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C1 Phillips ace Project • N tow 51 Phillips Place, Northampton, Massuchusetts 01060 i i i cX-u T �) v➢p➢Cc m O C ON n y� zm <oc o°moo O➢m EM ➢ n� ZrK Zm-UD6 ➢D AE xzz Z,OTC moo OF'&5m K_Z➢ j MU) m r m om+z-Oi y=1 MAGNETIC MERIDIAN D c j y Z5 2014 -�➢A ODr°Cn x Z-m Z W om oor<� \o x oom z°➢cZE n no ��z LnmZ �ozmx D0 i �zzm w IM i D° r➢D y�D 0°GU n➢� Wpm n ➢maW C y A GWr Ln MT K:Mmm '.. 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Box 2943 Order No. 82425 C/S/Z: Amherst, MA 01004 _ Rep SN Phone: 413-835-5950 email: Ism u.consultingdesign.com FOB 3/17/2014 Qty Description Unit Price TOTAL ASBESTOSCONSULTING SERVICES 51 Phillips Place, Northampton, MA 01060 P.O.Number: Verbal 1 Asbestos Inspection, limited $ 500.00 $ 500.00 27 PLM Bulk Samples, included in fee above $ - $ - 2-day turnaround ACCOUNT/INVOICE BREAKDOWN Original P.O.Amount $500.00 Change Orders: $0.00 P.O.Amount After Change Orders: $500.00 Invoiced to date: $0.00 P.O.Balance Remaining BEFORE this invoice: $500.00 credits $0.00 this invoice: $500.00 P.O. Balance Remaining after this invoice: $0.00 SubTotal $ 500.00 Shipping $ - Payment I Check Tax Rate(s) NET DUE ASAP-REPORTS 0.00% $ - Comments COMPLETE TOTAL $ 500.00 Name CC# Office Use Only Expires Please make check payable to Forbes&Wheeler, Inc. and remit with copy of this invoice to: 650 Dwight Street, #1337, Holyoke, MA 01041 Terms are net due 15 days or subject to interest at 1.5%per month on unpaid balance. Federal/Employer 1.D.#::04-3504807 Thank you! ASBESTOS-CONTAINING MATERIALS INVENTORY MATRIX Facility: 51 Phillips Place,Northampton,MA 01060 Date: 3/17/2014 Project#:MUE-14-B2425 Client: Linda Muerle,P.O.Box 2943,Amherst,MA 01004 CH-Chrysotile Asbestos ND-No Asbestos Detected PC Point Count AS-Assumed,no sample CR-Crocidolite Asbestos AM-Amosite Asbestos F-Friable H-Homogeneous KEY: NA-Not Applicable NF:Non-Friable PR_Previous/Historical Data X-Sample Location .......... ............................... COND(Condition): DA-Damaged DE-Deteriorated SD:Significant Damage IN-Intact E-Exposed/Uncovered O-Other ...................... ..................................... ......------........-----............................................. EPA Categories: I=Nonfriable ACM,packings,gaskets,resilient,floor covering,and asphalt roofing products II=All other Nonfriable ACM,excluding Category I RACM-Friable,Regulated Asbestos Sample/Mat MATERIAL LOCATION SLOCE QTY COND Cat Res b COMMENTS ID Number DESCRIPTIONITYPE 04 Sink Undercoating, black 1F Kitchen X 8 SF IN II 3%CH 2 each 06 Linoleum Flooring, light brown 1F Pantry X 50 SF IN I 25%CH on plywood 14 9"Floor Tile,tan 2F Bath, rear X 60 SF IN I 3%CH on wood,mastic negative but contaminated. Area to be demolished.May 16B Roofing tar, Edges,flashing tar Exterior, rear above kitchen X 100LF+ IN I 10%CH exist throughout entire roof area. 16/H Roofing tar,Edges,flashing tar Exterior,throughout Thru-out IN I 10%CH/H Notes: H=Similar materials to those identified herein that are located in other rooms are homogeneous,where indicated,and no additional samples were collected in those locations if no sample number is listed. The following inaccessible or out-of-scope areas were not inspected or sampled:Basement,wall and floor utility chases(unknown to exist);Pipe Tunnels(unknown to exist);Air plenums above permanent plaster or metal ceilings;Below-ground or below-grade(buried areas,parking lot,slab damproofing,driveway,etc.);Exterior behind siding,fire doors. All asbestos-containing material(both friable and non-friable)must be removed from a facility or facility component prior to demolitionfrenovation operations that will disturb these materials. Refer to the attached NON-ASBESTOS BUILDING MATERIALS for materials sampled that tested negative. Refer to the attached Asbestos Laboratory Report from the independent analytical laboratory. INSPECTOR: Stephen W. Niec ';N r ,<`; MADLS Lic.No.A1072378 Management Planner: Lic.No.:AP073456 ci Collected by:FORBES&,'WHEELER♦650 Dwight Street,#1337♦Holyoke,MA 01041 Analysis by:CEI Labs•107 New Edition Court♦Cary,NC 27511 T:413-221-8233•F:866-423-6355 NVLAP Code:101768-0♦MADLS Lic.