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HomeMy WebLinkAboutMiscellaneous - 38 BRADSTREET ROAD 4/30/2018', I N J, J 1 � � II4� o � '. � z' m� o � 0 0 o D 0 0 , E C 01,J?O Name (B, Address: www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. City/State/Zip: Phone #: 1J.C, 174 Are yo employer? Check the appropriate box: Type of project (required): 1. I am a employer with employees (full and/or part-time).* %. 0 New construction .2. F] I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] 3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 9. El Demolition 10 ❑ Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. Q Plumbing repairs or additions 5. ❑ I am a general contractor an12. um d I have hired the sub -contractors listed on the attached sheet. 12. PlumRoof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *`Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. Ifthe sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. n n 1 Insurance Company Policy # or Self -ins, Lie. #:_ nC-. Expiration Date: Z G I Job Site Address: Eq) � bT(( T— �A 1 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 MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover�f!Ad on. 4�\ I do hereby ify ugdjVXpai�V an 4penalties ofperjury that the information provided above is true and correct. Of use only. Do not wriVin this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 `< - t Boston, MA 02114-2017 Name (B, Address: www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. City/State/Zip: Phone #: 1J.C, 174 Are yo employer? Check the appropriate box: Type of project (required): 1. I am a employer with employees (full and/or part-time).* %. 0 New construction .2. F] I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] 3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 9. El Demolition 10 ❑ Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. Q Plumbing repairs or additions 5. ❑ I am a general contractor an12. um d I have hired the sub -contractors listed on the attached sheet. 12. PlumRoof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *`Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. Ifthe sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. n n 1 Insurance Company Policy # or Self -ins, Lie. #:_ nC-. Expiration Date: Z G I Job Site Address: Eq) � bT(( T— �A 1 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover�f!Ad on. 4�\ I do hereby ify ugdjVXpai�V an 4penalties ofperjury that the information provided above is true and correct. Of use only. Do not wriVin this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): i 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 liire, 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 not because 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 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-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 Depaftment of industrial Accidents foi• 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 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 permitilicense 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and.fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR egistration: <A66661 Type: Corporation :Expiration 6/2 P EDMUNDS GENERAUCONTR-CTT ING, LLC. DAVID EDMUNDS `- 18 ASHFORD RD HAMPSTEAD, NH 03841 Undersecretary z License or registration valid for individul use only before the expiration date. If found return .to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not MA' ut signature to 9/24/2015 Paybill - External Post Application Submitted Your application has been submitted and all fees have been applied to your credit card. Please print this page as your proof of submission and receipt of payment. tApRication Information Date Submitted: Thursday, September 24, 2015 Applicant Name: DAVID C EDMUNDS License Number: CS -104728 Agency: MADPS Process: Renew License process Payment Information Authorization Code: Received Date: Received Amount: 01718G 9/24/2015 3:07:23 PM $100.00 Massachusetts _��-- 8oar`q of department of 'public S Suilding Regulations afety Construction and Standards Supervisor 1. icense:,'CS_104728 DAA C ED11�7NS:. P.O. BOX 2214 ® ;. 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O N a� coo (D (D !