HomeMy WebLinkAboutMiscellaneous - 49 SUTTON HILL ROAD 4/30/2018 (2) I 49 SUTTON HILL RQAD ad
210.1097.0-0015-0000.0
JUN 01,2006 13:24 17816431255 Page 4
DI DLE Y ASBESTOS REMOVAL
P.O.Box 132
Mington,MA 02476
(A division of Dudley Services,Inc.)
Tel:781-643-4328
Fax: 781-643-1255
wwwAtidleyasbestas.com
MA Lic.# ACG 000112
RECEIVED
JUN ' Z 2006
TOWN OF N
Date: / D (v HEALTH RTI r UEpARTMENTER
Ta• Board of Health
o
Enclosed,please find copies of the Division of Occupational Safety and the Dept.of
Environtnental Protection fenn ANF-001 for an asbestos abatement project
to be performed in your city/town. Please feel free to call if you have any questions.
Sincerely,
Sa ,. tgtn III
SPECIALIZING IN RESIDENTIAL;AND COMMERCIAL
ASBESTOS ABA MMENT
JUN 01,2006 13:23 17816431255 Page 1
Commonwealth of Massachusetts
�ibb033616 ---�
Asbestos Notification Form ANF-001 Decal Number
Important:
When filling out A. Asbestos Abatement Description
forms on the
computer,use 1. a:is this facility fee exempt-city,town,district,municipal housing authority,owner-occupied
..
only the tab key residence 4f four units 4r less? ✓ Yes U NO Blanket
Decal'Number
to move your
cursor-do not b.Provide blanket decal number if applicable: _._....._.................._.._..._._.__._.._._._._........___.......__.........
use the return
key' 2, Facility Location:
-:--
"f
II4..----- __..._ T ---
--- ... . .
D DR.ROBERT KELLAN I 9 SUTT. ON HILL RD.
a.Name f F �lity,., b.Street Address
r..._.r._
LS
iNorth Andover JLMA (978)688-5103
.....T. c,Citytfown _—� — _- d.State e.Zip Code If.Telephone Number
INSTRUCTIONS 31 Worksite Location:
1.All sections of this BASEMENT......... ..............,.., t,,. .... �... ,... _l �........_..,,'...._.._..._ ,._ _..._....................................1 I..._._....__......._...__.._.__t
form must bo a.Building Name/Building l.ocaticn wi
b.Building# c. ng d.Floor e.Roorn
completed in order
to comply with 4. is the facility occupied? Fi Yes {,�No
DEP nolificafio
requirements L1310
CMR 7.15
P r_......._....--._._ -.-._._._._....._ .....- ----_ - ...._.._..—..- ._._._ ,_._..._..__.... ...---- ----._....-.__.,.., __ - - ........._...._-.....i
Safety Dos S INC '43 DUDLEY STREET PO BOX 132
of Occupational alto al rD NDLeEY SERVICE..................._.--- ......._...,..,..., . k,...,.,,..,.......,............. I
b.Address
ngrcaeor ARLINGTON 02176 17816434328 _._,_. 1
requirements*1453 —�._.._,_' -- .._-....._..,-- i.,.,,.,.....,:.,.,-.-.._....._ ,.............--•-............_..... _...................__...
CMR 6.12 c.Citylravm T„ _ d.Zip Code e.Telephone Number
-
IAC00011.2
7�S�icen Number g•Contract Type: ) „4 Written Verbal
,.i•acil;....�.:�........�ers n i.�ConlactPerson's..............._---------------.-..__.............
h ............_._...__....,
�!.- �..,, .,.,.,... Title
SAMUEL J NIGRO III. -------__-__ � fAS0�2802 , , ,. __. ....... �_ ........_...__.... ....!
- R —-�—P-- ..._..... sA -................._....................._........- ......_- -- ---J
ENVIROSAFE ENtaINEERING AM060297 'on Number
a.Name of On-Site Su ervlsor/Foreman b.:Su ervisorlForeman DOS Certification „•,
-- —--
7. ---- - — -- ........ ___
ENVIROSAF.6 FIVCrlAIEEFtING �AA�100131��-...,.-•,..,M.._,Certification N unbar
a.Name of Asbestos Analvtical Lab, b__ ! ie€1!h�!xhcal dab D,
t3. la. ame o ro' ct Monitor _ _ b Pro ect Monitor DOS Certif . -„
OS Certification Number
9 oar02/2ooB (06110912006
o _ .... --- --------------_...� r,.. ................................ •.-.,.-:...--.........................•------......._..,._.................�
ra.Proleol Start Date mm/ddfYYri1 Y+ .� _` bEnd Date mmrdd __..................._.._
Lt- --�. L_.__..-_._... r 1`11TMOI .k�_...._.......__...._.-..-.-_._.................._........-.__-
A 11-11,11-11,
�o ISAM-SPIYI11- 8AM-SPM
c. ork'hours Mon-tri. d.Work hours Sal-Sun.