#:AA000168 Page 1 of 1 Forbes&Wheeler NON-ASBESTOS BUILDING MATERIALS 51 Phillips Place, Northampton, MA 01060 Report Date: 3/17/14 Locate MATERIAL MATERIAL:DESCRIPTION LOCATION Sample SAMPLE D Cartected N/S or NS=Not Suspect as containing asbestos per judgement of Inspector. H=Similar materials to those identified herein that are located in other rooms are homogeneous, where indicated, and no additional samples were collected in those locations if no sample number is listed. It is recommended, but not required, that samples of negative resilient flooring&mastics(03, 07, 12) be further analyzed by destroying the interfering matrix materials and isolating any asbestos fibers that may be present and analyzed by Transmission Electron Microscopy(TEM). Inspection was limited to only those materials listed here as this is not a full pre-demo survey. Therefore, not all suspect building materials were sampled. No paper underlayment was observed beneath wood floor boards. Beneath plywood floors not inspected. The following inaccessible or out-of-scope areas were not inspected or sampled: Basement, wall and floor utility chases(unknown to exist); Pipe Tunnels(unknown to exist);Air plenums above permanent plaster or metal ceilings; Below-ground or below-grade(buried areas, parking lot, slab damproofing, driveway, etc.); Exterior behind siding, fire doors. Refer to the attached ASBESTOS-CONTAINING MATERIALS INVENTORY MATRIX for a listing of materials sampled that tested Positive for asbestos. Refer to the attached Asbestos Laboratory Report from the independent analytical laboratory. ASBESTOS INSPECTOR: Mfr' r° Stephen W. Niec 0 Lic. No. AI072378 Collected by:FORBES 8f, WHEELER 650 Dwight Street,#1337♦ Holyoke,MA 01041 T:413-221-8233♦ F:866-423-6355•www.forbeswheeler.com Analysis by:CEI Labs ♦ 107 New Edition Court♦ Cary,NC 27511 NVLAP Code:101768-0♦ MADLS Lic.#:AA000168 2 of 2 Forbes k Wheeler NON-ASBESTOS BUILDING MATERIALS 51 Phillips Place, Northampton, MA 01060 Report Date: 3/17/14 Locale MATERIAL -MATERIAL DESCRIPTION LOCATION sample, SAMPLE ID :'Collected 01A Sheetrock Wallboard 1F Kitchen wall X 01B Sheetrock Wallboard 1F Dining Room wall X 01 / H Sheetrock Wallboard Throu hout 02A Joint Compound w/01 1F Kitchen wall X 02B Joint Compound w/01 IF Dining Room wall X 02 H Joint Compound w/01 Throughout 03 Linoleum Flooring, Brown & Blue 1F Kitchen X 05 Window Glazing IF Pantry Window, ext. side sash X 05B Window Glazing 1F Dining Room ext side sash X 05C Window Glazing 1F Living Room large window sash X 07 Linoleum Flooring, each 1F Bath X 08 Ceramic Wall Tile Grout Mortar 1F Bath X 09 Tub Caulk white 1F Bath X 10 Waferboard Ceiling 1F Dining Room X 11A Plaster, basecoat 1F Dining Room wall X 11B Plaster, basecoat 1F hall by stairs wall X 11C Plaster, basecoat 2nd Floor Hall by Stairs wall X 11 H Plaster, basecoat Throughout 12 12" VCT brown self-stick 2nd Floor Hall by Stairs wall X 13 Loose Fill Attic Insulation debris 2nd Floor Hall by Stairs wall X 13 / H Loose Fill Attic Insulation Throughout 15 Black mastic with #14 9" Tile 2F Bath X 16 Roofing Tar, black top coat Exterior, rear above kitchen X 17 Roof Shingle, asphaltic, top layer Exterior, rear above kitchen X 17B Roof Shingle, asphaltic, bottom layer Exterior, rear above kitchen X NS 2'x4' Fiberglass Suspended Ceiling Panels IF Dining Room NS Rubber Caulk around sink 2F Bath rear 1 of 2 Forbes 8f,Wheeler Forbes &6 Wheeler BULK SAMPLE CHAIN OF CUSTODY SUPPLEMENT Project #: MUE-14-B2425 Dates) Collected: 3/13/14 Facility: 51 Phillips Place, Northampton, MA MATERIAL MATERIAL DESCRIPTION LOCATION SAMPLE ID 01A Sheetrock Wallboard 1F Kitchen all 01B Sheetrock Wallboard 1F Dining Room wall 02A Joint Compound w101 IF Kitchen wall 02B Joint Compound w/01 1F Dining Room wall 03 Linoleum Flooring, Brown & Blue V Kitchen 04 Sink Undercoating, black 1F Kitchen 05 Window Glazing 1F Pantry Window ext. side sash 05B Window Glazing 1F Dining Room ext side sash 05C Window Glazing 1F Living Room large window sash 06 Linoleum Flooring, light brown 1F Pantry 07 Linoleum Flooring, each IF Bath 08 Ceramic Wall Tile Grout Mortar 1F Bath 09 Tub Caulk