� X@ cu a� -r- L A N F E _ @ Y D _ O cco O p N j. c a -D ro 3 0) N. @ O O -o C U {^�, I- N o CO � N N V O N O IT rvc Ca) 0� U U @ +' O O a) C O> > v 4 N N co C 7 N C @ O C (D Z. @ _ p O E N a) L U U N V d j''„ 2.w N C7 al !- -E 47 ++ C N U O N @ Q Q. @ d op •. m opt N o o 3 Q u UL.. W co O .N d • : Ij Date . oI..I.. t.,.A ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform .... C...�°,.(vN D e.� .......................................................... wiring in the building of..........lo S �1�. ........................................................................ 41t ..... �Dw.........'..:...................PICAL rth Andover, Mass Fee .... ......... Lic. No. ,tM .... . ` ?ELEC INSPECTOR Check#�� 12459 ;y �ramonsifeallli o�� Official Use Only aLJePartrn¢nt o�._iare �erriice! Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7A �� City or Town -of: A & To the Inspector of Wires.- By Yires:By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) 3 F 4 17Re'�- cC Owner or Tenant CAL54 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box). Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ('mmnlofinn nfihn fnlTnw...n r..1,l0 ... , rr.., r..--- r.,...,riv;.. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires n- Swimming PoolAbove ❑ I ❑ d. d. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons Alerting No. of Devices g No. of Waste Disposers Heat PumpNumber Totals: Tons IKW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water _ IZ�78 Heaters No. of No. of SignsBallasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Fquivalent OTHER: Estimated Value of Electrical Work: nuacn aaaufonai aetait y desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this app ca ' n ' e and complete FIRM NAME: DAV I Q E L G & T R i (_A L_ CCN 7F_P AC ( LIC. NO.: Licensee: L�7 Signature cI (Ifapplicable, enter "exempt" in the license mrmber line) Bus. TeL No.:cl �!� 'tri: � L.� Per M:G_L,. c. 147, s. 57-61, security work requires Departrnetti of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required Owner/Agent law. By my signature below, I hereby waive this requirement I am the (check one ❑ owner ❑ owner's a ern ent Signature Telephone No. PERMITTEE: $ The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST City/State/Zip: NORTH ANDOVER, MA 01845 Phone #: 978-682-6262 Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 8 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have A no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. F] Manufacturing 11. ❑ Health Care 12.❑ Other ELECTRICAL CONTACTING "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Pdlicy # or Self -ins. Lic. # 9353694 Expiration Date: MARCH 1, 2015 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 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 Dr ins t an overage verification. I do hereby certify, nd the i sand penalties of perjury that the information provided ab ve is ue d correct. Signature: ._Date: i17 GS26:21.-2-- Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #• www.mass.gov/dia Date � ,�'v { �................ TOWN OF NORTH ANDOVER t PERMIT FOR WIRING' This certifies that .....J �SP SSS has permission to perform ..... .CE' 2r, -,.n2'., , ..................................................................................... wiring in the building of .� rlJ................................................................:............. at ...._. � oe* � � : -North Andover, Mass.... ............. .........C.... Fee.t)......... Lic. NoU& f . f (AELECTRICAL INSPECTOR Check # . '� T 11 593 Commonwealth ®f Massachusetts Official Use Only Department of Fire Services Occupancy No. ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev -1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code "C), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL )NFORMATION) Date: City or Town of. NORTH ANDOVER To the By this application the undersigned gives n ' e of his o e on t erfo tl Location (Street & Number) er Owner or Tenant 1 N Y I,/o Owner's Address I3 o Wires: work described below. Telephone No. t '� Is this permit in conjunctioiiwith a building permit? Yes U No Lt -r (Check Ap ro riate Sox) \\ Purpose of Building Utility Authorization No. 1pV Existing Service Amps ,% / Volts Overhead Undgrd ❑ No. of Meters New Service Amps Z/ %/i Volts Overhead © Undgrd ❑ No. of Meters Number of Fee ers and Am aci P tY Location and Nature of Proposed Electrical Work: Cmmnletinn nfthe fnllnwing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No, of Ceil: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lig ting Batteryits NO. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons ._.. KW ....................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Systems:' SecuritNo. o or E uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs - Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: /S Si nature LIC. NO.::i& (If applicable, er " xe " ' e imber ' e.) Bus. Tel. No.: Address: • Alt. Tel. No. *Per M.G. . 147, s. 57-61, securi work requires Department of Pub is a " License: Lie. No. � " OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. til rC,OMMONWEALTH,O.F.MASSACHUS S _ ELECTRICIANS,. i- > 1 AS. A REG, 'JOURNEYMAN ;ELECTRICIA�! ISSUES THE ABOVE LICENSE TO , } s d' )1)SCWNMGRASSIS n: 19. NORTH+ S�T..o ` AIJDOVFk'f,yn�MA 01`810 110 ,5, A 86233[- E Environmental / Demolition Contractors Commercial / Industrial / Residential February 12, 2013 Town of North Andover Health Department 1600 Osgood Street, Building 20, Unit 2035 North Andover. MA__ -01-845 ATS Susan Y. Sawyer, Director of,,Polic Health E: 38 Bradstreet Road, North Andovef, MA Ms. Sawyer: Please find enc ose a copy of the Asbestos Notification Form ANF -001 with respect to the above captioned property. Kindly contact us with any questions or comments you may have. Very truly yours, Susan A. Pappalardo E & F environmental 86 Carolan Avenue Hampton, NH, 03842 Office: 603-974-2503 Fax: 603-382-3376 "86-CAROLAN AVE, HAMPTON, NH 03842 (603)974.2803 FAX: (603)382-3376 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 INSTRUCTIONS 3. 1. All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 CMR 7.15 5 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 6. 7. 8. 9. Worksite Location: BASEMENT a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room Is the facility occupied? ✓❑ Yes ❑ No Asbestos Contractor: E&F ENVIRONMENTAL SERVICES LLC a. Name HAMPTON 103842 c. Ci frown d. Zip Code AC000767 f. DOS License Number h. Facility Contact Person FRANK BALOGH a. Name of On -Site Supervisor/Foreman N/A a. Name of Project Monitor FLI ENVIRONMENTAL, INC. a. Name of Asbestos Ana ical Lab 2/22/2013 a. Pro'ect Start Date mm/dd/ 17.4 c. Work hours Mon -Fri 10. a. What type of project is this? ❑ Demolition ❑ Renovation ❑ Repair 0 Other, please specify: 11. a. Check abatement procedures: ❑ Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑ Other, specify: ❑✓ Full containment 86 CAROLAN AVE b. Address 6032345581 e. Telephone Number g. Contract Type: ❑ Written ❑ Verbal REMOVAL b. Describe b. Describe 12. Is the job being conducted: Q Indoors? ❑ Outdoors? anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 FIF-61 2 G 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Important: A. Asbestos Abatement Description p . When filling out forms on the computer, use 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied only the tab key residence of four units or less? Q 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: RESIDENCE 38 BRADSTREET ROAD a. Name of Facifily NORTH ANDOVER b. Street Address 101845 c. Cityrrown d. State e. Zip Code f. Telephone Number INSTRUCTIONS 3. 1. All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 CMR 7.15 5 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 6. 7. 8. 