HomeMy WebLinkAboutMiscellaneous - 76 COLGATE DRIVE 4/30/2018Date... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. /vOi),.�..../ ...IE°�r� ......�-� C-
..............
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has permission to perform I)gryl......f f� v.............. �: <'..y::.:'r.:.......
......... ....................
wiring inthebuilding of ......... ..............................................
at ......7!� ..t...l ...6.: 127 ........0�.'L�'� ..................... . North Andover, Mass.
Fee.......s5...v ~Lic.NoI 22 .......... {4 i:�{ �l.:'Y�' ..... '
/ ELECTRICAL INSPECTOR' �
Check
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�JUL 15 2005
TOWN OF NORTH ANDOVER
HEALTH DF_ 'ART'4aNT
ServPro of Haverhill July 14, 2005
P.O. Box 1723
Haverhill, MA 01831
ATT: Mr. Dave Hart
RE: Donovan Residence
N. Andover, MA
Dear Mr. Hart:
This letter is to inform you that notifications have been sent out to all
necessary regulatory agencies concerning the asbestos abatement work to
be performed at the above captioned job locations. Regulations require
notification of intent to work at least ten working days prior to the start of
work.
The notifications for this work was sent out on July 14, 2005. We
plan to commence work at the above captioned job location on August 1,
2005. Enclosed please find copy of the Commonwealth of Massachusetts
Asbestos Notification Form ANF -001. I will be in touch with you prior to
this date to confirm our arrival.
If you have any questions regarding this matter, please do not
hesitate to contact me at your convenience at 978-683-7767.
Ick
Patrick . Sennott
PJS/jr President
CC. N. Andover Health Department
Envirotest Laboratory
145 Marston Street, Lawrence, MA 01841
Telephone: (978) 683-7767 • FAX: (978) 688-9998
Website: www.sencam.com
e
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
1. All sections of this
form must be
completed In order
to comply with
DEP notification
requirements of 310
CMR 7.15
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
Commonwealth of Massachusetts T ��
100020026 �J
Asbestos Notification Form ANF -001 Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? Rll Yes n No
b. Provide blanket decal number if applicable:
2. Facility Location:
RESIDENTIAL
a: Name of Fapility `_'. _.'_"`_"
NORTH ANDOVER
cCtylrown -
d. State
3. Worksite Location:
Blanket Decal Number
r76 COLGATE DRIVE
b. Street Address -
01845 _ (978) 374-8555
e. Zip Code f. Telephone Number
BASEMENT IgASEMENT
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
4. Is the facility occupied? o Yes EJ No
5.
6.
7.
8.
Asbestos Contractor:
JSENCAM INC
a. Name
LAWRENCE _
c_. City/Town., - .��-
PAC000129-M�
tl. Zi Code
f. DOS L(cerise
DAVE HART
It .I~acili ;–Oontacf peison w �`"
h__. ___
FE FLAVIO NUNEZ
a. Name of On -Site Supervisor/Foreman
ENVIROTEST LABORATORY
a Nemme of Project Monitor _
ENVIROTEST LABORTORY
a. Name oi'-Asbestos_Analytical Lab
7AM-4PM
6. W& -hour
10. a. What type of project is this?
-J Demolition (✓j Renovation
Ia) Repair [I Other, please specify:
11. a. Check abatement procedures:
} Glove bag Encapsulation
HEnclosure Disposal only
Cleanup 0 Other, specify:
[✓J Full containment
145 MARSTON STREET ___.___._I
6–Address — ----
9786837767 9786837767
e.Telephoner
g. Contract Type: E Written n Verbal
�b. Describe
17—
b.
b. Describe
12. Is the job being conducted: �J✓ Indoors? R Outdoors?
0 anf001ap.doc • 10/02
Asbestos Notification Form • Page 1 of 3 0
Commonwealth of Massachusetts
100020026
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
(encapsulated
0
k3l-101�-
5_T
a. -Total pipes or ducts (lin tal other suces'(s"gi�are it)"'
c. Boiler, breaching, duct, tank I !_ L
surface coatings Lin. gq: d. Insulating cement ft
Lin.