white 1F Bath 10 Waferboard CeilinQ V Dining Room 11A Plaster basecoat 1F Dining Room wall 11B Plaster, basecoat V hall by stairs wall 11C Plaster, basecoat 2nd Floor Hall by Stairs wall 12 12"VCT brown self-stick 2nd Floor Hall by Stairs wail 13 Loose Fill Attic Insulation debris 2nd Floor Hall by Stairs wall 14 9" Floor Tile tan 2F Bath 15 Black mastic with #14 9"Tile 2F Bath 16 Roofinq Tar, black top coat Exterior, rear above kitchen 16B RoofinQ tar, Edges, flashing tar Exterior, rear above kitchen 17 Roof Shin le asphaltic, top layer Exterior, rear above kitchen 17B Roof Shingle, asphaltic, bottom layer Exterior, rear above kitchen xxx 25 SAMPLES SUBMITTED xxxxxx 0 USE FIRST POSITIVE STOP METHOD between A, B samples of same material number Page: 1 of 1 ASBESTOS INSPECTOR: Stephen W. Niec Lic. No. AI072378 CHAIN OF CUSTODY "C'': E I t 147 New Edition Court, Cary,NC 27511 Ce L4 CCKIa: Tel 866-481-1412: Fax-919.481-1442 CS Lab LD.Rwyo. 2` , ► �(p COMPANY CONTACT INFORMATION Company Forbes&Wheeler, Inc. Client#: 23687 Address: 650 Dwight Street,#1337 .lob Contact. Stephen W. Niec Holyoke, MA 01041 Email: sniec @forbeswheeler.com Tel: 413-221-8233 Project Name: 51 Phillips Place,Northampton,MA Fax. 866-423-6355 Project 10#: MtTE-14-B2425 I P,0 #. B2425 TURN AROUND TIME } METHOD 4 HR' 8 HR* 24 HR 2 DAY 3 DAY ' DAY PLM�'tJt K 25 Samples EPA600 ❑ ❑ 1:1 l 1:3 C3 PL INT COUNT(400) EPA 600 ❑ ❑ ❑ ❑ ❑ PLM POINT COUNT(1000) EPA 600 ❑ ❑ ❑ ❑ ❑ PLM GRAVrMCTRIC CPA coo ❑ ❑ ❑ ❑ ❑ PLM GRAV w POINT COUNT EPA 600 ❑ ❑ ❑ ❑ ❑ PCM AIR NIOSH 7400 ❑ i^l.. ❑ ❑ ❑ TEN!AIR AHERA ❑ ❑ TEM AIR EPA Level It ❑ ❑ 0 C3 TI=M AIR NIOSH 74G2 ❑ ❑ ❑ ❑ ❑ ❑ TEM BULK CHATFIELD ❑ ❑ ❑ 11 ED TEM DUST V`JIPE ASTM DWO 05 ❑ ❑ ❑ ❑ ❑ TEM DUST MICR€'1VAC ASTM D5755-03 ❑ ❑ ❑ ❑ ❑ TEM QUALITATIVE CEI LABS 1:17 ❑ ❑ ❑ ❑ 1:1 OTHER: r7 13 CD❑ ❑ ❑ LEAD PAINT l4tETHQfJ 4 HR* 8 HR' 2O4 l 2.�AY DAY 5 I�A1t ; LEAD PAINT EPA S'A846 70000 ❑ ❑ ❑ LEAD WIPE EPA SIM46 70008 ❑ ❑ ❑ LEAD WIL EPA S VB46 7OC-05 ❑ ❑ LEAS}AIR NIOSH 7082 ❑ ID ID OTHER: _ © ® ❑ REMARKS" Q STOP AT l* POSITIVE(between A and B...samples) Accept Samples O Analyze All Samples Reject samples Reti» ulsl d : Daten`me Received : [9a1 'nns S. W. Niec 3113/14—17:55 Federal Express Drop box YLv' t3 *Call to confirm RUSH analysis. Samples will be disposed of 30 daysiaft04 analysis VERSION CCOC.4 41V2.1-1) Customer COC Page t yy kky CEILA"46" S LEGEND: Non-Anth = Non-Asbestiform Anthophylite Non-Trem = Non-Asbestiform Tremolite Calc Carb = Calcium Carbonate METHOD: EPA 600/ R93 / 116 and EPA 600/ M4-82/020 The detection limit for the method is <1% by visual estimation and 0.25% by 400 point counts or 0.1% by 1,000 point counts. Due to the limitations of the EPA 600 Method, nonfriable organically bound materials (NOBs) such as vinyl floor tiles can be difficult to analyze via polarizing light microscopy (PLM). EPA recommends that all NOBs analyzed by PLM, and found not to contain asbestos, be further analyzed by Transmission Electron Microscopy (TEM). Please note that PLM analysis of dust and soil samples for asbestos is not covered under NVLAP accreditation. CEI Labs, Inc. can perform positive stop analysis if requested by customer. However, it is the responsibility of the customer to determine if the samples grouped together are in fact the same type of material and belong to the same homogeneous area. This report may not be reproduced, except in full, without written approval by CEI LABS. CEI LABS makes no warranty representation regarding the accuracy of client submitted information in preparing and presenting analytical results. This report may not be used by the client to claim product endorsement by NVLAP or any other agency of the U. S. Government.v-,v""J be ANALYST: � APPROVED BY: Susannah Small Tianbao Bai, Ph.D. Laboratory Director m V NVLAP Lab Code 101768-0 CEI Labs,107 New Edition Court,Cary,NC 27511,Phone:(866)481-1412 Page 5 of 5 ASBESTOS BULK ANALYSIS C: EI ''s By: POLARIZING LIGHT MICROSCOPY L/�.Q Client: Forbes &Wheeler, Inc. CEI Lab Code: A14-2931 650 Dwight Street#1337 Date Received: 03-14-14 Holyoke, MA 01041-1337 Date Analyzed: 03-17-14 Date Reported: 03-17-14 Project: 51 Phillips