'0 o 10. a.What type of project is this?
�.,.I Demolition Renovation
(-•,. Repair ..]Other,please specify: e.Describe
11. a.Check abatement procedures:
C3 I,.--.1 Glove bag ,.,j Encapsulation
b LI Enclosure (^,i Disposal only _—......__..................._........._...----._._.-.-..-._......
u_ (._ Cleanup � i Other,specify:
Z Lj Full containment b.Describe
12. Is the job being conducted: ✓ Indoors? 1. ..1 Outdoors?
anf001ap.doc 10102 Asbestos Notification Form•Page 1 of,1
JUN 01,2006 13:23 17816431255 Page 2
Commonwealth of Massachusetts ■
�"• .. 100033616
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description cont.
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
en,rrapsulated:................... ....
0 1500
a. ota�pes ar3Gcts(linear t .Total oTFer su orf ces j�quareTi)"��
C.Boller,breaching,duct,tank q L... i.._.__. J L__-•—_-
rface
e.Corrugated or layered paper Lln_ft. Y Sq: d TrowleVSprayercemecoaiings il"in,;,-R,; Sq.ft. _
_ —.,
pipe insulation Lin.ft. Sq.ft. I in.ft. Sq.ft.
; ( I
g,Spray-on fireproofing -- —� h,Transite board,wall board i.•_.__—___i =
ft. Sq.ft, Lin.ft.
Lin.ft. S ft.
i.Cloths,woven fabrics -.n: -^`- �_- .... ;_..._.... j.Other,please specify: "...� .
^. _ .9:.... ........ ...............--�-----^-----------. .. .....Lin.fl-... ... 59:..fS:._..._
k.Thermal,solid core pipe VATILINOLEUM
insulation Vn Sq.ft. I.Specify __.._...........-....._..._.. -
14. Describe the decontamination system(s)to be used:
SYSTEM AND HlrP1.1.111.111.1! VA j
CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR _
15, Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6,14(2)(g): ---
WET ASBESTOS PACKED IN DOUBLE 6 MIL POLY SAGS LASELED FOR ASBESTOS MATERI '
---- ---- _—_---— --_ ----............................... ......
......,.....,........,, ,...... .,. . ...., .,..,l
For
DOS officials
16 rIM JORDAN—Asbestos,0 Operations,the DEP aid �fNSPECTOR ho,evalu ted the emergency' �
Emergency p I
.......
a.Name of b1r�6fec�al _ _ V.Title
``06107!2006 0606999.._..........--
C.DatA mmltld! of Authorization d.QEF'Waiver#
5 .�,..,ffy�._..._...� —-----...-------
GARY GASPARINSPECTOR
Name oT dOS Official (bps �ciel �t e
0610112006 _� OtS-184•NB __ _ _ _ __ _
g.nate(mmltldfyyyyj of Authorization h.POS Waiver#
�N
a 17. Do prevailing wage rates as per M.G.L.c, 149,§26,27 or 27A—F apply to this project?i , Yes 1✓I N4
B. Facility Description
0 1. Current or prior use of facility:
RESIDENTIAL DWELLING
�o
2. Is the facility owner-occupied residential with 4 units or less? [ ,)Yes [ f No
hOB_EIRT KE
LLAN
3,
LFaoili{ Name
b"."Addess� ---_.... __..........._..�....
�o
C.( _. d.ZI Code o.Tole none Number area cads and extensi n 1
LL
4, g,_._ _.._...-._ .... �.---.._.._ �......... i
---"-^"" _1YOwner'sryManager Atltlress
Z a. of Faaili On site Manager ble
- ----
Q c.CitylTown d.7.ip Code e."I aIBphon0 Number(area coda and extension)
■ anf007ap.doc 10102 Asbestos Notification Form-Pa a 2a o1`3■
JUN 01,2006 13:24 17816431255 Page 3
Commonwealth of Massachusetts M
�100033616w
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
---------..__.._..----................ _
5' ,Address
a.Name of General ConVactor .. .... .. ._---._.._ bddr ...... ___.-...___-----...... ._........._...-..............?
,.... _- ..., ss —............ . ....._ __ __ - .......
_ 4!p e.
�-~_..-�..�-., a code and extension)..
o.Gi drown_ d_ZI Cade e.Tele hone Number-a--,• .....,,,-•-,•,••,,,,,
er are
I i
C —... _�-__._._t..........., YYY.Y).
f.Contractor's Worker's Com .ins�er i ..Polic.Y..-•----..........._,.,...,.,.� �_.... .............................
