HomeMy WebLinkAboutMiscellaneous - 2 PARK WAY 4/30/2018 ---- -- - 2 PARK WAY
210/043.0-0011-0000.0
Date.. .s?. Ah q.. . .. .
OF MORTM ,h
32 '` TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
,SSACMUSEt
This certifies that . .L . . '/. . .���?? �. . . . . . . . . . . .
has permission for gas installation
in the buildings of . . . q.".w :`.... . . . . . . . . . . . . . . . . . . . . . .
at . . . .✓f`�.!� '.u! . . . . . . . I North Andover,,Mass.
Fee?!V"' . . Lic. No.. .P.� . . .
�GASINSPEG OR
Check#
Ti 38
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FTrnNG
e
(T Yr or print)) Date-
NORTH ANDOVER,MASSACHUSETTS
Building Locations 2- Permit#
Amount$
Owner's Name � ����vtJ
New❑ Renovation ❑ Replacement Plans Submitted ❑
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SiJB -BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
' 6TH . FLOOR
7TH . FLOOR
8.TH . -FLOOR
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(Print or type) A j A Check one: Certificate Installing Company
Name__ ( �1 ��1�1.s Gtt /"L El corp.
Address ts� s b D
1-1 Partner.
usmess a ep one 13—Firm/Co.
Name of Licensed Plumber or Gas Fittafq,;7 0�y d d' -2.6
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No�
If you have checked yes,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 0 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 "ons p ormed under Permit Issu for this application will be in
compliance with all pertinent provisions of the Mass us State as Code and hapter 14 f the Gen Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title 13—plumber 3
City/Town Gas Fitter Licens e 77umbe
easter
APPROVED(OFFICE USE ONLY) Journeyman
a
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Lec-dibl
Name(Business/Organizarion/Individual):
Address:
------------
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
with 4. Type of project(required):
L❑ I am a employer
❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.
❑ I am a sole proprietor orpartner- listed the attached sheet t 7. ❑
Remodeling
ship and have no employeeses These sub=contractors have 8. Demolition for mein any capacity. workers
comp.insurance.
[No workers' comp.insurance 5. 9• ❑Building addition
❑ We are a corporation and its
required.] officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself y [No workers'comp, C. 152, §1(4),and we have no
12.❑Roof repairs required-]]t employees- [No workers'
COMP.insurance required.] 13.0 Other
*Any applicant that checkr-box#1 must also rill out the section below shy
1.L_.,:
.., _ w 'com^en-ti t .....,F:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new
$Contractors that check this new
box must attached an additional sheet showing the name of the sub-contractors and their workers'caffidavit
in. Ii md�ormaeo'
P Policy
I am an employer that is providing workers'compensation insurance for my employees Below is the police and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
City/State/Zip:
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 ORD
of up to$250.00 a day against the violator. Be advised that a c Office
and a fine
copy of this statement may be
Inv forwarded
Investigations of the DIA for insurance coverage v y to the Office of
g enficahon.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and co
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
j Contact Person:
Phone#:
t
Information as d 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 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 notbecause 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 operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=npliance 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-contractor(s)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 r�
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 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.Commonwealth of Massachusetts
Department of Industrial Accidents
Off ee of Investibatiions
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-OS wwu,.masS.-LYov/dia
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ASBESTOS TECHNOLOGIES INCORPORATED
April 28, 1989
Board of Health
North Andover Town Hall
Main Street
North Andover, Massachusetts 01845
Dear Sir:
For your files, I 've enclosed copies of the EPA, Massachusetts
DEQE and Labor and Industries notification forms for the small
asbestos removal project located at:
Mrs. Ellenora O'Brien
2 Park Way
N. Andover, MA 01845
The project consists of removing boiler and pipe covering. Work
will be performed on May 22, 1989 through May 24, 1989 .
inc el ,
Michael J. Corcoran
President
MJC:md
Enclosures
71 Spit Brook Road Nashua,New Hampshire 03060 e 603/888-7400 1/800/283-ASTEC
•
ASBESTOS DEDIOLITION/RENOVATION NOTIFICATION
FROM CONTRACTOR:
TO: Regional EPA ASTEC - Asbestos Technologies, Inc .
JFK Bldg. , Room 2103 71 Spit Brook Road
Boston, MA 02203 Nashua, NH 03060
Attn: Ken Tarr (MA) (603) 888-7400
Attn: Phil Cutler (other than MA)
RENOVATION DATE: April 28, 1989
Facility Owner:
Name Ellenora O'Brien Telephone (508) 683-3344
Street 2 Park Way
City North Andover State MA Zip 01845
Address of Project:
Street SAME
City State Zip
Present Use of Facility Residence Intended Use Same
Description of Facility - Type of Building Woodframe Size 3000sq.ft.Age 40+
Nature of Asbestos Activity - Removal X Enclosure ; Encapsulation_
Approximate amount of friable asbestos :
Linear feet: 125 Square feet: 50
Start date : 5/22/89 Completion date: 5/24/89 X A.M. ; P.M. ;
NO Weekends
Description of work practices to be followed (to comply with 453 CMR 6 . 14)
_Full containment - double 6 mil . poly floors and double 4 mil poly walls
Negative pressure with required respiratory protection
Description of decontamination system(s) to be used (.to comply with
453 CMR 6 . 14 (2) (b) Three stage with shower unit.
Description of handling/disposal methods to comply with 453 CMR 6 . 14 (2) (g)
Wetted in double 6 mil poly bags
Name, address/location of disposal site (s) Meadowfull Corporation
Route 3 , Clarksburg, West Virginia 26301
Name, address of transporter (s) if other than asbestos contractor
Chemical Recovery Incorporated 197 Portland St Boston MA 02114
Name of Asbestos Abatement Project monitor (if applicable)
Person/Firm Dennison Environmental Inc. 35 Industrial Parkway,
Address Woburn MA 01801
Date : APRIL 28, 1989 Signed By:
Title President
Of ASTEC-Asbestos Te "hnologies, Inc .
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NOTIFICATION OF ASBESTOS WORK
(In accordance with the provisions of M.G.L. c. 149, §6-6F and 453 CMR 6.12)
All sections of this form must be completed in order to comply with
the notification requirements of 453 CMR 6.12
TEN DAY PRIOR NOTIFICATION IS REQUIRED OF ANY ABATEMENT PROJECT
GREATER THAN THREE (3) LINEAR OR SQUARE FEET
DLI FILE NUMBER
Contractor performing project ASTEC-Asbestos Technologies Inc License N AC000159
Do prevailing rates of wages apply to this project as required
under M.G.L c. 149, §26, 27 or 27F? (circle one) YES (DO
Address of Project
Building Name (if any) None (Residence)
Street Address 2 Park Way
city North Andover, MA Zip 01845
Project type (circle one): DEMOLITION RENOVATION REPAIR OTHER
If *Other* selected, please explain
Asbestos Activity: (circle one): ENCAPSULATION ASSOCIATED PROJECT
ENCLOSURE REMOVAL
Indicate amount of: asbestos surface on pipes or ducts 125 LINEAR FEET
OR
asbestos surface on structures other than pipes or ducts
to be removed, enclosed or encapsulated 50 SQUARE FEET
Start date May 220 19 am X pm weekends? No
Completion Date May 24, 1989
Project Supervisor Name Michael Corcoran Certificate # SF01467
Asbestos Analytical Lab Name Dennison Environmental Certificate # AA000007
Name s Address of disposal sites) Meadowfill Corporation , Route 3,
_Clarksburg, West Virginia 26301
0049all
Is asbestos contract written or verbal? Written
Contractor's Workers' Compensation Insurer Insurance Company of North America (CIGNA)
Policy Number C3 12 72 68 3
Facility Owner El Lenora O'Brien
Address 2 Park Way
City North Andover State MA Zip 01845
Description, of work practices to be followed: Full containment - double
6 mil . poly floors and double 4 mil . oly walls - negative pressure
with required respiratory protection.
Description of decontamination system(s) to be used
Three stage with shower unit.
Description of handling/disposal methods to comply with 453 CMR 6.14(2) (g)
Wetted in double 6 mil . poly bags
Name and address of transporter(s) if other than the asbestos contractor:
Chemical Recovery Incorporated
197 Portland Street, Boston MA 02114
The undersigned hereby states, under the penalties of perjury, that he/she has
read and understood the Commonwealth of Massachusetts Regulations for the
Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00, and that the
information contained in this notification is true and correc , to the best of
his/her knowledge and belief.
r
Date April 28, 1989 Signed:
Title: President /
Company:Asbe s tos Technologies Incorporated
ASTEC
Please return this form to:
Asbestos Control Technical Services
Department of Labor and Industries
Division of Industrial Safety
100 Cambridge Street, Room 1101
Boston, MA 02202
0049a/2
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL QUALITY ENGINEERING 1. ASBESTOS CONTRACTOR
DIVISION OF AIR QUALITY CONTROL Name: ASTF�—Asbestos Technologies In
cTelephone:(603 )888-7400
[SEE LAST PAGE FOR OFFICE LOCATIONS] • t rook Rd eaCit
NOTIFICATION FORM FOR Street Address•11--9p� B
— KTcwn:Nashua,NH 03060
ASBESTOS REMOVAL AND GENERAL DEMOLITION/RENOVATION Department of Labor and Industries Certification# AC 0 0 015 9
-- 2. ON-SITE SUPERVISOR
Name: Michael Corcoran
F;T
APPLICABILITY Department of Labor and Industries Certification# SF 0 1 4 6 7
DemolitiontRenovalion operations involving asbestos-containing material(ACM)and 8eneral Demoli- 3. SPECIFIC WORKSITE LOCATION(S)(i.e.Building name;number,wing.Floor,room,tunnel.Is
lion/Renovation operations are regulated by the Department of Environmental Quality Engineering the job indoor or outdoor?) Basement
(DEOE),D+vrson of Air Quality Control,under Regulations 310 CMR 7.00,7A9 and 7.15.Notification to the
REGIONAL OFFICE of general demolitionfrenovation operations and demolition/renovation operations 4• ESTIMATED AMOUNT OF EACH TYPE OF ACM TO BE HANDLED(in linear and/or square feet)
involving ACM is required under 310 CMR 7.09(2)and 310 CMR7.15(1)()twenty(20)days prior to any work 50 boiler,breeching,dud,tank surface coatings
1 performed.The lollowing information is required pursuant to 310 CMR 7.15
Copies of"Regulations for the Control of Air Pollution 310 CMR 6.00 to 6.00 maybe purchased from thermal,solid tyre pipe insulation
the State Bookstore;State House, Room 116, Boston.Massachusetts,02133. Telephone number(617) corrugated or layered paper pipe insulation
727-2634.Please Print. insulating cement
spray-on firoproofing
trowel/spray coatings
cloths,woven fabric
B GENERAL PROJECT DESCRIPTION
transile board,wall board
1 other-please describe
I. FACILITY Ellenora O'Brien Telephone:(508)--hR �—� T44 -�5TOTALINLINEARFEET
5 n_TOTAL IN SQUARE FEET
Street address: 2 Park Way City/Town:N.Andover,MA 01845 3 5. DESCRIPTION OF TECHNIQUES USED FOR ESTIMATION
Size of Facility:in square teat: 300 _
in number of floors: MPa s rPmPn t
Was the Facility built prior to 19807 yes X no i I 6. ASBESTOS REMOVAL START DATE: 5/2 2/8 9 END DATE: 5/2 4/8 9
Current or Prior use of Facility: Residence I HOURS OF X DAYS OF X
OPERATION: daytime OPERATION: Mon.-Fri.
Is the Facility Occupied? Yes X No I evening Sat.-Sun.
T. FACILITY OWNER I night
Name: SAMETelephone:( ) I (s OTE: Any changes in these dates must be reported to the appropriate regional office.If a removal
postponed for more than thirty (30)calendar days,spearate notification will be required.)
Street Address: City/Town 1 7. DESCRIPTION OF ASBESTOS REMOVAL PROCEDURES TO BE USED
3. ON-SITE MANAGER I X glove bag
full containment
Name: Telephone:( ) encapsulation
Street Address: City/Town enclosurecleanup
disposal only
4. GENERAL CONTRACTOR I other-please describe
Name: NONE Telephone:.( )
Street Address; City/Town 8. TRANSPORTER OF ASBESTOS-CONTAINING WASTE MATERIAL FROM SITE TO TEMPORARY
STORAGE SITE(IF NECESSARY)TO FINAL DISPOSAL SITE
Does this project involve the removal arxVor alteration of any Asbestos Containing Material(ACM) Name: Telephone:( )
as drfined and applied In 310 CMR 7.00 and 7.15? Yes X No Street Address: Coyllown
9. TRANSPORTER OF ASBESTOS-CONTAINING WASTE MATERIAL FROM REMOVAUTEM-
IF Y6S,you must suppy in full the.In formation requested in sections C through E below.IF N0, PORARY STORAGE SITE TO FINAL DISPOSAL SITE
YOU rfiust supply In full the Infonnation in sections D and E. Name:hem1Cal Recovery' Inc. Telephone:(617 }523-7740
Street Address:197 Portland St-. City/To,•rn Boston,_MA 02114
1
d
10. REFUSE TRANSFER STATION FACILITY AND OWNER(IF APPLICABLE)
Name: _ Telephone:( )
Street Address: Cityf7bvm:
Owner's Name:
(NOTE:Transfer Stations must comply with the Division of Solid Waste Regulations 310 CMR
18A0.) FPREPARER OF ORMA
11. FINAL DISPOSAL SITE t Name:ASTEC—_Asbestos Tecbnoloailephone:(603 )8$R-7.400
Name; MeadowfTll Corporation Telephone:( 304 842-2784 I1 Street Address:71 Spit Brunk -Rd -City/Town:_WAagh„a, NH mnFn
Street address: Poute._3 - ,CayfT,,., Clarksburg_WV 26301 �• THIS FORM MUST BE SIGNED BY THE OWNER OR BY THE RESPONSIBLE OPERATOR OF THE PRO-
Owner's
RO-
Ownei s Name: COrpOratlOn POSED PROJECT. i
(NOTE:Disposal ofACM must compywiththe Division dSord Waste Reguiatirx�s 310 CMR 19.00) CI*f�TlP'j.CATION:I CERTIFY THAT I HAVE EXAMINED THE ABOVE AND THAT TO THE BEST OF MY I
KNOW4EDGE IT IS UE���lIIRID COMPLETE.SIGNATURE SUBJECTS SIGNER TO THE PROVISIONS
i 12. FOR EMERGENCY ASBESTOS REMOVAL OPERATIONS.NAME AND TITLE OF DEOE OF- I OF THS GE;RAL T TSS REGARDING FALSE AND MISLEADING STATEMENTS).
i FICIAL WHO EVALUATED THE EMERGENCYI ✓ �y--� President
Name. Title: 1 ' I SidNATURE) (TITLE)
Date of Authorization: ASTr,C—Asbestos Technologies Inc. April 28, 1989
L_ (REPRESENTING) (DATE)
D GENERAL DEMOLITION/RENOVATIONDESCRIPTION
1. DEMOLITION/RENOVATION CONTRACTOR
I
Name: Telephone:( ) I F I REGIONAL OFFICE IACATIONS
I
Street Address: City/Tcwn: I
2. ONSITE SUPERVISOR I I
AIR QUALITY SECTION CHIEF AIR QUALITY SECTION CHIEF
I DIVISION OF AIR QUALITY CONTROL DIVISION OF AIR QUALITY CONTROL I
Name: j I MET BOSTON/NORTHEAST REGION SOUTHEAST REGION LAKEVILLE HOSPITAL
3. SPECIFIC WORKSITE LOCATION(S): f 5 COMMONWEALTH AVENUE MAIN STREET
WOBURN.MA 01801 LAKEVILLE,MA 02347
( TELEPHONE: (617)947-1231
1 I TELEPHONE: (617)9352160 OR 7Z7-1440 X680
I OR 727-5194
1 4. WAS THE FACILITY SURVEYED FOR THE PRESENCE OF ASBESTOS CONTAINING MATERIAL I
(ACM)? yes no r AIR QUALITY SECTION CHIEF AIR QUALITY SECTION CHIEF
WHO CONDUCTED THE SURVEY? I I DIVISION OF AIR QUALITY CONTROL DIVISION OF AIR QUALITY CONTROL i
1 Name:
WESTERN REGION STATE HOUSE-WEST CENTRAL REGION
436 DWIGHT STREET-4th FLOOR 75 GROVE STREET �
Department of Labor and Industries Certification 8: I SPRINGFIELD.MA 01103 WORCESTER,MA 01605
S. DEMOLITIOWRENOVATION START DATE: END DATE MAIL TO:P.O.BOX 2140
TELEPHONE: (617)792-7653
6. DESCRIPTION OF DEMOLITIOWRENOVATION PROCEDURES 70 BE USED TELEPHONE: (413) 785-5327
jI
(NOTE:Demolition/Renovation Operatons must comply with 310 CMR 7.09 to control emissions to For official use only:
i preYera a condition of air pollution.) original resubmittal
7. FOR EMERGENCY DEMOUTIONIRENOVATION OPERATIONS,NAME.TITLE AND AUTHORI- notification incomplete/returned
TY OF STATE.OR LOCAL OFFICIAL WHO EVALUATED THE EMERGENCY
Name- Date cert.mail M
Title:
Authority: Date of Authorization: a
(GENERAL SU.TEMENT.if AsbeskxWonta�Material is to npooedly found or damaged during a Derndi_ �.
IaNfirxiovalan operation.all responsible parties must comply with 310 CMR 7.00,7D9,7.15 and Chapter