Place, Northampton, MA; MUE-14-132425 ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 14 Floor Tile Homogeneous 97% Vinyl 3%Chrysotile A1665391 Tan Non-fibrous Tightly Bound 15 Mastic Homogeneous <1% Cellulose 100% Mastic None Detected A1665392 Black Non-fibrous Tightly Bound 16 Roofing Tar Heterogeneous 5% Fiberglass 90% Tar None Detected A1665393 Black 5% Cellulose Fibrous Tightly Bound 16B Roofing Tar Heterogeneous 90% Tar 10%Chrysotile A1665394 Black,Grey Fibrous Tightly Bound 17 Roof Shingle Heterogeneous 25% Fiberglass 50% Tar None Detected A1665395 Black,Grey 25% Gravel Fibrous Bound 17B Roof Shingle Heterogeneous 25% Fiberglass 50% Tar None Detected A1665396 Black,Grey 25% Gravel Fibrous Bound Page 4 of 5 ASBESTOS BULK ANALYSIS By: POLARIZING LIGHT MICROSCOPY CEIL Client: Forbes &Wheeler, Inc. CEI Lab Code: A14-2931 650 Dwight Street#1337 Date Received: 03-14-14 Holyoke, MA 01041-1337 Date Analyzed: 03-17-14 Date Reported: 03-17-14 Project: 51 Phillips Place, Northampton, MA; MUE-14-62425 ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 10 Waferboard Heterogeneous 90% Cellulose 10% Binder None Detected A1665385 Tan Fibrous Loosely Bound 11A Plaster Base Coat Heterogeneous 3% Hair 65% Silicates None Detected A1665386 Off-white 25% Binder Fibrous 7% Paint Bound 11B Plaster Base Coat Heterogeneous 3% Hair 65% Silicates None Detected A1665387 Off-white 25% Binder Fibrous 7% Paint Bound 11 C Plaster Base Coat Heterogeneous 3% Hair 65% Silicates None Detected A1665388 Off-white 25% Binder Fibrous 7% Paint Bound 12 Vinyl Flooring Heterogeneous 100% Vinyl None Detected A1665389A Brown Non-fibrous Tightly Bound A1665389B Mastic Homogeneous 100% Mastic None Detected Clear Non-fibrous Tightly Bound 13 Insulation Homogeneous 90% Cellulose 10% Binder None Detected A1665390 Tan Fibrous Loosely Bound Page 3 of 5 ASBESTOS BULK ANALYSIS C: E I By: POLARIZING LIGHT MICROSCOPY LAC35 Client: Forbes &Wheeler, Inc. CEI Lab Code: A14-2931 650 Dwight Street#1337 Date Received: 03-14-14 Holyoke, MA 01041-1337 Date Analyzed: 03-17-14 Date Reported: 03-17-14 Project: 51 Phillips Place, Northampton, MA; MUE-14-132425 ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 0513 Window Glazing Heterogeneous 65% Binder None Detected A1665379 Off-white 25% Calc Carb Non-fibrous 10% Silicates Bound 05C Window Glazing Heterogeneous 65% Binder None Detected A1665380 Off-white 25% Calc Carb Non-fibrous 10% Silicates Bound 06 Linoleum Heterogeneous 10% Cellulose 50% Vinyl 25%Chrysotile A1665381 Tan 10% Binder Fibrous 5% Mastic Bound 07 Linoleum Heterogeneous 25% Cellulose 50% Vinyl None Detected A1665382 Peach 10% Fiberglass 10% Binder Fibrous 5% Mastic Bound 08 Ceramic Wall Tile Heterogeneous 75% Binder None Detected Layer 1 Off-white 25% Silicates A1665383 Non-fibrous Tightly Bound - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ° Layer 2 Grout Homogeneous 60% Silicates None Detected A1665383 Beige 25% Binder Non-fibrous 15% Calc Carb Tightly Bound 09 Tub Caulk Homogeneous 100% Caulk None Detected A1665384 White Non-fibrous Tightly Bound Page 2 of 5 ASBESTOS BULK ANALYSIS MR % By: POLARIZING LIGHT MICROSCOPY CEIL"AMB" S Client: Forbes &Wheeler, Inc. CEI Lab Code: A14-2931 650 Dwight Street#1337 Date Received: 03-14-14 Holyoke, MA 01041-1337 Date Analyzed: 03-17-14 Date Reported: 03-17-14 Project: 51 Phillips Place, Northampton, MA; MUE-14-132425 ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 01A Sheetrock Heterogeneous 10% Cellulose 90% Gypsum None Detected A1665372 Off-white Fibrous Loosely Bound 01B Sheetrock Heterogeneous 10% Cellulose 90% Gypsum None Detected A1665373 Off-white Fibrous Loosely Bound 02A Joint Compound Homogeneous 70% Calc Carb None Detected A1665374 Off-white 15% Binder Non-fibrous 15% Silicates Loosely Bound 02B Joint Compound Homogeneous 70% Calc Carb None Detected A1665375 Off-white 15% Binder Non-fibrous 15% Silicates Loosely Bound 03 Linoleum Heterogeneous 25% Cellulose 50% Vinyl None Detected A1665376 Brown 10% Fiberglass 10% Binder Fibrous 5% Mastic Bound 04 Sink Undercoating Homogeneous 90% Tar 3%Chrysotile A1665377 Black 7% Silicates Fibrous Bound 05 Window Glazing Heterogeneous 65% Binder