: �3 57d,�l,ut:,Tc�� J / Owners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑— Plans Submitted: Yes❑ No❑
FIXTURES
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SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 TH FLOOR
-i'FLOOR
6 1H FLOOR
7 1 H FLOOR
8 FLOOR
Check One Only Certificate#
Installing Company Name:� (. / -ti /L� 7L !77
Corporation 7U
Address:���LCity/Town: L State:
❑
/� \ Partnership
Business Tel:`7)� �d—?_3 Fax:
❑ Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes 0-Wo❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy E3—" 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing d d hapter 142 9khe General Laws.
Type of License:
By .0'Plumber
Title ❑Gas Fitter Sig at of Licensed Plumber/Gas Fitter
Q Master
Cityrrown ❑Journeyman LP Installer License Number:
APPROVED OFFICE USE ONLYEj
Date.. . Rel
A NORTH �+
3j °` 11 TOWN OF NORTH ANDOVER
s i .7
• PERMIT FOR GAS INSTALLATION
�'ISSACaHUSE��
This certifies that . 1.� .� ._. ,� .����. . . . . . . . . . . . . . . . .
has permission for gas installation }:- -� .e.�. . . . . . . . . . . . .
in the buildings of ... . . . . . . . . . . . . . . . . . .
at /�. . North Andover, Mass.
od
Fee ��t . . . . Lit. No:: . . : . . . .'
GAS INSPE TOR
Check
7023
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations l 3 ✓tD Permit#
Amount$ �
Owner's Name fi it
New❑ Renovation Replacement Plans Submitted ❑
a a c WH �a
c1 rn F w O O ;D p z F
v� W QQ M W
w W vs z d x a' C4 w CG W � Ca F" x
d W Q W F" H W U O > w F. U F W
w > w z Q z ¢ o o W °o w N
O O x w o C7 a U a > A w F O
SUB -BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
-
6 T H . F L O O R
7TH . FLOOR
8TH . FLOOR
(Print or type / � Check one: Certificate Installing Company
Name F' V J Af Zl/ Zvi, Corp.
Address 0,k- /_ t'1L_ Partner.
Bu�sTe ep one f y T fo 77•-0 � El-Firm/Co.
Name of Licensed Plumber or Gas Fitter
I
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes Er No 13
If you have checked Les,please indicate the type coverage by checking the appropriate box.
Liability insurance policy 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 0
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 in ti s p rmed u er Permi sued fort is application will be in
compliance with all pertinent provisions of the Mass u Stat as Code d Chapt 142 of eneral Laws.
By:
,Signature of Lic sed Plumber Or Gas Fitter
Title Plumber 341
City/Town 0 Gas Fitter License NTrnber
Master
APPROVED(OFFICE USE ONLY) Journeyman
1
The Commonwealth of Massachusetts
s Department ofIndustrial Accidents
Office ofInvestigations
600 Washington Street
Boston, MA-02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 E] New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling
ship and.have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12,0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
tI applicant that checks box#,I rn-_=-Iso f11 out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. oIicY information.
I am an employer that is providing workerscompensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
a
Policy#or Self4ris. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a co of the workers'copy s 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalfies of perjury that the information provided above is true and correct
Sip-nature: Date
Phone#:
Official 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#:
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."
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 or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartrnents 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 Iicensing agency shall withhold the issuance or
renewal of a license or permit to operate 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 time 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
'1
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 NOT 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 Com nonweald of Massachusetts
Dgmrtment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0.2111
Tel. 4 617-7274,900 ext 406 or 1-8.77-MAS:SAFE
Fax # 617-72.7-7749
Revised 5-26-05
ur"r"7.massx0vfdia
i
I
ger -
Air Quality =xperts, nc. aft
349 So. Broadway• Suite#8 Asbestos Removal
Christopher Thompson Salem, New Hampshire 03079 Residential• Commercial• Industrial
APRIL 6 , 1992
NO. ANDOVER BOARD OF HEALTH ce,
120 MAIN STREET
NO. ANDOVER, MA 018451
DEAR SIR/ MADAM:
ENCLOSED PLEASE FIND COPIES OF D.E.P. AND D.L. I . NOTIFICATIONS FOR
ASBESTOS ABATEMENT WORK TO BE PERFORMED ON APRIL 8 , 1992 AS AN
EMERGENCY RG NCY JOB.
PROJECT: 1.3STONIN_GTON ST T
— —_----- -----
N-O-.--- -AND-OVER,__MA_ __01 —
845 g
IF YOU HAVE ANYQ UESTIONS PLEASE CALL ! !
