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Home My WebLink AboutMiscellaneous - 33 UNION STREET 4/30/2018N O � C O Z O O W Z cn om o 0 Claim # 2265503 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings Town Hall North Andover, MA 01845 Re: Insured: Donna J. Hayes Property address: "32 Union_St. } V f a North Andover, MA 01845 Policy #: 2265503 Loss of: 2012/09/10 File or Claim No. AD 9731 Board of Health Board of Selectmen Town Hall North Andover, MA 01845 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass._Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_ Gen_ Laws, _Ch. _139_Sec. _3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 09-10-12 Signature and date Claim # 2211833 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings Town Hall North Andover, MA 01845 Rc: Insuzed: 32 34-& 3 on St Property address: 32 Union St. North Andover, MA 01845 Policy #: 2211833 Loss of: 2012/09/10 File or Claim No. AD 9732 Board of Health V/ Board of Selectmen Town Hall North Andover, MA 01845 Condo Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._ Laws,_ Chapter_ 143,_ Section _6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 4� 09-10-12 Signature and.date - 3 PATRICK J. DONOVAN ASSOCIATES, INC. elaim and Jass Aiiastments P. 0. BOR 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 — FAX (781) 245.7016 April 19, 2001 Building Commissioner City or Town Hall North Andover, MA 01845 Insured Property Address Insurer Policy Number Type of Loss Date of Loss Our File # : Patricia Johnson 33 Union Street, North Andover : Hingham Mutual Insurance Company : H09927064 Fire 4/18/01 WAP32337 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. �Lz ern Laws, Adjuster VL/so ASSOCIATION OF INDEPENDENT INSURANCE 11JI)STERS of Massachusetts �s° N° is. 4. 5 '} NORTIy Of • �4, O p +'++r�o ••'�qh �SSACMUS- Date.... ....�. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING n This certifies that :�................ has permission to perform ......... L tom .; ................... . a plumbing in the buildings of ............... • ..... . at. ................ . North Andover, Mass. Fee ......... Lic. No.! ............ . PLUMB fNG INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ' (Print or Type) 1i /L) A Mass. Date )4 192�_ Permit # Building Location 33 (),/)I /1 S I Owner's 10 1 "i -bo �� 2i M A O (a 4,7 Type of New ❑ Renovation ❑ Replacement 2 -11 FIXTURES r fft Installing Company Name 1' tlEel 1- M d T A e Q Check one: Certificate address A (� C0 4 c H /)' 4 &) s- Pi ❑ Corporation /Y) E % N l ' F_ n 0 ill r<a,❑.,, Partnership Business Telephone -�7� Z -i9L7 1 -Wff-n/Co. Name of Licensed Plumber 14 rK oO INSURANCE COVERAGE: I have a current I' biiity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, ple�ase/indicate the type coverage by checking the appropriate box. A liability insurance policy 1d" 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: 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral laws. Title re of Licensed Plum r Type of License: Master Joumeymah C3City/Town _ APPFIONED O FICEUS ONL License Number Y33 I �IN • Y • • JUCE fft Installing Company Name 1' tlEel 1- M d T A e Q Check one: Certificate address A (� C0 4 c H /)' 4 &) s- Pi ❑ Corporation /Y) E % N l ' F_ n 0 ill r<a,❑.,, Partnership Business Telephone -�7� Z -i9L7 1 -Wff-n/Co. Name of Licensed Plumber 14 rK oO INSURANCE COVERAGE: I have a current I' biiity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, ple�ase/indicate the type coverage by checking the appropriate box. A liability insurance policy 1d" 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: 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral laws. Title re of Licensed Plum r Type of License: Master Joumeymah C3City/Town _ APPFIONED O FICEUS ONL License Number Y33 I z 0 I" m m IW m r O 0 0 m c N m 0 z r'! u aIle GJir '.tell6umfffi of �� r�ss�IcCllt�c � DEPARTMENT OF LABOR AND INDUSTRIES } DIVISION OF -INDUSTRIAL SAFETY (In accordance with the IJOTIFrt,ATxON OF ASBESTOS : 0pr pro All sections of this visions of N.C.L. c. form mu14.9, §5-6F and 453 C::R 6.12) st be compZ�ted in order to coc the notit�Ecation requirements o" 453 CALR 6.12 ply witr TEN DAY P4IOR NOTSFICATICN IS REpUIRED OF ANY•ADA7ZUENT PR0.7EC71 CRcATER TITAN THREE (3) LINEAR OR SQUARE FEET • DLI PILE NUMBER Contractor perforr�irg project_AIR QUALITY EXPERTS, INC • License „ AC 000 16 7 Do prev412irg rates of wageg .