e. Corrugated or layered paper
pipe insulation Lin ft gq ft f. Trowel/Sprayer coatings __
F
LinftSq. ftg. Spray -on fireproofing... �1 h. Transite board, wall board �j (n.ft. Sq. ft-- _
i. Cloths, woven fabrics --- �-�_����I t..--- j, Other, leases f_.._____ _� [i. 00
`Tin ft: -� $ , ft. P specify: Lin ft.
k. Thermal, solid core pipe � _ � � � (VAT/MASTIC A--.--�-•-�j
insulation Lin. ft.` Sq. -
14. Describe the decontamination system(s) to be used:
FULL CONTAINMENT
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
WASTE WETTED, DOUBLE WRAPPED IN 6 MIL POLY/EPA APPROVED LANDFILL
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name o#t3Ff iSicTai w b�de"
c. Date �mm%dd/y'yyy f Authorization �y�� d, DEP Waiver #
N
g. Date (rnm/dd/yyyy) of Authorization "� ""
h. D�1Naiver
o 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? J -J Yes Li No
0 B. Facility Descriptioin
N
RESIDENTIAL "
��— 0 1. Current or prior use of facility:
0
2. Is the facility owner -occupied residential with 4 units or less? (✓J Yes U No
3 rL EO DONOVAN
r6 COLGATE DRIVE
a Faclltty Owner Name �� b. Address
o NORTH ANDOVER--~� 55 -
w_..___ __ i01845 [978-3748555 -
o c'.,City/Town d. A Coda e. Telephone Number (area code andammmextension)
u. 4 [DAVE HART --------- - —
a. Name of Facllit�i Owner's On-Sit'e Manager " '[ 1723
Z b. On Site Manager Address ---:=1—
OMESESEEM [HAVERHILL01831
— -- ---
Q
d.�i'p Code e. Telephone Number (area cod's and extension) f
anf001ap.doc • 10/02
Asbestos Notification Form • Page 2 of 3
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
B. Facility Description (cont.)
a. Name of General Contractor
c. City/Town d. Zip Code
f. Contractor's Worker's CComp—insurer
6. What is the size of this facility?
IA
100020026
Decal Number
b. Address
e. Telephone Number (area code and extension)
Polc Number
h. Exp. Date (mm/dd/yyyyy)
n---
%,. muuestos I ransportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
�SENCAMMINC.�
a. Name of Transporter_
[LAWRENCE 01841 ��
c. Cityrrown -_� d. Zip Code
2. Transporter of asbestos -containing waste material
RED TECHNOLOGIES
a. Name of Transporter
145 MARSTON STREET
E. --Address'- _
[(978) 68_3-_7767_
e. Telephone Number
from removal/temporary site to final disposal site;
10 NORTHWOOD DRIVE
BLOOMFIELD-002 �� 860) 218-2428
c_City/Town_ d.Zip Code e. Telephone Numt
3. ["N/'A _
Y�. °•. Zip Code rl
4. [MINERVA ENTERPRISES INC_
a. Final Disposal Site Location Name
9000 MINERVA ROAD ` -{
w. - __-.. �i_._..�..e-- --.,....,... J
C. Final Disposal Site Address
[OH _ _ _�44688 _.—
e. State f. Zlp Code
u. %oval- iluation
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.
0 anf001ap.doc • 10/02
e. i eiephone Number _ ---
�STEFANO
b. Final Disposal Site Location Owners Name W`
WAYNESBURG
d CLgL!own
(330) 866-3435
g. T4iephone Number��'
J. 3ENNOT �j Qa" J�
PRESIDENT i
683-7767 __...._..._.
SENCAM, INC.
145 MARSTON STREET
p. Address _
LAWRENCE
101841
h. City/Town — —
L Zip Code
Asbestos Notification Form • Page 3 of 3 0
1 nkr 3... NQLAND CLAu,15 SEK CE., INC.