9. Worksite Location: BASEMENT a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room Is the facility occupied? ✓❑ Yes ❑ No Asbestos Contractor: E&F ENVIRONMENTAL SERVICES LLC a. Name HAMPTON 103842 c. Ci frown d. Zip Code AC000767 f. DOS License Number h. Facility Contact Person FRANK BALOGH a. Name of On -Site Supervisor/Foreman N/A a. Name of Project Monitor FLI ENVIRONMENTAL, INC. a. Name of Asbestos Ana ical Lab 2/22/2013 a. Pro'ect Start Date mm/dd/ 17.4 c. Work hours Mon -Fri 10. a. What type of project is this? ❑ Demolition ❑ Renovation ❑ Repair 0 Other, please specify: 11. a. Check abatement procedures: ❑ Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑ Other, specify: ❑✓ Full containment 86 CAROLAN AVE b. Address 6032345581 e. Telephone Number g. Contract Type: ❑ Written ❑ Verbal REMOVAL b. Describe b. Describe 12. Is the job being conducted: Q Indoors? ❑ Outdoors? anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 �N �o �o �N �o 0 0 �o =LL �l� z 1Q Commonwealth of Massachusetts Asbestos Notification Form ANF -001 A. Asbestos Abatement Description (cont.) ■ 100172178 Decal Number 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 110 0 a. Total pipes or ducts (linear ft) D. I otal o er su aces square 14. Describe the decontamination system(s) to be used: FULL CONTAINMENT c. Boiler, breaching, duct, tank d. Insulating cement surface coatings Lin. ft. e. Corrugated or layered paper 110 pipe insulation Lin. ft. Lin. ft. Sq. ft. g. Spray -on fireproofing Lin. ft. i. Cloths, woven fabrics Lin k. Thermal, solid core pipe j. Other, please specify. insulation Lin. ft. 14. Describe the decontamination system(s) to be used: FULL CONTAINMENT 1. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (a): 16. ALL METHODS WILL COMPLY I For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: N/A a. Name of DEP Official b. Title d. DEP Waiver # t. DOS Taal Title h. DOS Waiver # 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes QQ No B. Facility Description 1. Current or prior use of facility: RESIDENCE 2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No MATTHEW WELCH 6 COUNTY ROAD 3' a. Facility Owner Name b. Address IWINDHAM, NH c. Ci /Town N/A 4' a. Name of Facili c. Citv/Town ■ anf001ap.doc • 10/02 II d. Zip Code Asbestos Notification Form • Page 2 of 3 0 d. Insulating cement Lin. Sq� f. Trowel/Sprayer coatings Lin. ft. Sq. ft. h. Transite board, wall board Lin Sq. ft. j. Other, please specify. Lin So. 1. Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (a): 16. ALL METHODS WILL COMPLY I For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: N/A a. Name of DEP Official b. Title d. DEP Waiver # t. DOS Taal Title h. DOS Waiver # 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes QQ No B. Facility Description 1. Current or prior use of facility: RESIDENCE 2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No MATTHEW WELCH 6 COUNTY ROAD 3' a. Facility Owner Name b. Address IWINDHAM, NH c. Ci /Town N/A 4' a. Name of Facili c. Citv/Town ■ anf001ap.doc • 10/02 II d. Zip Code Asbestos Notification Form • Page 2 of 3 0 Note: Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 �O 0 C C C LL Z �Q Commonwealth of Massachusetts Asbestos Notification Form ANF -001 B. Facility Description (cont.) N/A 5' a. Name of General Contractor c. City/Town d. Zip Code f. Contractor's Worker's Comp. Insurer 6. What is the size of this facility? 100172178 Decal Number 17 b. Address e. Telephone Number area code and extension g. Policy Number h. Exp. Date mm/dd/ y a. Square Feet b. Number of floors C. Asbestos Transportation. and Disposal 1. Transporter of asbestos -containing material from site to temporary storage site (if necessary): E & F ENVIRONMENTAL SERVICES, LLC a. Name of Transporter HAMPTON, NH 03842 c. City/Town d. Zip Code 86 CAROLAN AVENUE b. Address 6039742503 e. Telephone Number 2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site (SERVICE TRANSPORT GROUP, INC. 158 PYLES LANE a. Name of Transporter c. Position/Title b. Address NEW CASTLE, DE JE & F ENVIRO 18779999559 c. Ci /Town d. Zip Code e. Telephone Number 3. HAMPTON, NH a. Refuse Transfer Station and Owner b. Address c. Ci frown d. Zip Code e. Telephone Number 4. IMINERVA ENTERPRISES INC a. Final Disposal Site Location Name b. Final Dis osal Site Location Owner's Name 9000 MINERVA ROAD 1 IWAYNESBURG c. Final Dis osal Site Address d. City/Town OH 44688 e. State f. Zip Code g. Telephone Number D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. FRANK BALOGH IFRANK BALOGH a. Name OWNER b. Authorized Signature 2/11/2013 c. Position/Title d. Date mm/dd/ 6039742503 JE & F ENVIRO e. Telephone Number f. Representing 86 CAROLAN AVENUE . Address HAMPTON, NH 03842 h. City/Town i. Zip Code E anf001 ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 N