•a 27 pply to this y under•X.C.L c. 149;X26, or. Project as reggjred ` 27F? (circle oreJ A�'S ddress ot..Pro ect • Bui2d,ing•Name (if any) Street Address• City • Zip_ �=� 5 Phone S o (0 G2i p72 Project type (circle one): DEMOLITION ` E QVATION Sf 'Other• selected, . CTBSR please explain ex --� Asbestos Activit y.(circle one): E1LCA.DSULA7•I0'v ASSOCIATZD PRQ7ZCT • - -ENCLOSURE . ZZ EPI indicate amount of: asbestos surface on pipes or, ducts /20 OR LINEAR. PEST PiPes or ducts to beasbestos surface on zQmoved,• enclosed or encapsulated. _., tructures otter than Start date c/ FEET an. �. Con. ple-Jon Date pm--- -_ weekends? 7•iy.9a No Project Supervisor Name CHRISTOPHER THOMPSON AsbesCosMal "rtjficate y SF06466 ytical Lab Name FINAL CLEARANCE A_ NLYS _` Certificate ,N AA000085 Address of disposal site(s)TURNKEY LANDFILL -� 90 ROCHESTER NECK RD. 00C9a/1 ROCHESTER NH 03867 i,. N r • r . •''CStOS CW:.. J . or- vcrb4l7 , ff E Cnnz.;jccor'a workers' Conpensacion 17n•surer COMMERCIAL UNION Policy mumbbcr ., CM91H548299 ?ac1Zi.�y Owner Am Address city State �i p r`-9cr_pC1o1k of work practicas to be followed: ALL WORK WILL BE DONE IN_.COMPLIANCE WITH LQC.A�, 'STATE AND!FEDERAL REGULATIONS -:riptio.7 of deconCamiration system(s) Co be used cscr1pC3on•of handling/disposal methods to comply with 453 CPR 6.14(2J•(gJ WET REMOVAL INTO EMIL POLY DOUBLE ASBEST'08"LLED' BAGS. -1me and address of transporters) it octJcr than the asbestos contractor: unda=igned hereby states, under the penalties of perjury, .that helshc has -- :,3d and 'understood the Co=..onw--alth of Massachusetts Regulations for the :I:oval, Containment or &Icapsulation of Asbestos, 453..61?R 6;:00, and that the .farmaCidiV`Contained in this notificatioD is true and correct to the best of sjhcr knowledge and belief. C Signed: Title: klnT— Compan y : ll &L l 7• �-/ 9Ct'�->�i2 S �, r 3 Q� rtll' u0 oa Lf •as return this form to: S.�L_ LIVI '?q Asbestos Control Tect,nical Services bment of Labor aIndus rd ttieS. ... Division of Industri:l._S-dfety' 300 Cam.hr.idcc..Sr~r�et, Room 1101 Dos ton, HA 02202 Massachusetts Department of Environmental Protection /J Bureau of Waste Prevention — Air Quality ./ I Transmittal i BWP AQ 04 Asbestos Removal Notification BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos Facility 10 (if knoi.,:� . Telephone Asbestos Removal Description I. Asbestos Contractor /l r......:.....� fS ............. Name .............3..........1...1:... N i w G O ;� ,? ✓ C� . ................................................................. Address Rev. 1/91 ---- � k 9 M U 3 c '7 61 rryAown Telephone ...... lkparbnent of Labor and Industries License Page 1 of 4 ��.�,,.......... : r Applicability Permit No ......................... Received Date ................... Reviewer-- Demolition/Renovation operations involving asbestos- renovation operations and demolition/renovation operations Permit 0Appr. 0 Denied containing material (ACM) and general DemoMionlRenovation 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 —. 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/ 13 General Project Description 1. Facility UiJlq/Q ................................................................................. 3. On -Site Manager Nara: ,,11 .0 Grd S— Address A% Nara .......................................................................:.................................... ................................................................................................................ C!ry/Town Address ....'............3 ............................... ................ ............................................................................................................ Telephone . City/Town . Size ............................................................................................................... Telephone ..........:.....U...G.......................................................... svuareieer 4. General Contractor ............................................................................................................ Number of floors Nara ----- -- --- Was the Facility built prior to 1980? 