None Detected A1665378 Off-white 25% Calc Carb Non-fibrous 10% Silicates Bound Page 1 of 5 Asbestos Report Summary By: POLARIZING LIGHT MICROSCOPY L/�.L�S PROJECT: 51 Phillips Place, Northampton, MA; MUE CEI LAB CODE: A14-2931 -14-132425 METHOD: EPA 600/ R93/ 116 and EPA 600 /M4-82/020 ASBESTOS Client ID Layer Lab ID Color Sample Description % 01A A1665372 Off-white Sheetrock None Detected 01B A1665373 Off-white Sheetrock None Detected 02A A1665374 Off-white Joint Compound None Detected 02B A1665375 Off-white Joint Compound None Detected 03 A1665376 Brown Linoleum None Detected 04 A1665377 Black Sink Undercoating 05 A1665378 Off-white Window Glazing None Detected 05B A1665379 Off-white Window Glazing None Detected 05C A1665380 Off-white Window Glazing None Detected 06 A1665381 Tan Linoleum 07 A1665382 Peach Linoleum None Detected 08 Layer 1 A1665383 Off-white Ceramic Wall Tile None Detected - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - Layer 2 A1665383 Beige Grout None Detected 09 A1665384 White Tub Caulk None Detected 10 A1665385 Tan Waferboard None Detected 11A A1665386 Off-white Plaster Base Coat None Detected 11B A1665387 Off-white Plaster Base Coat None Detected 11C A1665388 Off-white Plaster Base Coat None Detected 12 A1665389A Brown Vinyl Flooring None Detected A1665389B Clear Mastic None Detected 13 A1665390 Tan Insulation None Detected 14 A1665391 Tan Floor Tile 15 A1665392 Black Mastic None Detected 16 A1665393 Black Roofing Tar None Detected 16B A1665394 Black,Grey Roofing Tar rz to' 17 A1665395 Black,Grey Roof Shingle None Detected 17B A1665396 Black,Grey Roof Shingle None Detected Page 1 of 1 C E LABS ASBESTOS LABORATORY REPORT Prepared for Forbes & Wheeler, Inc. PROJECT: 51 Phillips Place, Northampton, MA; MUE-14- B2425 CEI LAB CODE: Al 4-2931 DATE ANALYZED: 03/17/14 DATE REPORTED: 03/17/14 TOTAL SAMPLES ANALYZED: 25 # SAMPLES >1% ASBESTOS: 4 TEL: 866-481-1412 www.ceilabs.com g TIE(OMMONWEAITH OF MASSACHUSETTS E # ° EXICUT F OFFICE OF IABOR AND WORKFORCE DEHLOPMENT DEPARTMENT OF LA11OR STANDARDS Currently Certified Asbestos Anglytrcal La bbs AS OF 112312013 Th,z9 List is Ordered ky'`Ti3L4n and Company Name Licenses Number: Company: Services Offered: AA GDlCe Exp. 101111#X14 CE€LABS.INC. CLASS A CERTIFICATE 919-481-1413 107 NEIN EDMON COURT CLASS C CERTIFICATE CARP,NC 27i 11 Comfmnweafth of Massachuseft CoMmIrtweem of JNamwchusem mow#of Labor Standards Depar anu of Labor SUrodards Ran fcr tfQaOWE Raw Dffwa r---r Asbestos Mwtagement P aa:ner Asbestos 1nspeaw STEPHEN W.MEC STEPHEN W.NiEC fM:tame M07x13 Eft, 0W113 FJXP.tie 06Q214 �„ EXP.CJece 0&=14 f AP073456 A1072378 14 fiketardC(3Tt- 5 1eszoxal"C +dES W7 W8p 1111 IN 1111111111111 � 11N OR 11 oil 1111111111 ,� Limited Asbestos Bulk Sampling and Analysis Report 51 Phillips Place,Northampton,MA 01060 Project No.: MUE-14-82425 In accordance with EPA NESHAPS regulations (40 CFR Part 61) and the Massachusetts Department of Environmental Protection(MADEP)regulations 310 CMR 7.00, building owners or their contractors must remove all ACM's from a facility (or portion of a facility) before any activity begins that would break up, dislodge, or similarly disturb the material. Additionally, In accordance with the OSHA regulations(29 CFR Part 1926.1101 and 1910.1001), building and/or facility owners must notify the following persons of the presence, location and quantity of ACM or PALM, at the work sites in their buildings and facilities. Notification either shall be in writing, or must consist of a personal communication between the owner and the person to whom notification must be given or their authorized representatives: • Prospective employers applying or bidding for work whose employees reasonably can be expected to work in or adjacent to areas containing such material; • Employees of the owner who will work in or adjacent to areas containing such material: • On multi-employer worksites, all employers of employees who will be performing work within or adjacent to areas containing such materials; • Tenants who will occupy areas containing such material. Please do not conclude that materials having trace amounts of asbestos do not pose a