Incorporated 1985
ED Kepis To-
RO. BOX 345
MANSFIELD, IvLk 02048
uarn:rFaroeNi
TEL. (594) 3-37-8058
'°"E `•
ill. I
FkY (500) 339-5035
Tr7Tn8
Rep]y To
100 CO),TIFER HILL DPJVE, SUITE 3 08
DAMMERS, MA 01923
TER '' , 7.9- °100
PAX'_ (978) 774-9295
v7raladall@ueurengland.claiins. com
AUG 16 2005
LN
I
TOWN OF NORTH A.• ; )"E'j
HEALTH GL 1"k:
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
inspector of Buildings
Board of Health or
Board of Selectmen
P,E: Insured:
Property Address: 7
cis
T
Policy Number:
Date/Cause of Loss:
File or Claim Number: d�� � a 2 `2
Claim has been made involving loss, damage or destruction .of the above- captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION B, to be applicable. If any notice under MASSACHUSETTS GENERAL 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 claim or
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.
Date
(.ommonwsaGth o� %�%a3sac�iusslfl Official Use Only
1Js/oarinian� o�.yirs Jsrvics! Permit No, � 3� � •
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/o7] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: 5-
City or Town of: Po a ,cj A o u 2 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) '7 eo r * r b 21 ug
Owner *or Tenant LD A �i A 10 Telephone No.
Owner's Address _C ,a ri c
Is this permit in conjunction with a building permit? Yes ❑ No 0-' (Check Appropriate Boz)
Purpose of Building h 11 Utility Authorization No. �
Existing Service _J_q 0 Amps 4a,o 1 �Lyo Volts Overhead
New Service leo .Amps / t 2 Volts Overhead ®
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: f s P C—" O2
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
S{ QV,t(_,fA
Completion of thefollowing table may be waived by the I actor of lyres.
No. of Recessed Luminaires.No.
of CeiL-Susp(Paddle) Fans
o. of Total
Transformers KVA
No, of Luminaire Outlets
No. of Hot Tabs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ -
grnd. 91711d.
❑ o, o mergency Ilgliting
Battery Units
No. -of Receptacle Outlets
No. of Oil Burners
F1RE ALARMS No. of Zones
No, of Switches
No. of Gas Burners
o. of -Detection an
Initiating Devices
No. of Ranges
Na of Air Cond. Total Tons
No: of Alerting Devices
Na, of Waste Disposers
eat ump
Totals:
m uer
Tons
o, ofSelf-Contained
Detection/Ale rtin Devices
I
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal [I Other
No. of Dryers
Heating Appliances KW.
SecuritySystems:*
No. of Devices or Equivalent
o. of Water
Heaters KW
o. o o. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage BathtubsNo.
of Motors Total HP
Telecommunications Wirmg:
No. of Devices or Brit,
uivalent
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 NEC 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 a BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information. on this application is true and completes
FIRM NAME: n 9 1 ,L L LIC. NO.: / 2 o/ r7 !�
Licensee: ��t„ ��- /S 14"J4,3 5�" Signature �/���'j /��_ LIC. NO.:
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 4 h 9 9 7 5' Clgd�5_
Address: 1clv-LIU m Alt. Tel. No.:
*Per M.G.L. c, 147, s, 5 -61, security work requires Department 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 by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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 Legibly
Name (Business/Organization/Individual):
Address: 1,-,( C9 C m a C ,nk t rte:.
itv/S
Phone #: S2y Q7 :' - I,( q s- T_'
Are you an employer? Check the appropriate box:
1. R I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have noemployees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance reQuired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.13Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*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.
:Contractors 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. If the 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.
Insurance Company Name: pe /14Z/, n_
Policy # or Self -ins. Lic. #: (.3 c. c,, { 3Q S 2 9 0 6 3 Expiration DateZ l
Job Site Address: IA 4 P 2 / ( Po. City/State/Zip: /1i o /9 Mo o w
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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
a
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone M
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