2-9es 0 No -- Address Cmn:nrorPrioruseolfacllily — WON -....... Is Is the Facility Occupied? 2r Yes 0 No Is this Facility Owner-OccupiedRe idenGal with 4 units or less? Aes Telephone 0 No 2. Facility Owner Does this project involve the removal and/or alteration of any Asbestos Containing Material (ACM) as defined and ................................''?..E........................................................... applied In.310 CMR 7.00 and 7.157? Name 2/yes E3 No ....................................:....................................................................... Address If Yes, complete Sections C and D ............................................................................................................ If No, complete Sections D and E. ciry/roKn Telephone Asbestos Removal Description I. Asbestos Contractor /l r......:.....� fS ............. Name .............3..........1...1:... N i w G O ;� ,? ✓ C� . ................................................................. Address Rev. 1/91 ---- � k 9 M U 3 c '7 61 rryAown Telephone ...... lkparbnent of Labor and Industries License Page 1 of 4 'vid.wChuseffs w jai imeat of [nt,i; c;,E„«„fal Protection Bureau of Waste Prevention ; Air Quality Transmittal ,� BWP AQ 04 Asbestos Removal Notification BWP AQ 06 Notification Prior to Construction or Demolition .... Permits for Asbestos Facility iD (if kno.: 2. On -Site Supervisor 7. Description of techniques used for estimation CN,�is.r•o1-714E�{ �'�o.M�.;o�J TAPS kame ' o616b DoWnent of LaWf and tndusbles Certification 3. Hygienist ........r.i. !. �a..c..... s:..�.k A c . �.n..4.. e ........ �r A.� /.. s'.i. �...... Name 4. Specific Worksite Locations(s) (i.e. Building name, ` number, wing, floor, room, tunnel.) ....................................................................... 5. Is the job being conducted indoors or outdoors? i'nf DO 6. Estimated amount of Each type of ACM to be handled Linear /Square Feet boiler, breeching, duct, tank surface coatings / ............................ thermal, solid core pipe insulation / ............... corrugated or layered paper pipe insulation /, U / ............................ insulating cement / spray -on fireproofing / trowel/sprayer coatings / cloths, woven fabric / ............................ transite board, wall board / other- please describe / ............................ Total in Linear Feet );0 / ............................ Total in Square Feet / Rev. 1/91 8. Asbestos Removal ........�.........Y......(.................................. . Staff Date ......................................... :7.. ....... !..�..:...2..�...................................... End Date " Hour of.pperation �. daytime ❑ evening ❑ night aeon.0-- Operation Fri. ❑ Sat.— Sun. (Note: Any changes in these dates must be reported to the appropriate regional office. If a removal is postponed for more than thirty (30) calendar days separate notification will be required.) 9. Describe the asbestos removal procedures to ed. ❑ glove.bag ❑ enclosure 0<11 containment ❑ cleanup ❑ encapsulation ❑ disposal only ❑ other -please describe 10. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal site Page 2 of Massachusetts Department of Environmental Protection Bureau of Waste Prevention-: Ak Quality BWP AQ 04 Asbestos Removal Notification BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos 11. Transporter of asbestos -containing waste material from removal/temporary storage site to final disposal site QUAD Name 3 -woV Sheet Address — Civrown Telephone 12. Refuse transfer station facility -and owner (if applicable) Name Address citylrown ........................................................................... Telephone ................................................................................................ Owner's Name (Note: Transfer Stations must comply with the Solid Waste Division regulations 310 CMR 18.00.) 13. Final Disposal Site Transmittal 1 .................................. Facility 1D (if knov,,, ' ...iw.`,L...... !U 2 .!...�=./ ......... . Name 90 l� or�arsrcaJ Eco ......................................................r.,...