health risk, and certain OSHA regulations may still apply. If you have any questions regarding this report, please do not hesitate to contact us. Sincerely, FO�RBES &WHEELER Ste hen W. N� Asbestos Inspector MADLS Lic. #AI072378 Enclosures: Asbestos-Containing Materials Inventory Matrix Non-Asbestos Building Materials Asbestos Laboratory Report/Chain of Custody Licenses&Accreditation FORBES «'HEELER Page 2 of 4 � � -011)-dr FObi �"I 650 Dwight Street, #1337 *Holyoke, 42 01041 ,j+ �,,.,j j� TEL: 413-221-8233 ♦ FAX: 866-423-6355 HEELER www.forbeswheeler.com Members:AIHA/ASTM Asbestos • Lead Paint• Mold/Fungi • EH&S Training . Indoor Air Quality♦ Industrial Hygiene . Demolition Consulting • Hazardous Materials March 17, 2014 Linda Muerle P.O. Box 2943 Amherst, MA 01004 RE: Limited Asbestos Bulk Sampling and Analysis Report SITE:51 Phillips Place, Northampton, MA 01060 Project No.: MUE-14-132425 Dear Mrs. Muerle: At your request, on March 12, 2014, Forbes & Wheeler conducted bulk material sampling of specific materials of concern by you that exists at the above-referenced location and area. The inspection was limited to only those such materials in the specific areas that were requested to be sampled as they are suspect of containing asbestos and may potentially be subject to disturbance or future renovations and selective demolition (rear area kitchen, etc.). No other suspect materials were inspected or sampled. Therefore, the work did not consist of a complete pre-demolition survey, as other materials and areas outside of the work scope were not inspected. The subject facility was built circa 1848 in the late federal style, also known as the C.M. Kinney House. It consists of approximately 2870 square feet. The lower level consists of double parlors, a large bedroom, dining room with built-in hutch, kitchen with exposed beams and rafters, an office and full bath. Front and central staircases lead to the upper level, which consists of two large bedrooms, a sitting room or bedroom, a small bedroom or office, and a full bath. As required by federal and State regulations, sampling was performed by an EPA-accredited and State- certified asbestos inspector. Sampling was done in a manner to prevent airborne fiber release and were placed in appropriately labeled containers that were sealed and submitted to an independent laboratory for petrography analysis using the EPA-endorsed Polarized Light Microscopy with Dispersion Staining (PLM/DS) method, using an improved method for analysis (EPA Method 600/R-93/116: "Method for the Determination of Asbestos in Bulk Building Materials"). The percentage of asbestos present in each sample was determined by the visual area estimation technique. Please refer to the attached ASBESTOS-CONTAINING MATERIALS INVENTORY MATRIX for a listing of materials sampled that tested Positive for asbestos. Refer to the attached NON-ASBESTOS BUILDING MATERIALS for materials sampled that tested negative. Also please refer to the attached Asbestos Laboratory Report from the independent laboratory and Forbes & Wheeler's Bulk Sample Chain of Custody Supplement for sample descriptions and analytical results. ��-�-�--� UUMNA-1 OP IL):AU CERTIFICATE OF LIABILITY INSURANCE DAT0/251 DIY2013 10/25/ 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone:413-589-0901 CONTACT Ideal Insurance Agency,Inc. NAME: _ 187 East St. Fax:413-583-6511 PHONE 1 ,E:t): Ludlow,MA 01056 E-MAIL House ADDRESS: - INSURERL)AFFORDING COVERAGE _ NAIC# _ INSURER A:Admiral Insurance CO INSURED Compass Restoration _INSURER_B:Arbella Protection Ins Co 41360 _ Services, LLC INSURER C;Atlantic Charter Ins Co P O Box 384 Ludlow, MA 01056 INSURER D INSURER S: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP I LTR POLICY NUMBER MM/DDIYYYY I (MM/DD/YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIA81LITY ECC18143 1011612013 10116/2014 DAMAG�O RENTED PREMISES(Ea occurrence) $ 50,00 CLAIMS-MADE � OCCUR ME EXP(Any one person} $ 5,00 A X_ PROFESSIONAL ECC18143 10/16/2073 10/16/2014 PERSONAL 8 ADV INJURY _ $ 1,000,000 A X POLLUTION ECC18143 10/16/2013 10/16/2014 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,00 PROF/POLL $X