Number h._Ex . a[e mmldd!
6. What is the size of this facility? 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):
Note:transfer a.Name of TraneP9!e�.:... ._ _ b.Address. __._.._...-.......------._....._.._
l
Stationsmust I I � .-._.__� �........,----........_..._.._—_.._.-......�............................_.__.__..._.,...........;
comply with the `._____._.......,...,-....................._.----._.._. .... .
P Y c.CityrTown d.Zip Code e.Telephone Number
Solid Waste
Division 2, Transporter of asbestos-containing waste material from removalltemporary site to final disposal site-,
Regulations 310 — __.._.— _......... , --...- ----
CMR 19.000l
J.O_B ROLLOFF
.1.,.,.................__..._..-- -- ---1.1-1------.--—--- -....-...
a.Name of Transporter_ b.Andress
L-...............
.....--- - -
C.Ci frown a.Zip Gode— B.Telephone Number
............
LI1......-,..__µ - ---- ,
a.Refuse Transfer Station_and
.,.Owncr !._.. 1 �n. Address
_.
_i
_
(G.C it Mown _ d.ZipCode_ e.Telephone Number
4. WASTE8YSTEMSINCORPORATED
_ Disposal,S_i.a...Location „... - b-'Final.DIspose.l._S.....i_.t.e.—..L_o
.c_a.._n.—on O..w..n...e..r'sName
190ROHESTER
... . . . ......
,....
_...__..__...._ ......
c Finalpi p
�.
#_"._..,.._ L1..._.._r.___1
0r� e.State f.Zip Code g.Telephone Number
D. Certification
N [SAM ---.............._........,..
The undersigned hereby states,under the [ISAM NIG
o L i.,...................--
penalties of perjury,that he/she has read the a.Nameh.Authorized Si�natllre -
° Commonwealth of Massachusetts regulations PRESIDENT ! 0610112006
for the Removal,Containment or � •"--"---1w --•--V---- --'
c,PositionrTitl d.Date1mm/adwvwf_,_„•_.......... ...
encapsulation of Asbestos,453 CMR 6.170 and - ----- - '-” I
310 CMR 7.15,and that the information DUDt PY SERVICES INC.
contained in this notificatlon Is true and correct e.Telephone Number t.Represenpn�
to the best of his/her knowledge and belief.
h.Cityfrown i.Zip Coda
Q
anf001ap.doe-10102 Asbestos Notificatlon Form-Page 3 of 3■
i
P.O.Box 305
Westbrook,ME 04098
'January 26, 1994
Board of Health or Board of Selectmen
Town of North Andover
North Andover, MA
RE: our insured: Robert and Pauline J. Kellan
49 Sutton Hill Road
policy no.: 207 HO 1377565PCAV
date of loss: 1-9-94
type of loss: water damage
Dear Board Members;
Claim has been made involving loss, damage, or destruction of the above captioned
property which will either exceed $1,000.00 or cause Massachusetts General Laws
Chapter 143, Section 6 to be applicable.
If notice under Massachusetts General Laws Chapter 139, Section 3B is
appropriate, please direct it to the undersigned and include a reference to our
insured,the location, the policy number, and the date of loss.
If you have any questions, please call me a 1-800-422-3340 ext 759.
Sincerely,
Claire Bell
Property Claim Representative
i
WATERSHED RESIDENTS QUESTIONNAIRE .
1. Name �2? !
2. Street Address '
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
eptic tank and leaching area
Connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
❑ yes ❑ no ❑ do not knaw'"-- _-
6. Ho old is your sewage disposal system? El 0-5 years El 6-10 years El11-20 years"=-"
H
20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes ❑ no ❑ do not know
If yes, approximately how long ago? years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
+� ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
,�/
- 9• Have you had any problems with your sewage disposal system? ❑ yes Lam' no
_ If yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each ap liance re connected to your sewage disposal system?
washing machine dishwasher garbage disposal l�
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub
11. Please state the b nd andt3'p a 'quid or powder) of detergent you use for:
dishwasher
clotheswasher
12. Does your property have a lawn? a- yes ❑ no
If yes, approximately what size?
❑ lass than 1/4 acre . ❑ '/4 acre ❑ lh acre ❑ 3/4 acre ❑ 1 acre
more than 1 acre (Specify) --2 !Z1=4cres
f '
13. How often do you fertilize your lawn?
No. of applications per y r
Season(s) of the year --`
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
{ Check here if your lawn is maintained by a professional landscape contractor.