=......... Address City/rown .:::::_::.......... .o.......... 3.3 ...............3..:: '........................ Telephone i,� rtj .................................... 0..E:.... Owners Name (Note: Disposal of ACM must comply with the Solid Waste Divisions regulations 310 CMR 19.00.) 14. Emergency Asbestos Removal Operations DEP official who evaluated the emergency: ................................................................................................I............... Name ............................................................ I................. Title. .............................................................................. Authority ............................................................................. Date o/Aulhodzation General Demolitionmenovation Description 1. Demolition/Renovation Contractor 4. Was the facility surveyed for the presence of asbestos containing material (ACM)? Name -- ❑ Yes ❑ No If yes, who Conducted the Survey? Address city/Town Telephone 2. On -Site Supervisor .................................... Name 3. Identify the specific Worksite Location(s): Rev. 1/91 ................................................................ ........................................... Name`-. ............................................................................................................... Deparbnent o/ Cahor and Industries CeAilicalion 5. If yes, who conducted the survey? Name Departnenl of Labor and Industries Cerlilkifion f 6. Demolition/Renovation Asbestos Removal Start Dale ............................................................... End Dale Page 3 of Massachusetts Department of Erl. ,;omental Protection Bureau of Waste Prevention —Air Quality BWP All 04 Asbestos Removal Notification BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos 7. Describe the demolition/renovation procedures to be used: (Note: Demolition/Renovation Operations- must.compiy with 310 CMR 7.09 to control errissloris to prevent a condition of air pollution.) 1v Transmittal � ............................... . Facility ID (, ` kn o v_ 8. Emergency Demolition/Renovation Asbestos Removal Operations State or local official who evaluated the emergency: Title •AUthGlTly . ---- - -- - --_------- Date DIAMDfinfion (General Statement: If asbestos -containing material is unexpectedly found or damaged during a Demolition/Renovation operation, all responsible parties must comply with 310 CMR 7.00, 7.09, 7.15 and Chapter 21 E of the General Laws of the Commonwealth. This would include but would not be limited to filing an asbestos removal notification with the Department and/or a notice of a releaselthreat of release of a hazardous 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). /............:.... ....................... ..� i...............�. Pdnl Name Avbodzed S/pnalure Es SEN UAB EX�°E r nl� ............................................................................................/.:.............�x....:....................................Iz......5.................."......................... Posilion/Tilie Aeptesedn' d -/-�z .............................................................................................. Dale Rev. i/9i Page 4 of . v Air Quality Experts, Inc. 349 So. Broadway • Suite #8 Asbestos Removal Christopher Thompson Salem, New Hampshire 03079 Residential • Commercial • Industrial APRIL 29, 1992 NO. ANDOVER BOARD OF HEALTH 120 MAIN STREET NO. ANDOVER, MA 01845 DEAR SIR: ENCLOSED PLEASE FIND COPIES OF D.E.P AND D.L.I. NOTIFICATIONS FOR ASBESTOS ABATEMENT WORK TO BE PERFORMED ON MAY 18, 1992. IF YOU HAVE ANY QUESTIONS CONCERNING THIS MATTER PLEASE CALL!! THANK YOU, 1 �I✓'� i S �r:`n ju v j CHRISTOPHER THOMPSON PRESIDENT ,� •• Eji; VJItiI'rE1TE1;cz11fh of �.+ ussadflisciiz DEPIIRTNIENT OF LAhOR AND YNDUSTi2IES DIVISION OF rN7 1 USTLILIAL SAFr--TY NCTrPIC,�TION OF 'ISBESTOS WOp1; lIn•accordance with the provisions of H.C.L.AZZ sectloas of c. 149, S6 -6F and 453 C:R 6.I?) this. 