POLICY P 1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _LEa accidenl1_ _ $ B ANY AUTO 1020019826 05/04/2013 05/04/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED -- AUTOS 1_?X�_ AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS NO N-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE EXS18144 10/16/2013 10/16/2014 AGGREGATE $ DED I X RETENTION$ 10000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TQRY LIMIT$ F� _ C ANY PROPRIETORlPARTNER/EXECUTIVE YIN WCV0082630 08/2812013 08128/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 I I I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) ASBESTOS, MOLD, & LEAD ABATEMENT CERTIFICATE HOLDER CANCELLATION INSRECD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR INSURED'S RECORD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: <-1 .41LL ( PS t(.i4{66 mil- 01660 The debris will be transported by: QoxkPA-55 The debris will be received by: Building permit number: Name of Permit Applicant l4 WA- Date Signatuffl of Permit Applicant a 4W October 15,2013 Pill a �� tllilUlil'lllllll ��1(Il�i� � Iiii�i111111111Q1'lll� 1) 1{llslii��ll �1� I f� r f n �� . . . � N��illlllllIllllti z 75/'� ..a ASBESTOS,LEAD AND MOLD ABATEMENT S Victor Rodrigues-President 1020 East Street,Ludlow,MA 01056-1517 413-265-1569 • Fax 413-583-2963 Email:compassrestoration @yahoo.com City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: The debris will be transported by: The debris will be received by: Z: Building permit number: Name of Permit Applicant . Date Signature of Permit Applicant 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 hire, express.or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall 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 Department of Industrial Accidents for 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-20 10 Fax#617-727-7749 www.mass.gov/dia • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): C )_Iok S1 VkV P9L�j Address: . City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions q ] officers have exercised their I L Plumbing repairs or additions 3.�I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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. 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK 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 4 the D for insurance coverage verification. I do hereby ce ti nd h a s nalti s r'ury that the in ormation provided above is true and correct Sip-nature: �[-3 Z Date.. _ 2 Phone#: 6 I �— �4 57© Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 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 hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall 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 perfonnance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ����% Address: City/State/Zip: ter- hone Q 8 ? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. r] Building addition [No workers' comp.insurance comp. insurance.+ required.] 5.'o We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#I 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. lContractors 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: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK 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,ceW under the and penalties o er'ur that the in ormation provided above is true and correct. Signature, Date: Phone#:_ / 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor': Not Applicable ❑ Name of License Holde 0�6�/8,Z License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Oe5 0->! Company Name Registration Number c h'7izl ;2 Address Expiration Date s-,- -/ /��rz �� Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance aff avit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bt4lding permit. Signed Affidavit Attached Yes....... 41 No...... ❑ 11, - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not res Itin in Death)of the sachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for ou The undersigned"home o r"certif and ass es nsibility for m liance with the State Building Code,City of Northampton Ordinances, ate c Zo g L w State of assa etts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition M.7 Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[I:]) Other[o) Brief Description of Proposed 'O&M / t&A,, Work: Renovation of and addition to exiting single-family residential building to a 2-family with I- garage. Alteration of existing bedroom Yes No Adding new bedroom)_Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building :One Family Two Family X Other b. Number of rooms in each family unit: 7/9 Number of Bathrooms 2/3 c. Is there a garage attached? YES f{wR11ri1 (5 IPL>%fJ d. Proposed Square footage of new construction. * GjJ{ Dimensions e. Number of stories? 