SINCERELY,
I
CHRISTOPHER THOMPSON
PRESIDENT
I
:• 1 11C 0,T0mn xifi,culfh of a ussachuscls
DEPARTMENT OF LA$OR AND xNDUSTT.tES
DIVISION OF-INDUSTRIAL SAFETY
(In accordance wity the I10'rPxcaTxoN OF ASBESTOS WORT;
Provisions of M.C.L. c. 14.9, §64F and 453 CY
All sections of R R
this .ot must tae compl• Ced'in order to comply with
the not.�t'lcation requircrcents Of 453 CALq 6.12
TEN DAY PRIOR NOTZ'FSCATION IS
Rc p U1 RED OF ANY•A$ATF�••IENT PRa7ECT
CATER T"YAM THREE (3) LINEAR OR
_TUAIL.
• DLI PILE IIUMBER
Cor-tractor perForrairg Project I
T�)
S
License #.'A C o o Cj j 6 7
Dc prevailing rates of as e
under• H-C.L c. I 9 ..apply to this project as re
d9;..a?6. 27 or• 27F7 (circle dre) vctired
Address of YES ?io
Building Name (if any) %•� � EJB I f
---------------
Street Address 3
CityG?v E c�
Zip - yJr Phone S•D 6 b' a y`I
Project•.tyPe (circle one):
DEMOLITION•
erRMNOVATION �pASR r
It' •Oth • . se•Lectad •' oT8•..R
• "please exPlain
Asbestos Act.fvity:. (circle one): ENCA.DSULATIO.v
ASS0CIAT3D PRCa7ZCT
ENCLOSURE •
REN.OV� ;
Indicate amount of: asbestos su
fa
C
.. ce on
pipes
C7i
ordLits.
/ LINEAR ?ES
T
i
es
P P or• dnctsto be removed. encloasbestos surface on structures
sed o:� encapsulated �O other than
Start date0 �,r SOUPLPW FEET
stir'
Con g --- `-�-- pm /(-) weekends? Af 0
ple,.lon Date
Project Supervisor Name -�
CHRISTOPHER T} OMPSON
Asbestos Anal C rtit'jcate y SF06466
Ytical Lab Name FINAL CLEA.^ANCE ANLYS
Nane 6 Certificate X AA000085
Addreax of disposal sites) TURNKEY LANDFILL'
• 90-ROCHESTER NECK RD.
0009alz ROCt'ESTER, NH 03867
. •'Cos
'I��, ^ y J
. C�ili•.:J�;; =�.:'C.n Or' VCiJGl7. Vti �C.IT L•'1^
T-
cnn�saetar,•a workers• conac�sation rncurcr COMMERCIAL UNION
i -
Policy Number .�r CM91H548299
Pacil!ty Owner ✓�1
,address
Ci ty
•, State ^
- ajP
scr:PC104 of work pracfilcQs to be followed: _
_ ALL WORK WILL BE DONE IN_.COMPLIANCE WITH LOCA, STATE
AND EDERAL REGULATIONS.
iPtio:l of decontamination system;s) to be used
J 7 � r0Aj m F�
."cscriptYotl•of handling/disposal rzathods to comply with 453 CPR 6.14(2) • (g)
WET REMOVAL INTO 6MIL POLY DOTTPLE ASBESTOS LABELED BAGS.
v
.ane and address of transporterls) if other than the .asbestos. con Cractor:
undc=;.f7ncd hereby states, under' the penalties oi' perjury, •that.he/she has
ad and undQrstood the COMOnwealth of Kassachusetts Regulations for the
:rroval,. ConCalrcent or Encapsulation of Psbcstos, 45�:Ct!rZ 6.:00, and that the
fornstiantcontained in thus notification is' true and correct to the best of
sihcr knowledge and belief.
t c Si grl e,d: C- / 13 rZ ,• L// of
Title: p2�St n F nT-•
Company:
-n t_�`(1,�i•.L 1 ��-/ -�oC��,Q.'7'S' T'vr�` ,
Isc return this form to: S.�l— iYt , �' '• • 43d '? .
Asbctos Control Tec';nical ServSCes X03
10-irtmenC of Tabor and I•ndustrigs.. . ••:
Division of 1'ndu stria.,1..,,^afeCy"
100. Cambridcc.•S-tr�Yet Room 1101
Boston, HA 02202
.................................
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality Tran....smitta...............
Tranttal ea
BWP All 04 Asbestos Removal Notification r
t Facility ID(If known)
BWP AQ 06 Notification Prior to Construction or Demolition ,.
Permits for Asbestos
Foy
Perm*k No..Go.a.mry............... 13Applicability
..........................:
Rcu.;gid Date
Rev ewa._
"' """" ' Demolition/Renovation operations involving asbestos- renovation operations and demolition/renovation operations.
Per t a aper.❑Dented containing material(ACM)and general Demolition/Renovation involving ACM is.required under 310 CMR 7.09(2)and 310
Decision Date.................... : operations are regulated by the Department of Environmental CMR 7.15(1)(b)twenty(20)days prior to any work being
i Protection(DEP),Bureau of Waste Prevention—Air Quality performed.The following information is required pursuant to
Division,under Regulations 31'0 CMR 7.00,7.09 and 715. 310 CMR 7.15.
Notification to the REGIONAL OFFICE of general demolition/
General Project Description
1� Facility
f....�..E .E......l.:I...C... ........t................................. 3. On-Site Manager
Nair:
1... ..Al ` ,
AddressOne
.................... ..........
........
.4..
C.......... ......... ..................................................
Cry/Town
C' pp� // Ll
..f.�....4 . �.. ...................................................
/�
Telephone . CIy/rotm
................................................................................................................
Size Telephone
. .........................................................................................................
Squareleel 4. General Contractor
.................................... .............:.......................................................
Number ofnow
Name
Was the Facility built prior to 1980? 0,"Yes O No
I�ES,oEN .� Address
C
.. .. ....................._............................................
Cuient orPrhr use of Fx1lityC!ry/lown
Is the Facility Occupied? C9'Y O No
Is this Facility Owner-Occupied Re dentia)with 4 units or less? Telephone
Yes O No
2. Facility Owner Does this project Involve the removal and/or alteration of
any Asbestos Containing Material(ACM)as defined and
............................ .............:............................................................... applied In 310 CMR 7.00 and 7.157?
Nair 2/yes O No
....................................................................................I.......................
Address 11 Yes,complete Sections C and D
................................................................................... If No,complete Sections D and E.
Cfry/fown
Telephone
Asbestos Removal Description
1. Asbestos Contractor —- s i' t M , /"J 14 3
u ��r/...... x PER.rs.................... clry/Town G o 89 `� 6 `( 6 5
..............R..... .....q........ 3
Name Telephone
.�.!J.. ....... ..V.E A C O O O f r. '7 _
Address L>°parhnentofLSWrdinduslitsLicense/
Rev.1/91 Page 1 of 4
�1��ilChhu�:tr��e{lartrl��nt,o�E/IYIi't�lii.iGltta'r,s�/atectlon
Bureau of Waste Prevention'=Air Ouality, L................................
BWP.AQ 04 Asbestos Removal Notification 'Transmitt"ali
' BWP A 06 i
Q Notification Prior to Construction or Demolition
Permits for Asbestos facility l0(ilknown;
2. . On-Site supervisor , 7. Description of-techniques used for estimation
S� Fo6yb6 •
e��anenratsaor>namdusr�es e�ruraaon �—�---.
3. Hygienist
Name .........
4. Specific Worksite Locations(s)(i.e.Building name, 8. Asbestos Removal
number,wing,floor,room,tunnel.)
f'1SEM C-iJ �. ........................ ..............1........�............`��......................
.. .. ... . ..... ............................................... ftfDate 1� f�
............................................................................................................ fltODate..»..........»............................1........ ....... .. .........................
5. Is the job being conducted indoors or outdoors? H u(s of Operation
daytime O evening O night
Da of Operation -
Mon.—Fri. 0 Sat.—Sun.
(Note:Any changes in these dates must be reported to the
6. Estimated amount of Each type of ACM to be handled appropriate regional office:If a removal is postponed for
more than thirty(30) calendar days separate notification will
. ... . . ....... . . ... .. � . be required:)
Linear/Square Feet
boiler,breeching,duct, 9. Describe the asbestos removal procedures 1p,66 used.
tank surface coatings / 5
............................ ❑ glove bag ❑ enclosure ull containment
O cleanup O encapsulation O disposal only
thermal,solid core pipe insulation / ❑ other-please describe
corrugatedor layered ................—.. . ..»...»...»..........».........................................................
paper pipe insulation
/..0......./ ....... 10. Transporter of asbestos-containing waste material from site
insulating cement
to tempbrary storage site(ii necessary)to final disposal site
/
............................
..........:........................................................................................
spray-on fireproofing Name .•••
...........................
...........................................................................................
trowel/sprayer coatings /
Aaaress
............................
.............
cloths,woven fabric cpy/fown.......................... ........................................................
.................................. ............................................................................
transits board,wall board / retepVione
............................
other—please describe /
............................
Total In Linear Feet C) /
.............
Total in Square Feet /l
............................
Rev.1/91
Page 2 of 4
Massachusetts Department of Environmental Protection 0 G
Bureau of Waste Prevention—Air Quality Transmittal/
BWP AQ 04 Asbestos Removal Notification
' BWP,AQ 06 Notification Prior to Construction or Demolition .......................
Facility ID(if knoivn)
Permits for Asbestos
11!. Transporter of asbestos-containing waste material from 13. Final Disposal Site
removalRemporary storage site to final disposal she
/al R Q uA1- :'1-V n E RrS Name pa
Name ......1..�......!�....t ia.....T E:........!J... .K.... ..
✓
nl o E
3 E � adores �
� /� r_w v �
SheelAddress °c ii E.S.T..E..R ..... .-!l........b. .7.
� H - v-3.0�9 cly . .. .. ..,... .. . '�
clry/rown .� ...... .........a.3...8
6 D� $9 G/, 6.�/ 6 S lelepAane... ... ....................
Telephone Al A N A G,E M E h/f Q
Owners Name
12. Refuse transfer station facility and owner(if applicable) (Note:Disposal of ACM must comply with the Solid Waste
Divisions regulations 310 CMR 19.00.)
Name 14. Emergency Asbestos Removal Operations
............................................................................................................ DEP official who evaluated the emergency:
Address 1 •.
..�. .........�.....r 4..........................................................
Ciry/lown Name
1� SP � cTo2
............................................................................................................ ...............................................................................................................
Telephone Title.
Owners Name Aulho*y
(Note:Transfer Stations must comply with the Solid
Waste Division regulations 310 CMR 18.00.) aaadAnuroriralron
U . General Demolition/Renovation Description
1. Demolition/Renovation Contractor 4.. Was the facility surveyed for the presence of asbestos
containing material(ACM)?
Name O Yes O No
If yes,who Conducted the Survey?
Address
..............»...............................................................................................
Name
city/Town
Oeparb'nen!of LaDaand lndusldes CerliliaGon/
Telephone
5. If yes,who conducted the survey?
2. On-Site Supervisor
...................................................................... ....-..................................................................................................
Name
...............................................................................................................
Depati nlolLawswindusldesCerllticatlon/
3. identify the specific Worksite Location(s):
6. Demolition/Renovation Asbestos Removal
............................................................................................
............................................................................................................ StrrlOale End Dale
. ............................................................................................................
Rev.W1 Page 3 of 4
Mawchus�etts Department of fnviromai;,uj,'1 J utl;�llolS. i
Bureau of Waste Prevention—Air Oualiiy Tranamittatl
BWP AQ 04 Asbestos Removal Notification
BWP AQ 06 Notification Prior to Construction or Demolition ............focility (r known
Permits for Asbestos
7. Describe the demolition/renovation procedures to be 8. Emergency Demolitlon/Renovation Asbestos Removal
used: Operations
State or local official who evaluated the emergency:
Name ..
Tule
...........................................................................................................
Autnodry
(Note.Demolition/Renovation Operations must comply
with 310 CMR 7.09 to control emissions to prevent a Date o/Authofilauon
condition of air pollution.)
(General Statement:If asbestos-containing material is unexpectedly found or damaged during a Demolition/Renovation a�
operation,all responsible parties must comply with 31010MR 7.00,7.09,7.15 and Chapter 21 E of the General Laws of the
Commonwealth.This would include but would not be l rgited to filing an asbestos removal notifibation with the Department
and/or a notice of a releaseRhreat of release of a h;,zardous substance to the Department If applicable.)
Certification
I certify that I have examined the above and that to the
best of my knowledge it is true and complete.The
signature below subjects the signer to the general statutes
regarding,a false and misleading statement(s).
C. 3...... , .. ...J . ... . . '..•...j...�........ .�.............
� ,.....................................
PdniName S�natwe
........
...................................... ......i 1.!........U A.�:[-r�l.. .. .'(.!°.ER.T S .......N.C................... .
PosilioNlitle
Representln j.. ......
.....................Y..... ........
..ale J.. ..........................................
Rev.1/91
Page 4 of 4