'forma' oust be comp1�ted in order tl:e notjfjcation requires�ents of 653 C1&Le 6..Z.2 TEN crjth TEN DAY PRIOR NOTrFICATICN GREATdR 7 -,AN IS Ra THREOU1RED OF AlJY•ARATZI.IZNT T PRW=.CE (3I LXREAR OR SbUARr FEET DLI i?LE 1JUNBER Certractor performing Project _A jIR_ QUALI-TY EXPERTS, INC. Zicense y • ' AC 0 0 016 7 o preva;ilirg ;ales of waged .aop1y to this � . under•H.C.Z c. 349, §26' projec- as teQuired 27 or.27F? (circle one, AddressYES ?�O. of..P_o• ect Buildin' any) 9' Name (if an 11 -• AV, Street Address* �� n U.N 0nl .57- city r! Np o ✓ E /� .Zip :: i- C - Phone U ProjecC hype (circle one): DEFfOI,.T 1'.rON 'NOVATIO 'T f ether.' selected -PAIR OTBER .•please explain Asbestos Activity:. (circle one ): ENC1L°SULA71-ON Et CLOSURE . Indicate amou AS-50CXATZD pRCJ-PCT nt of: asbestos surface on PiPes or ducts• / ,� Q ..OR LINEAR FEET Pipes or ducts to beremovedasbestos surface on , enclosed or encapsulatedq FEET structures other that start c'ate an � Conpletlon Da to l n n Pm--�_____ weekends? A) n Project S --- upervisor Na,re CHRISTOPi-JJ?I� 'I'iIOMI',;ON 1lsbestos — - --__ Lerti- icate // SF06466 Analytical Lab Name FINAL CLEAR__ANCE A_ NLyS CertiPicat t&7rle �� e IJ: AA000085 6 Address of disposal site(,, TURNKEY LANDFILL 90 ROCHESTER NECK RD. OOC ROCHESTER, NH 03867 r ,. ..,�•ytUs CW:��J�� __ �t`n or' vc�.'�n17 � �'v�% � � �•� .,, Cnn�r�ctJr's s✓orkcrs • ConpCnc„cton Z7l:i.,i COMMCP.CIAL UNION Policy Number CM91H548299 — ocil!ty ovncr ddresa City state Zip scr_pL_or1 of work practices to be folloc.-cd: ALL WORK WILL BE DONE IN.COMPLTANCE WITH LOCAL, STATE AND -FEDERAL REGULATIONS riptioa of decontamjrat.ion system(s) to be used AJ C :-escripC 0d of handling/disposal methods__to comply with `453 CPR 6.14e2) -(g) WET REMOVAL INTO 6MI.L.-P01Y DOUBLE ASBESTOS LABELED BAGS. me and address of transporters) i� oth.:r than the 'asbestos contractor: %a unde=s.fgncd hereby ,tater, under the penalties of perjury, that he/shc has" :ad and understood the CorunonaQalth of Massachusetts Regulatior_s for the :rrOval.- COntair✓r:ent Or EIcapsLvlaCion of 1IsLestos, 453..&.8 6.:00, and that the fornation``conCain ed in this not.ificatic» is true and. correct to the best of s%hcr knovled9e and belief. L/�Jl tc 1. / �/ Signed: �. %Vl /C: TICle: Company: - I S (- J rJ iL J�7' u� oa LJ L � s return this form to: ✓ .� L- L!� , ll1 ` �-�-• Q. j v .7 Asbestos Control 9'cc';nical Services rt'•nent of Tibor ar:d Industries... 1 Division of 1ndu cL-Jj1_Saf, 100 C.�m!�ridcc..Str e�, Room 1101 VosCon, ifA 02202 >>/2" ' T.�:VEP For'DU UtrOnly•••••••••••••••+ Perm No. ........................ i Received Date . ................... : Reviewer._. Permit p Appr. O Denied Decision Date Rev. 1/91 Massachusetts Department of Environmental Protection p Bureau of Waste Prevention —Air Quality - - Transmiral ' BWP All 04 Asbestos Removal Notification - --- BWP AQ 06 Notification Prior to Construction or Demolition Facility ID (i( knot•.. Permits for Asbestos ' Applicability Demolition/Renovation operations involving asb!� :Ios- containing material (ACM) and general Demolitic,r,'Renovation operations are regulated by the Department of E;: ;ronmental Protection (DEP), Bureau of Waste Prevention —'. i.. Quality Division, under Regulations 31*0. CMR 7:00; 7:0 .;nd 7 15. Notification to the REGIONAL OFFICE of general J.:molition/ General Project DescriptiR n 1. Facility I��1..✓..t.��........ �. j ..... ................................ Name.•/ Address...................................... ....lv 1 o v'E �- CiWDwn ........................................... !.......... ............................... Telephone Size .00 ........................................................................................................... Square reel ..............................:..................................................................... Number of floors Was the Facility built prior to 1980? C: Yes 0 No .Es...-:.E..C....................................... Curren) or Prior u or Fxilify Is the Facility Occupied? t3 Yes ❑ No Is this Facility Owner -Occupied Resordial with 4 units or less? es O No 2. Facility Owner ................. :. �1...6 ................................................. Name ................................................................................................... Address ................................................ . .......................................................... Cily/ToKn ............................................................................................................ Telephone Asbestos Removal Description 1. Asbestos Contractor. Name .............. lr . Address.............................. renovation operations and demolition/renovation operations involving ACM is.required under 310 CMR 7.09 (2) and 310 CMR -71.5°(1) (b) twenty (20) -days prior to any work being performed. The following information is required pursuant to 310 CMR 7.15. 3. On -Site Manager ............................................................................................................. Name Address :.�x...:................................ ::::........................................................... . Ciwpwn ......................................................................................... Telephone 4. General Contractor Narre Address Clfy/Town Telephone Does Does this project involve the removal and/or alteralion of any Asbestos Containing Material (ACM) as defined and applied In 310 CMR 7.00 and 7.157? t>'res O No If Yes, complete Sections C and D If No, complete Sections D and E. /\J Ciry/Town ... . —___— --- -- — _.... —................... Telephone / v U G ; (, DepaRmenlor Labor and Industries License / — Page 1 of Massachusetts Department of Environmental Protectlon W Bureau of Waste Prevention — Air Quality _ -• Transmittal>h BWP AQ 04 Asbestos Removal Notification -- .................. ' BWP AQ 06 Wotif!cation Prior to Construction or Demolition .............................. Facility ID (i/xr: Permits for Asbestos " 2. On -Site Supervisor _ Name 5')--66y66 Depaftent o/tabor and tndustdes Certititalion r 3. Hygienist - ............. 1 .L, A........C: .f.... 1. .:. ' C .. ......................... Name 0-NI-)I-ysl 5 4. Specific Worksite Locations(s) (i.e. Building name, number, wing, floor, room, tunnel.) ..............................%1............................... ....:... - ....................... ............................................................................................................ 5. Is the job being conducted indoors or outdoors? 6. Estimated amount of Each type of ACM to be handled Linear / Square Feet boiler, breeching, duct, tank surface coatings / thermal, solid core pipe insulation / ............................ corrugated or layered paper pipe insulation (� / insulating cement / ................. spray -on fireproofing / trowel/sprayer coatings / ............................ cloths, woven fabric / transite board, wall board / other— please describe / ............................ Total in Linear Feet Total in Square Feet / ............................ P-:. 1191 7. Description of techniques used for estimation TA P 8. Asbestos Removal .._............. :...................'..................................................................... Start Dale .......................................................... End Dale Ho7s of Operation EY daytime ❑ evening ❑ night Day/of Operation �, Mon. — Fri. ❑ Sat.—Sun. (Note: Any changes in these dates must be reported to the appropriate regional office. If a removal is postponed for more tharrthirty (30) calendar days separate notification v:i be required.) 9. Describe the asbestos removal procedures to used. ❑ glove bag ❑ enclosure full containment O cleanup ❑ encapsulation ❑ disposal only ❑ other -please describe .............................................................................................................. 10. Transporter of asbestos -containing waste material from sit: to temporary storage site (if necessary) to final disposal si!: We ............................................................................................................ Address ................................................................................................ CirylTown ........................................................................... .................................. Telephone Page 2 c T ................... Massachusetts Department of Environmental Protection Bureau of Waste Prevention —Air Quality Transmittal ar BWP AQ 04 Asbestos Removal Notification --- BWP AQ 06 Notification Prior to Construction or Demolition Facility lD (if kno c Permits for Asbestos 11. Transporter of asbestos -containing waste material from removal/temporary storage site to final disposal site Natm n Street Address Ci y/Tom �. _G 3 P� 9 N.— --------- Telephone 12. Refuse transfer station facility and owner (if applicable) --------------.............................................. Name .............. .............................................. I........... Address ........................................................................................... Ciy/Tawn . ................................................................................. Telephone 13. Final Disposal Site .......... T.�.r:�.l�,.!5...`,f ......L.L ....................... Name Ir.S.T-C �� EC r -....f .. .......... ........................................ .............. Address I� i; c 11 ^ b ...................... . CVTown i........................r.......... ..�...:.........:: }....?.... ... (� .................... .z..... Telephone ........: ..................................... . Amens Nacre (Note: Disposal of ACM must comply with the Solid Waste Divisions regulations 310 CMR 19.00.) 14. Emergency Asbestos Removal Operations DEP official who evaluated the emergency: ............................................................................. Nacre .................................................................................................. TWO ........................................................................................................................................................................................................................... Dmees Nano Authonly (Note: Transfer Stations must comply with the Solid............................................................................................................ Waste Division regulations 310 CMR 18.00.) Dateo/Aulhonranon General Demolition/Renovation Description 1. Demolition/Renovation Contractor 4 Was the facili s d f h ty urveye or t e presence of asbestos containing material (ACM)? O Yes O No If yes, who Conducted the Survey? Address ................................................................................................... Name CiyAown --`— .................................................... Telephone --- Departrnenl of Labor and Industries Ce.nili.rali.....on / 2. On -Site Supervisor Nane 3. Identify the specific Worksite Location(s): 5. If yes, who conducted the survey? ........................... ..................................................................................... Name Departrnent of Labor and Industries Certilip6on / 6. Demolition/Renovation Asbestos Removal ....................................... ............................................................... Start Dale FWD* Rev. 1/91 Page 3 of Afas.'ssaciiusetts Deparirrrant of Environnii;ii1J1 Protection Bureau of Waste Prevention —Air Quality BWP AQ 04 Asbestos Removal Notification ' BWP AQ 06 Notification _ Prior to Construction or Demolition Permits for Asbestos 7. Describe the demolition/renovation procedures to be 8. Emergency Demolition/Renovation Asbestos Removal used: Operations State or local official who evaluated the emergency: (Note. Demolition/Renovation-Operations must comply with 310 CMR 7.09 to control emissions to prevent a condition of air pollution.) AbIM Title AuNdly Ne o/Authodialion (General Statement: It asbestos -containing material is unexpectedly found or damaged during a Demolition/Renovation operation, all responsible parties must comply with 310 CMR 7.00, 7.09, 7.15 and Chapter 21 E of the General Laws of the Commonwealth. This would include but would not be limited to filing an asbestos removal notification with the Department and/or a notice of a release/threat of release of a hazardous substance to the Department if applicable.) 13 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(sl Au ..................... .... .......... c....................................'."!...................J................................... ........................... Prin! Name morUed Sipnalure 7 PospioMiUe Rcpresenbnp C ........................................................................................... Date Rev.. i/9t __ -- Page 4 c;