2 f. Method of heating? GAS Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction WOOD FRAME i. Is construction within 100 ft.of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade Z3 t Z/ k. Will building conform to the Building and Zoning regulations? !( Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of per Date I, wuth orized Agent he th the atem informa Ion o the foregoing application are true and accurate,to t y knowledge and belief. Signed under the pains and penalties of perjury. C,t jl>A S - M.ttfF-� Print Name Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size •27 27 Frontage 123-4" 123'-4" Setbacks Front 16'-9' 16'-9' Side L: 10'-1"R: L:10'-1''R: Rear 16'-11 20'-0' Building Height 1r Bldg. Square Footage 2870 28 °�° 3000 34 Open Space Footage % (Lot area minus bldg&paved 72 8016 66 parking) #of Parking Spaces 3 4 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW e YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW e YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO e IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Reg2 croYTtaw Sec 96,q'o' 11-19'86a— Department use only City of Northampton Status of Permit: ` Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Z,2 Z�14 Room 100 Water/Well Availability, rthampton, MA 01060 Two Sets of Structural Plans nsP =587-1240 Fax 413-587-1272 Plot/Site Plans No�namPtOn' Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office �—( C R(LUPS PLA-C . Map Lot Unit C t0&o Zone Overlay District l L tom- Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Odier of Record: Lin a S. le/Phillips Place, LLC4 P.O. Box 2943 i AZ �' � Nam (Pr' Current Mailing Addre s: 413 835-5950 Telephone Sign e 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only competed by ermit applicant 1. Building mot• ®o (a)Building Permit Fee 2. Electrical 00 (b)Estimated Total Cost of OW• Construction from 6 3. Plumbing CM.0 0 Building Permit Fee ,( 4. Mechanical(HVAC) 00 lau 5. Fire Protection Q B 0 6. Total=(1 +2+3+4+5) I-A G �), Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1089 APPLICANT/CONTACT PERSON MUERLE LINDA ADDRESS/PHONE P O BOX 2943 AMHERST (413)253-0080 Q PROPERTY LOCATION 51 PHILLIPS PL MAP 32A PARCEL 201 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building_Permit Filled out / / 1 o L7 Fee Paid Typeof Construction: DEMO REAR ADDITION CONVERT SFH TO TWO FAMILY W/SINGLE CAR GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure - Building Plans Included• - Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO RMATION PRESENTED: P��'" Approved Additional permits required(see below) 1 rL P )L LANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management o 'tion la / Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 51 PHILLIPS PL BP-2014-1089 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-201 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateyory:renovation BUILDING PERMIT Permit# BP-2014-1089 Project# JS-2014-001647 Est.Cost: $210000.00 Fee: $1200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD DENNO 066189 Lot Size(sa. ft.): 11891.88 Owner: MUERLE LINDA Zoning.URC(100)/ Applicant: RICHARD DENNO AT. 51 PHILLIPS PL Applicant Address: Phone: Insurance: 551 FLORENCE RD (413) 584-0852 FLORENCEMA01062 ISSUED ON.512012014 0:00:00 TO PERFORM THE FOLLOWING WORK.DEMO REAR ADDITION, CONVERT SFH TO TWO FAMILY W/SINGLE CAR ATT GARAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType• Date Paid: Amount: Building 5/20/2014 0:00:00 $1200.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner