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23A-062 (2) 63 112 MAPLE ST BP-2006-0412 GIS#: COMMCLNWEALTH OF MASSACHUSETTS Mao:Block:23A-062 Cr.TW OF NORTHAMPTON Lot:-001 Permit: Buildina Category: BUILDING PERMIT Pemrit# BP-2006-0412 Proiect# JS-2006-0599 Est.Cost:$45000.00 Fee: $225.ao PERMISSION IS HEREBY GRANTED TO. Cons[.Class: Contractor: License: UseGmup; DAVID R JOHNSON 048790 Lot Sizetsa. D.1: 6141.96 Owner: SUBURBAN LINOLEUM CO INC p a :GB Applicant: DAVID R JOHNSON AT: 63 1/2 MAPLE ST Applicant.4ddress: Picone., insurance: 30 ALVORD ST (413) 534-3331 SOUTH HADLEYMA01075 ISSUED ON:11/2/'005 0:00:00 TO PERFORM THE FOLLOWING fVORK.INTERIOR RENOVATION FOR NEW OOFICES INCLUDING HVAC, WINDOWS & SIDING POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Uudergroundllly-0�'(yService-J aS O]"gMetcr; � r Footing:: Rough:] Rough-/ Huuse# Foundation: '�lJA/pJJ D1 .y Fhe.k Final�$ 'yj -Qb �/' Final: /�/G � Rough Frame:BX /-8 oG L1 a„ Gas: Fire Department Fireplace/Chimney: Rough: oil: Insulation: Ok 0i126106 furs a Final: Smoke: 1��'\ Final: 01l1- tf-Al,-04 .J THIS PERMIT MAY BE REVOKED BYTHE C OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy sienature: __'C �� FeeTWoe: Date Paid: Amount: — Building I InJ20050:00:00 $225.00 212 Main Street,Phone(413)587-1240,Fac:(413)587-1272 Building Commissioner-Anthony Patillo 63 112 MAPLE ST BP-2006-0412 1O S#:.. _ COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-062 CITY OF NORTHAMPTON Loth Perron: Building Category BUILDING PERMIT Permt# BP-2006-0412 Project# JS-2006-0599 Est Cost: $4500000 Fee:$225.00 PERMISSION IS HEREBY GRANTED TO: Const Class- Contractor: License: UsgGloup_ DAVID R JOHNSON 048790 Lot Smefsa. fy.l: 6141 96 (hvner:, SUBURBAN I INOLEUM CO INC Zoning GB Applicant: DAVID R JOHNSON AT.. 63 1/2 MAPLE ST Applicant Address: Phone: Insurance: 30 ALVORD ST (413) 534-3331 SOUTH HADLEYMA01075 ISSUED ON.•11121,2005 0:00:00 TO PERFORM THE FOLLOWING WORK:INTERIOR RENOVATION FOR NEW OOFICES INCLUDING HVAC, WINDOWS & SIDING 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: Paiwv ay 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 $iensturin FeeTvpe: Date Paid: Amount: Building 111212405 0:00:00 $225.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Conanissioner-Anthony Patillo Vmsioal.7 Comm=ial Building PennitMy 15,2060 r. I bf Northampton Ion [ Ing Department pgg5Main Street \R\ qCS Room 1 m ton, MA O1060 3- 40 Fax 413-587-1272 qua{Of B v. tiL` AAWCATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SEC17ON3.xZ5j�INFORMA710N' _-. _. �fw TO- '17' z tsra jl� I>z 4Y � ,, s SECTION2-PRgPERTY pirYti143t:,tHiPLgUTHOi2tZEDAGENT.r 2.1 Owner of Record: I M)OPAa N.Vm AA,...e Pew. ec. <aa 77a rxc n.+ J"f Name(PfirR) �!1' �Y/ey2 r,vr�l., /ryrls.FFf� Cunz+d MaRng AdlRess: Ji '. C.L�cocu- Lry.q i� X0.3 SignaWre .n"� " /� Te!°Ohoro il ' '�5�7��L v� 2.2 Authorized Aaent: Name(Perot} ,. Cunent Marli ii Address: Slgnawm Telephone .SECj1ON 3-ESTIMATED CONST)tUCTION COSTS Item.. - Estimated Cosf(Dollars)to be :O it UseOmy mm fetedb mtRa pliesm 1. Building (aj'Bwldrug PermttFee �. _— 2 EleCinml (b)Esffioatod Topl,Cost# d �..�� `t`orasb'l.Idmn7ram fi #�� 3. Plumbing 1 BuildingPretniRl'ee 4. & Pmte ire i l(HVAC) S FireProsection '- 6. Total=(t +2+3+4+5) OhedkNumber .-thisSectioti`fac DHicial use Onbr iftli9lTPendIC;No`m,bei - r,: Data., _ Issued` $igRdtUrE aurid Commissb rtiluupxttxofB+iAahgs Data Ver ionl.7 Commercial Building Permit May 15,2000 SEG7fOTb7+C.0�7S,TR17G-diiijERH)CES:+FQI bJECTS`1:ESSSNAN35,Ooo.. , C1i610EEETD6RNCL'"OGEp.SP,ACf Interior Alterations ® Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building[3 Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description (Enter a brief description here. i3X112 nti U. ins , ilxf 10r�IlAlaw Of Proposed Work: w,g,f Am-4 r V Ba a SECTION S-USEIGROUPIASWCON33F3UC)70)i' USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ - F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1.3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U utility '❑ Specify M Mixed Use ❑ Specify. S Special Use El Specify.I COMPLETE7k95,SEG710N1F_}(IS7INGBUILDINGUNDEBGGIh7G"RENOVATIONS,ADDM. ONSANDIORVMGEIN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):F-- SECTION SIBUIUMNSVEISt --SECTION-:SBUIUMNG$EIGN BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(so n 2'! 3° . 3" I A 4° 4 Total Area(sf) Total Proposed New Construction(sf) _ Total Height(ft) Total Height ft i _ 7.Water Supply(M.G.L.e.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private [I ZInei Outside Flood Zone❑ Municipal ❑ On site disposal system[] - Version I.7 Commercial Building Permit May 15,2000 ,r.. Existing Proposed Required by Zoning Thb column m be fillet in by Funding Dgmrm¢nt Lot Sim �— Frontage Setbacks Front �F— Side L:-_., ''R:, L:_ j A:— F ,. Bldg.Square Footage r- % J J Open Space Footage l (Im am minor bid,&pavW of Parkin Space; Fill: ' whuvda Licadon) A. Has a Special Permit/Variance/Finding over been issued for/on the site? NO Q DONT KNOW Q YES O ' IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �^^ NO Q DONT KNOW O YES 0 IF YES: enter Book Page,; ' and/or Document S B. Does the site contain a brook, body of water or wetlands? NO © DON'T KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained 0 , Date Issued: C. Do any signs exist on the property? YES © NO V IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: j 1 E. Will the mnsbucAon activity disturb(clearing,grading,excavation,or filling)over 1 acre or is It Part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial Building Perndt May 15,2000 SECTION 4 PRO FESM0NALDESIGN ARDY'.ONMuCTIONSERYIGEs-PoRBuILOWGS ANDSTRuO.TUREs'411BJECTTO. COl15TRUCTIoN CONTRGLPORSU71NTT07EO CMR-716{COR7AINING MORE T,-mm--N35 UOOC:F.OF @ICLOSEDSPACE). 9.1 Registered Architect Not Applicable ❑ Name(Registrant): Registration Number i Address Ex radion Date I Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility I Address Registration Number Sigrawre Telephone Fxpiradco,Date I Name Area of Responsibility Address Registration Number i Signature Tekpfora Expiration Date I � ' Name Area of Reaponsibrliy Address Registration Number SigreWre Telephone Expiation Date I I Name Area a Responsibility Add.. Registration Number I, I Sigraw. Telephone Expiation Date 9.3 General Contractor y/L7 tib dd Not Applicable❑ Company Name: Responsible In Charge of Construction U�17 79 Add.-.v,..al s Sdu��/�iAl' �AS3f13 �ry /�//6 i Signature Telephone Ver naril.7 C,oamcrcial Building Pemut May 15,2000 SEC7ION10•STRUCT&M PEER REVIEW(80 CMR-1'iD_71J.,:- ,+� ItMegeroient Structural Engineering Structural Peer Rewew Required Yes t„f No SECTION 11-.•OWNER:AU'(AiUR iI0N-TOBECOMPLETED WHEN OWNERS AGENT OR CONTRACTIDR APFLIES FOR BUILD7NG'PEwT .4 as Domer of the subject grocery, hereby authorize act on my behaH,in all matters relative to ooh authommd by this building permit application. Signature of Oamer ... Data _ f ,as boner/Authoazatl Agent hereby declare that the statements and information on the foregoing application are one and accurate,to the best of my knowledge aro belief. Signed underthe gains and penaltiesof pedu Print Name - — i SignaW, of l ,/Agent Date ,SECTION 12-CONSTRUCTION.SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Nameof License HoIdgr: USD 1� U,1 y/— license Number 3/�4 r/lam u7A = a 1 a 7 f tiB q� — Address Expeatiar:Dare SigaW 3s Fe j SECTION 53-.. 32MW CONPENSATIONINSURANCE'AFMC)IAVT((M.G.L.c 752,§.2$C16)j Workers Compensation Insurance affidavit most be completed and submitted with this application.Failure to provide this at8davi!will result in the denial of the issuance of thq buildingun/t i Signed Affidavit Attached Ye '�s No tom,/ afic Np�`e CrLiiL) of �ynrfl�a))}}stoil - ® GtEPhR7hlEM" bF DUI[D('Hb rNSPPfT)o1.:5 212 M.m Strcct DSuoicipnl B ld��g Karlhnmpton, Mncs. 01060 ta'QRIMI, S COaITENSATIO R. (licces-Jt�mirtccl .vvt�.-a{alia�-��++a�.sks-sidecar€zz;—.. .— I ' :,��L)��I n"r' ./ . `�.=Kt` if '" Flr• s -(7'gonCs=) .� w .F k3,'TJ (scr..rtci rylsutr;'np} do hereby certify, under the pair's -'ad penalties orpedury, { ) I am an employer providing d)x following :borkcr's cornpcnszuon covemge (or ury• employes /woriing on utis job Clnsw ac Cnopz�) lPclir: kcabcr) (6xyv"xuor, Dare) . Lam a sole proor,etor, general cootrz or or homeow e: (cecie orae) z o bzve hired Lhheee ccooffcluactors hsed below wbo have the following worker's racaerrsaoon policies- hvam: at�—_ (Inn:rancc Comperprt c6cr !Jum'c.;.) _ r;:pl•'anc,,. oRcdorzd /t (N.'.mc Cyo/nnnzao!) jln Haan¢ Camnaac/PoGc• Nunccq (L�pu..aon DzIU ON-=t of Comma e ) ' (fnsy2 Compan)'/Poun) NusU_) (5,P�=boo Dare) (N �� (Nana ai Contractor, ([asurauc ComcurylPoliq Numbs? - iExUimuan Ditc). ({.vad:C:eml a.0 Joaca.:}.u'mCuS_icl'v.muw w%a+�6'n.11 srvcGa'a) 1 am a sole proprietor and have no one worMo& for me. ( ) I a l a home oxwer perforzn)ning all the work myself. NolE:0lcsshcc-vcl^-r:w.Jclxm-c+u-ra uba n�loy)>cuw�a la c�c+oaey�:xi. cTp✓wu�z oa.d•.cll_i of ott_tL: L`"a reila Wu'iA Ne�.WdY evi6ela M16cQ y.iP'nm'+'l11-v e.'e a-.t �-'rally mn'd-valw le iplay=suu+ t4 uui:.n�-�Cati�M(G l2 SL i(5}�c�+ii�imu tya6�n=m fatly`=:armor c:n-�x�'� IcgJ n,;.a..o.e>vyleyu un' rye Wyky.Co�a,m.4en/,y, (ued�a-"-+da¢aary of ibv m[mm mr.ybelwwWadw Wo Dywvm allu6.viJ luedemY 06m nrLcr.ea(x:W mw+t;.viGdim MW-a t.l+ �e.mv.m.may vmdr smion 25n NMot.l3R ooiadmibe•�+Qa efewu.il SaoaLxi mmiAp�pra La of�gbS11W.W atNwolvO baa lTv m'I oil Va`f°ie h.fum ela SbV N'rt OtdvWa f clSlW.W adaY+G++�uc PcTN)I Numtxs _ MIDDLE HAMPSHIRE DEVELOPMENT GROUP, L.L.C. October 14,2005 FIRE NARRATIVE Building Address: 63 '/3 Maple Street Florence, MA Size: 1.074 to be improved(360 SF unheated storage) BUILDING: The existing Single Story Frame Commercial Building is having non-structural interior design renovations consisting of individual offices and cosmetic finishes. Floorplans are attached. The fallowing Fire Control Devices are being installed: A. Battery/Emergency/Exit Lights B. Heat Detector: Attic C. Smoke erector: Lounge/Break Area D. Strobe/Hom & Smoke Detector in Toilet E. Wall hung fire extinguisher: Entrance F. Fire Evacuation Plan: Wall bung G. Wall mounted Emergency Light Pack: Open Area The building is adjacent to the Florence Fire Station and is accessible to Fire Trucks and Equipment. There are no hazardous materials within the Building or on the Property MIDDLE HAMPSHIRE DEVELOPMENT GROUP, L.L.C. 270 Exchange Street, Chicopee, MA 01013 Tel.(413)746-5500 Fax(413)747-5600 i i r r / mw]Tj r� -I{ COUNSEL RECEPT)ON Northampton Department i Memorandum To: Tory Paullo From: Duane Nichols CT 2 { Date: October 24, 2005 M. Chief Duggan Re: 63 '12 Maple St. Middle Hampshire Group Secondary W a review of the fire protection narrative and plans that were submitted to me for review, I concur with the issuance of a building permit subject to the following conditions. • Keys with engraved key tags to be placed in Fire Department Emergency Access Key Box • A Fire Department Emergency Access Key Box is required on the exterior of the structure near the main entrance • A red 120-candela strobe light that actuates upon an alarm condition is required above the Fire Department Emergency Access Key Box. • 5 tb ABC fire extinguishers are required in kitchen and adjacent to exit doors. • Proposed smoke detection needs to be interconnected with heat detector • Installation shall follow the Northampton Fire Department Fire Prevention Checklist and Installation Guide. 0 Page 1 File k BP-2006-0412 APPLICANT/CONTACT PEPSON DAVID R JOHNSON ADDRESS/PHONE 30 ALVORD ST SOUTH HADLEY (413)534-3331 PROPERTY LOCATION 63 1/2 MAPLE ST MAP 23A PARCEL 062 001 ZONE GB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TviceofConstruction: INTERIOR RENOVATION FOR NEW OOFICES INCLUDING HVAC WINDOWS& SIDING New Construction Non Sumctmal interior renovations Addition to Existine Accessory Structure Building Plans Included Owner/Statement or License 048790 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON tNFQ&61ATION PRESENTED: _AZApproved_Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major ProjecC Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER § Finding Special Permit Valiance* 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 Pemtit from Elm Street Co saion Signature ofBuilding 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. innommomww BP-2007-0745 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: BUILDING PERMIT Permit# BP-2007-0745 Project JS-2007-001158 Est Cast: $0.00 Fec: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DIETZ CONSTRUCTION CORP 078886 Lot Sae(sa.ft.): 18120.96 Owner. MIDDLE HAMPSHIRE DEV GROUP Zoning:GB Applicant: MIDDLE HAMPSHIRE DEV GROUP AT: 77 MAPLE ST Applicant Address: Phone: Insurance: 270 EXCHANGE ST (413) 537-9109 O WC CHICOPEEMA01013 ISSUED ON.5/9/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMOLISH HOUSE & 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: FeeTvae• Date Paid: Amount: Building 5/9/2007 0:00:00 $50.00235 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Paulo File#BP-2007-0745 APPLICANT/CONTACT PERSON MIDDLE HAMPSHIRE DEV GROUP ADDRESS/PHONE 270 EXCHANGE ST CHICOPEE (413)537-9109 Q PROPERTY LOCATION 77 MAPLE ST MAP 23A PARCEL 065 001 ZONE GB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid TvoeofConstruction: DEMOLISH HOUSE&GARAGE New Constmction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 078886 3 sets of Plans/Plot Plan THE F9151 OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON E%F9AMATION PRESENTED: _Approved_Additional permits required(see below) PLANNING 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 Peanuts 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 Pe our Elm Shet ru ession SignaNre of ��66 dig O ficial Dat 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. "_' Deparimerrtuseony City of Northampton Statns:ofPermtC #.m Building Department CurtsCutFDrerevrayrP,errte7� x- 212 Main Street Sewerf5`epaciaJatim` `""` { Room 100 Wafer(KaIFAva0a3lrtt+y: -- r Northampton, MA 01060 Fwn fietsof8[nniDlafPlans- 'e" 'n -�' phone 413-587-1240 Fax 413-587-1272 Ptotic{e Plans - Others en ` p &- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - 1.1 Property y7Address: � -This section-to be completed byoifice - /L° ` s"'-I Map Lot unit Zone -Overlay District Erm SL Distnc[_-.'. _ Ct1ObMc_f SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam (Pool) C" M ling Addr Telepho Signature 2.2 Authorized Apent: 91f�' r�tcDo7a• � S'�imc 9I FI6� Name Pd) Current Mailing Address: �ra �11i�< 9s 960 v Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a).Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from fi 3. Plumbing Y Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+ 5) 094- 40 Check Number e2 — This Section For Official Use Only Building Permit Number. Date Issued: Signature: Building Commissipnerllnspector of Buildings Date Section 4. ZONING7 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 Depamnem Lot Size Frontage --- Setbacks Front Side Li R:. L: R. Rear — Building Height Bldg.Square Footage % — Open Space Footage __ % (Lor Brea minus bldg&paved Parade) — kofParking Spaces Fill: -- volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW � YES Q IF YES, date issue& IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page, and/or Document N' B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,r excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO 071 IF YES,then a Northampton Storm Water Management,Permit from the DPW is required. File N BP-2007-0745 _ — .APPLICANT'CONIACT PERSON MIDDLE HAMPSHIRE DEV GROUP -:,.�I --- ADDRESS/PHONE 270 EXCHANGE ST CHICOPEE (413)537-9109 H - PROPERIY LOCATION 77 MAPLE ST FEB 2 2007' - MAP 23A PARCEL 065 001 ZONE GB L - ---- THIS —THIS SECTION FOR OFFICIAL USE ONLY: ! --P''" '-�--i,�a9 — PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Perron Filled out Fee Paid I Tvoeof Construction DEMOLISH HOUSE " H590 ,cra 8 Acre< STT�CTVr'(�-G.,.nga, New Construction Non Stmttural -nterior renovations Addition to Exismea 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 INFORMATION P NTED: Approved -_ dditional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate ProjectSite 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 Cutfrom 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 Co ssion 00 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replae¢ment Windows Altehation(s) ❑ Roofing ❑ Accessory Bldg. ❑ Demolition Ip New Signs [O] D¢ekS [0 Siding[Ell Other[O] Enef escdption of Proposed Work: ILiro r / lel. �� Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Nametwe Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6,.If Newhouse and oraddliori to existTna haustna.'como�le&Vke'-,folioviina: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms C. Is there a garage attached? J. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr, floodplain_Yes No j. Depth of basement or cellar Floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ City Sewer Private well City water Supply SECTION 7.-OWNER AUTHORIZATION-TO BE COMPLETED:WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. A&411 /J/COaryo��l-,I {�l4dA✓ , /n��✓li �f�-r�.0 /)e✓_ " . '/v. LL e— as Owner of the subject property, hereby uthpdze r" to act n my behalf, ' all tters relative to work authorized by this building permit application. 2 rl.-7 51 afore of Ownqyl Data I, �(�kyp t"� {�(CCAry'l1t/ pC DI LTL �n]S"rrtx'rl`Dn) .as Owner/�thorized Agent hereby declare that the statements a inm%Eion on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. A Pri Na g ur Sign ot0 n Ag nl Date SECTION 8-CONSTRUCTION SERVICES_ u_ 8.1 Licensed Construction Supervisor: Not Applicable yy ❑ Name of License Hower'. F' License Nvmber Addrevs EepimaneDate TR#ggya SignaW Ta aphone 7 X)-711-6'- L a—nt 11-6'-CdntNot Applicable ❑ Company Name Registration Number Address Expiration Dale Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L,c.152,y 2SC(S)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit Signed Affidavit Attached Yes....... No...... ❑ —y' UIIIIl` @2YIR#16 The current exemption for"homeowners"was extended to include Owne,"cumied Dwelliaes ofoee(1) or two(2)families and to allow such homeowner to engage an individual for hire who dues not possess a license,provided that the owner acts CMR 780 Sixth Edition Section 1083.5.1. 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 suuctures.A Pwr9w. ha comstrided;more thin hamse in a trem-vear.pariod shall not be considered a ho er Such"homeowner"shall submit to the Building Official,an m form acceptable to the Building Official,that he/she shall be responsible per alt adult work Performed under the buildine mernift. 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 o{Employers do Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Amended. Homeowner Signature_,,,, The Commonwealth of&fassactutsetts Department of Industrial Accidents Ojfice of Invesh.-atlons 600 IlVSton, 11A 0 Street Boston,211A 02171 www.mass.gov/dia Workers' Compensation Insurance Affidavlt: Builders/ContractorslElectricians(PIumbers Applicant Information Please Print LeMhh, Name(Business/Orgmiratiodlndividual): pLcrz (fir'�,t)(`M4 ) � _ Address: "IX .'Zl�lj 51:RA.L,..... PA tR Y LJ A CitytState/Zip:EAZTtiAj�� Phone#: lt3—S _ 695' Are you an employer?Check the appropriate box: Type of project(required): I am a employer with —F 10 4. 0 tam a general contractor and I 6. 0 New construction employees(full and/or part-time)." have hired the subcontractors ?[.) I am a sole proprietor or parser- listed on the attached shed 7. _F]Remodeling ship and have no employees These sub-contractors have g wemobtem workingfor me in env capacity, employees and have workers' 1�"" anc t 9, 0 Building addition req workers' comp,insurance comp-insurance. required-3 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 120 Roof repairs insurance required.]T c. 152,y 1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required] _ 'My appiievat that chinks box#1 must also fill nut rbe sectlov below showing Neir workers'cnmpensanon policy intomnrion. T florveriwvas who submit Nie affidavit indicavng ones arc ding all workand thin hitt ou¢ide contcxwrs must subrrulanewa davi[indirapng such. rContrar:rors drat check dais bex musr attached an u3diromd sh«t sheuing the name ofrhe subconrcaewrs and sate whetfrcorvoe those esvdas have employees. If the sub-,onvactws have mIaloymi,rhes mco provide Heir workers'comp.pati,,number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job sire information. ��}} Insurance Company Name:i I Isfz2 r1a9 JAJTEIN'v!"T/a,U 9 G iaf{xJ1 .,_ Policv#or Scif-ins, [.ic.#,,:,rtt LJC— Fr7G lGe3 _ Expiration Date: Job Site Address: 4 !"/4 ^.IJT City/State/Zip: Fjj iC (4M 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 free up to S 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 m$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded m the Office of Invesueatious of-the DIA for insurance covera everification, I do hereby cc c u r he�p ' s and a allies of perjury that the information provided aboveis true and correct 5ienature ` Date- P A4.4'1 Phone#: /ra. — Of:ciaf ususe only. a moor ni wraewretc v+this area,to be comptet¢d�y cif,or Lawn offPeiat City or Town: Permit/I.icense# _ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityl.rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: trityr of Dior#F�aul #on DEPARTMENT OF BUIL.DNG INSPECTIONS INSPECTOR 212 Kun Street i Mumellcd Building V Nurduvnpron, MA 01060 --^" . r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup;:: . ;,or. Tlie state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or twofumily 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption., to act as thew own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings{before backfill). sonotube holes (before pour), a rough buildine inspection (before work is concealed). insulation inspection (ir reouired) and a final building inspection.The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing&gas) the homeowner will be responsible to make sure that the trades )tired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Homeowner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location Northampton, MA Property Detail Page 1 of 2 City of Northampton, MA: Residential Property Record C New.Search Property Tyne Classification Code Reference Card 1 of 1 Parcel - Location - Zoning - Assessment Map-Block-Lot: 23A-065-001 Zoning: EB Location: 77 MAPLE ST Neigborhood: 5 #Living Units: 1 Deed Book: 8150 Class: R-101 Deed Page: 127 Dwelling Information Building Sketch Style: Conventional / Year Built: 1900 Story Height: 1.5 Attic: None Basement: Part Total Rooms: 4 18 Bedrooms: 2 1F 0 Full Baths: 2 0 tsa Half Baths: 0 3e Exterior Walls: AlumNinyl 1.5Fr/B 12 Unfinished Area: 0 �u Ground Floor Area: 744 20 Total Living Area: 1482 28 .EFPI Finished Basement Living 0 X 0 35 Area: 16 Basement Recreation Area: 0 X 0 Woodburning Fireplace 0/0 is Stacks/Openings: oFP Metal Fireplace 0/0 'zs Stacks/Openings: Heat/Central A/C: Basic Heating System: Stream Fuel Type: Oil Quality Grade: C Physical Condition: Average Interior/Exterior: Same Addition Information: Condition/Desirability/Utility: AV Vacant/Dwell/Oby Status: Dwelling Additional Features: htLp:H/ .northamptonassessor.us/noho/propertydetail.php?map_no=23A-065-001&page... 1/24/2007 DEMOLITION REVIEW APPLICATION Activity Tracking Sheet Property: �/� wE_ Map Z�;S& Parcef _a5 I .� Received in Building Department: Referred from Building Department: Zig-TD— Action Taken/ Northampton Historical Commission Action Taken Bv: Entire Commission Sub-Committee of the Commission .j1.��-',�ll240 Commission Designee/ Staff W1_6Ttq — Date Action Taken: Initial Determination Public Meeting held Public Hearing Held Determination Made: / V Property has been determined not to be Significant according to Ordinance definition. No further action will be taken. Demolition Permit may be issued. Property has been determined to be Significant according to the Ordinance definition and a Public Hearing has been/will be scheduled. Demolition Permit may not be issued at this time. Public Hearing has been held, Property was determined Significant but not Preferably Preserved. No further action will be taken/ Demolition Permit may be issued. Photo documentation may be required. Public Hearing has been held. Property has been deemed to be Preferably Preserved. The demolition review period has been initiated. No demolition permit may be issued until the Historic Commission approves an alternative plan or the twelve month period concludes. Alternate plan has been approved/ delay terminated. Demolition may or may not be approved as part of plan. Twelve month time period has expired, demolition perm't may be issued. Referred by: Date �— CITY OF NORTH-AMPTON, MASSACHUSE ITS DEPARTMENT OF PUBLIC WORKS _ 125 LOCUST STREET Q NORTHAMPTON, MA 01060 A 13-587-1570 PAX A G-537-1 i76 Edward S Huntley, P.P. D—um April 10,2007 Anthony Patillo, Building Inspector Municipal Office Annex 212 Main Street Northampton,Ma 01060 Dear Mr.Patillo: -1 he water service at 77 Maple Street has been shut at the property line and the meter removed from the premises as of 1/24/07. Please contact me if you have any questions. S David Sparks Superintendent of Water Cc:Ned Huntely, Assistant City Engineer e -d SLSTL89E14 daie, dTT :eT Lo 01 J80 Bay State Gas ANiSourarCompan '262 P0DG4rt..r . Box 2321'i _ Spring�ie iE M.p'r May 07.07. 2007 DIETZ CONSTRUCTION 7 INDUSTRIAL PKWY Eq STHAMPTON MA 01027 Dear DIETZ CONSTRUCTION, The address listed below has had the gas seraice(s) disconnected and ie now ready for demolition. ADDRESS: 77 MAPLE ST TOWN FLORENCE STATE Massachusetts Sincerely �J r Terri Miner Workforce Planning vx IGJ ' 39Hd �H101 *� llhationalgrid ' - April 11,2007 77 Maple Street Florence.MA 01062 a ; To Whom It May Concern, This is to verify that National Grid has removed the electric service and metier 77 Maple Street,Florence,Massachusetts, effective April 11,2007 for Building Demolition. Sincerely; fnn � Jim Nichols Supervisor Distribution Design JN/ekp },546 Hayd twill¢Road,Lm .MA 01056 ■ w ..natcn ignd. me 11' 16 ' d BLEEL25E[b[6 of 789E 2GS o83s isno D31i ssukW di wd sc :G Loot 11 ddb' riccuTec I INSULATION & CONTRACTING,INC. Ir STATE STREET, BUILDING #119 1-800-244-8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WBE April 10, 2007 Mr. Matt McDonough Middle Hampshire Development Group 270 Exchange Street Chicopee, MA 01013 RE: Vacant Houses, 77 & 81 Maple St., Northampton, MA-Basements Dear Mr. McDonough: Thank you for selecting AccuTech insulation & Contracting, Inc. to service your environmental needs. Enclosed please find copies of the final documentation for the above referenced project. This documentation package should be retained as part of your permanent records. Included you will find: 1. Regulatory Notifications 2. Personal Air Sampling Results 3. Area Air Sampling Results 4. Documented Waste Manifest 5. Contractor's License 6. Contractor's Certificate of Insurance 7. Worker Certifications Please call if you have any questions, or require additional information. Sincerely, AccuTech Insulation & Contracting, Inc. Heather R. Crepeau Administrative Assistant LEIMassachusetts Department of Environmental Protection 160050238 Bureau of Waste Prevention -Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 When ane: A. FacilityLocation When filling out forms on ihC VACANT HOUSE computer,use only the tab key 1.Name of Facility to move your 177 MAPLE STREET cursor-do not 2.Street Address useNe return key. NORTHAMPTON MA D 3,City 4.State 5,Zip Code w 6.Telephone Number INSTRUCTIONS B. Project Cancelled 1. This form is only available for E]Check here if this project is/was cancelled. online time of project data revisions. 2. Enterproject decal number. C. Project Dates 3. Validate that 01/24/2007 01/26/2007 the project location is come 1.Ori incl Start Date mmlddl 2. d incl End Date mmlddl forth,entered 01/29/2007 decal. 3.Latest Revised Start Date(mmlddi 4.Latest Revised End Date(mmlddlyyyy) 4. Enter your new project dates. 5. Certify your notification. D. Revised Project Dates Submit data changes. 01/31/2007 1.Revised Start Date(mmlddlyyyy) 2.Revised End Date Date(mmlddlyyyy) E. Other Project Revisions F. Revision History EDEP: 01125/200711:00:08 AM EDEP: 01/251200712:00:12 PM OTHERPROREV: JOB WILL BE PUT ON HOLD 1/26107 DUE TO FRIGID CONDITIONS. anf06pdm.doc•rev.95104 Massachusetts Department of Environmental Protection 100050236 Bureau of Waste Prevention —Air Quality Decal umber a Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. 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. i JUDY CROWLEY I � d 1, Name A homed nature OFFICE MANAGER �0�/29/2067 Q� 2. Posilionaitle 3. Date mm/ddl ACCUTECH INSULATION &CONTRACTING 413) 563.5500 4. Re resenGn 5. Tele hone 100 STATE STREET P.O.BOX 376 6. Address LUDLOW 01056 7. Cityfrown 8. Zip Code enfO6pdm.doc•rev.2/5/04 Massachusetts Department of Environmental Protection 160050233 Bureau of Waste Prevention —Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 'rop°"a"" When filling out A. Facility Location corms toe VACANT HOUSE computer,use only the tab key 1.Name of Facility to move your 181 MAPLE STREET cursor-do not 2.Street Address use the return key INORTHAMPTON MA O 3.city 4,State 5.Zip Code m 6.Telephone Number INSTRUCTIONS B. Project Cancelled 1. This form is only available for Check here if this project is/was cancelled. online filing of project date reNsions. 2. al numb r. C. Project Dates 3. Valldate that 01/24/2007 01/26/2007 the project location is coned 1.Original Start Dale(mril End Date mmldOmyl forme entered 01/29/2007 tlecal. 3.Latest Revised Stan Date(mm/ddlyyyy) 4.Latest Revised End Date(comical yy) 4. Enter your new ,.led dates. 5. Certify your notification. D. Revised Project Dates Submit date changes. 10113112007 1.Revised Start Data(mm/dd/yyyy) 2.Revised End Date Date(mmldtllyyyy) E. Other Project Revisions F. Revision History EDEP: 01/25/200711:00:08 AM EDEP: 01/25/2007 12:00:12 PM OTHERPROREV:JOB WILL BE PUT ON HOLD 1/26/07 DUE TO FRIGID CONDITIONS. .ms6pdm dm,•rev.215/04 013 Massachusetts Department of Environmental Protection t00056z33 Bureau of Waste Prevention —Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. 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. JUDYCROWLEY 1. Namezed nature OFFICE MANAGER 129120 7 2. PoetioNritle . Date mm tltll ACCUTECH INSULATION &CONTRACTING 413) 583-5500 IAN— . Re rasentin 5. Telephone 100 STATE STREET P.O.BOX 376 6. Address LUDLOW 01056 7. Cny/town 8. Zip Cade anfO6pdm.doc•rev.215104 L0``�!!�� Massachusetts Department of Environmental Protection 100050233 Bureau of Waste Prevention —Air Quality Decal Number I\ Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 important: A. FacilityLocation When filling out mons on VACANT HOUSE computer,ter,use only Ne lab key 1.Name of Facility to move your 181 MAPLE STREET cursor-do not 2,street Address use the return NORTHAMPTON MA O ILEI 3.city 4.State 5.Zip Code 6,Telephone Number INSTRucTIoNs B. Project Cancelled 1. This form is only available for Check here if this project is/was cancelled. online filing of project dale revisions, 2Endecal nvr rojed C. Project Dates 3. Validate that the lidatd 01/24/2007 01/26/2007 the location is coned 1.Ori ural Start Date mm/dd/ 2.On final End Date mmld It the entered decal. 3.Latest Revised Start Date(mmldd/yyyy) 4.Latest Revised End Date(mmldd/yyyy) 4. Enteryournew project dates, 5, Cediyyaur notification D. Revised Project Dates Submit date changes. 1,Revised Start Date(mmldd/yyyy) 2.Revised End Date Dale(mm/ddlyyyy) E. Other Project Revisions JOB WILL BE PUT ON HOLD 1/26/07 DUE TO FRIGID CONDITIONS. F. Revision History anf06pdmooc•rev.05104 103 Massachusetts Department of Environmental Prtection 100050233Bureau of Waste Prevention —Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. 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. �7 JUDY CROWLEY */262 n A ,�u" 1. Name M�ROTetl S' nature / OFFICE MANAGER /251200 2. Posilior,Mtle 3. Date mm/dd/ ACCUTECH INSULATION &CONTRACTING 1 J(413) 563-5500 4. Re resentin 5. Telephone 100 STATE ST. P.O.BOJ(376 6. Address LUDLOW 101056 7. CitylTowo S. Zip Code anf06pdm.doc•rev.25/04 LEI Massachusetts Department of Environmental PrtectionBureau of Waste Prevention —Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 nnd ank When out A. Facility Location Whe forms the VACANT HOUSE computer use only the tab key t.Name of Facility to move your 77 MAPLE STREET cursor-do not 21 Street Address use Ne return key. NORTHAMPTON MA 3.Ciry 4.State 5.Zip Code m 5.Telephone Number INSTRUCTIONS B. Project Cancelled 1. This forth is only avallable for Check here if this project is/was cancelled. online filing of project date revisions, 2. number. C. Project Dates decal ealnumnumroje Validate that the project 101124/2007 01/26/2007 th location Is correct i.original Start Datemmlddl Colorist tl Date mmltltllvvi for the entered decal. 3.Latest Revised Start Data(mmldd 4. Enter your new NYYY) 4.Latest Revised End Date(mmldd/yyyy) project dates. 5. Certify your notification D. Revised Project Dates Submit date changes. 1.Revised Stan Date(mmlddlyyyy) 2.Revisetl End .in Date(mm/ddlyyyy) E. Other Project Revisions JOB WILL BE PUT ON HOLD 1/26107 DUE TO FRIGID CONDITIONS. F. Revision History anf06pdm.doc-rev.115104 LEIMassachusetts Department of Environmental Protection 1100050238 Bureau of Waste Prevention —Air Quality De al Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. 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. JUDY CROWLEY 9,t1;c I Name 1 _ simnaWre OFFICE MANAGER 1125121107 U 2. Positmo ptle 3. D to mmldd/ ACCUTECH INSULATION&CONTRACTING 413 583-5500 4. Re rese in 5. Tela hone 100 STATE ST. P.O.BOX 376 6. Address LUDLOW 01056 7. CityfTown 6. Zip Code anfO6pdm,doc•rev.215104 ILI] Massachusetts Department of Environmental Protection 100050233 Bureau of Waste Prevention —Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 Important: A. Facility Location When filling out forms on the VACANT HOUSE computer,use only the tab key 1.Name of Facility to move your 81 MAPLE STREET cursor-do not Z.Sheet Adtlress use the realm key. NORTHAMPTON MA 3.CIV 4,State 5.Zip code m 6.Telephone Number INSTRl1CnoNs B. Project Cancelled t. This form is only available for ❑Check here if this project is/was cancelled. online filing of project date revisions2. Enter. decal C. Project Dates decal number. 3. valldatethat 01124/2007 01/26/2007 the project location is coned 1.Ori incl Start Date mmlddl 2.Original End Dat mm dd/ for the entered decal. 3.Latest Revised Start Date(mmlddlyyyy) 4.Latest Revised End Date(mmlddlyyyy) 4. Enter your new mount dates. . Certifyyour notification. D. Revised Project Dates Submit date changes. 01/29/2007 1.Revised Start Date(mmltldlyyyy) T Revised End Date Date(mmldtllyyyy) E. Other Project Revisions F. Revision Histo anf06pdm don,•rev.215/04 Massachusetts Department of Environmental Protection 1100050233 Bureau of Waste Prevention—Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. 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. JUDY CROWLEY 11,- t. Name �1i ttibnzedPSionature _ OFFICE MANAGER �Q/i/25/2A07T 2. PositionRitle 3. Date mmltld/ ACCUTECH INSULATION&CONTRACTING 413)583-5500 4. Re resentin 5. Tele hone 100 STATE ST. P.O.BOX 376 6. Address LUDLOW 01056 7. CityFown 8, Zip Code anM6pdrn.doc•rev.115/04 Massachusetts Department of Environmental Protection 199050238 Bureau of Waste Prevention—Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 'mp°"°"" When filling out A. Facility Location ont corms computer,use VACANT HOUSE tu onllyythe tab key 1.Name of Facility to move your 77 MAPLE STREET cursor-do not 2.Street Address use the return key INCIRTHAMPTON 3.City, 4.State 5.ZIP Code ^lam 6.Telephone Number INSTRUCTIONS B. Project Cancelled 1. This forth is only available for F-1 Check here if this project is/was cancelled. online filing of preed date revisions. 2. Enter project decal number. C. Project Dates 3.0 Valide project ate mat th01/24/2007 01/26/2007 location is corzect 1.Original Start Date mmlddl 2.0' incl End Data Itldl Pore entered decal. 3. 4. Enew Latest Revised Start Date(mmlddryyyy) 4.Latest Revised End Date(mmlddlyyyy) project dates,dates, 5. Cehifyyour notlfcaeo° D. Revised Project Dates Submit date changes. 01/29/2007 1.Revised Start Date(mmlddlyyyy) 2.Revised End Date Date(mm/dd/yyyy) E. Other Project Revisions F. Revision History 1— — 7 anf06ptlmild,-rev.215104 Massachusetts Department of Environmental Protection 1100050238 Bureau of Waste Prevention —Air Quality Decal um Project Revision Notification For Asbestos Notification ANF-001 and AQ 06 G. Certification The undersigned hereby states, under the penalties of perjury,that he/she has mad 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 me and correct to the best of his/her knowledge and belief. JUDY CROWLEY C�„ A �a�,)L _�a JI_D_,�y 1. Name tl ionature _ OFFICE MANAGER /25I2d117 2. Posifil 3. Oate mm/dd/ ACCUTECH INSULATION &CONTRACTING 413 583-5500 9. Re resent 5. Telephone 100 STATE sT. P.O.BOX 376 fi. Address LUDLOW 01056 7, Cty Town 8, Zip Code anfO6pdmAoc•rev.215/04 Commonwealtn of Massachusetts 10 Asbestos Notification Form ANF-001 Decal ai Numb"amber Whenf filling out P A. Asbestos Abatement Description Imporfilin forms the computer,use a. Is this facility fee exempt-City, town, district, municipal housing authority, owner-cicculpied only the tab key residence of four units or less?❑Yes ENO to move your cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: �. VACANT HOUSE 77 MAPLE STREET a.Nam_..__ e,_of.FaGli_ry.N b.StreetAddress 'NORTHAMPTON II MA 01060 M1 a Citynom d.State e.Zip Code f Telephone Number INSTRUCTIONS 3. Worksite Location: 1.At sections of this BASEMENT 1_ST&2ND form must be a.Building Name/Building Location b.Building# n Wing it Floor e.Room completed In order to mmply with 4. Is the facility occupied? ❑Yes Q No DEP notification _ requirements of 310 CMR 7.15 5. Asbestos Contractor and the oimsion ACCUTECH INSULATION&CONTRACTING 100 STATE STREET of occupational Safety(DOS) a.Name b.Address ootiafmsmomenls of 453 LUDLOW 01056 4135635500 rnIfie CMR 6.12 a Ci �Rown d.Zi Cup e.Telephone Number AC000005 r Do License Number g. Contract Type: El Written E)Verbal h.'..ury Cvri Person i.Contact Person's Title DALE A HARDY JAS071733 6' s.Name of On-Site Su ervwercoreman b.Su ervisor/Foreman DOS Certification Number ATC AA000005 T a.Name of Project Mondor b.Pro eel Monitor DOS Unification Number 6 SCILAB AA000162 a.Name of Asbestos Analytical Lab b.Psbeslos Anal icel Lab DOS Cedifcation Number 01:1x2: 007 01/26/2007 9' a.Pm est Start bate mMdtll b.Entl Date mm/dtl 0 7:30.4:00 N/A " c.Work hours Mon-Fri, J.WOW hours Sat-Sun. 0 10. a. What type of project is this? o ❑✓ Demolition ❑ Renovation ❑Repair ❑Other, please specify: b.Describe 11. a.Check abatement procedures: 0 ❑✓ Glove bag ❑ Encapsulation F� Enclosure El Disposal only LL ❑ Cleanup ❑Other, specify. ❑✓ Full containment b.Describe z G 12. Is the job being conducted: ❑✓ Indoors? E]Outdoors? ■ ant0inap.doc•10102 Asbestos Notification Form•Page 1 of 3 1 Commonwealth of Massachusetts ■ 1000 50 238 Asbestos Notification Form ANF-001 De al Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or spice suI ted: 250 2821 —� a. oto p pes or ucts(Ilnear ) o s o er su aces square a Sailer,breaching,duct.tank F__7 38 d.Insulating cement surface coatings Lin ft, Sq R. Lin 5 3 e.Corrugated or layered paper �� 2303 f.Trowel/Sprayer coatings pipe insulation Lin.ft. Sq fl Lin.fl. Sq R g.Spray-on fireproofing Lin � h.Tensile board,wall board Sq.fl Lin.R. q i. Cloths,woven fabrics � � j.Other,please specify: 466 Lin R S fl. Lin.ft. S R. k.Thermal.solid core pipe 250 FLOORING/DEBR insulation Lm. Sq.fl. I.Specify 14. Describe the decontamination systems)to be used: TWO LAYERS OF 6 MIL POLY ON THE WALLS AND FLOOR WITH AN ATTACHED 3 STAGE DE 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: NIA a.Nam o Ilial D. I ite c.Date mmldd/ of Authorization J.DEP Waiver# N/A e.Name of DOS Official T.LOS urcialIte g.Date(mn/dd/yyyy)of Authorization h.DOS Waiver# N o 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes Z No B. Facility Description N 0 1. Current or prior use of facility: RESIDENCE 0 2. Is the facility owner-occupied residential with 4 units or less? [I Yes Z No 3 MIDDLE HAMPSHIRE DEVELOPMENT GROU 270 EXCHANGE STREET a Faciffily Owner Name b.Address o CHICOPEE 01020 413.748.5500 LLn Ci /Town d_ Zip Ce�one Number(area code antl eAension MATT MCDONOUGH 4' aa.Name of Facility Owners On-Site Manager b.On site manager Address ZI 413-537-9109 Q o.Ciry/Town d.Zip Code e.Telephone Number(area code and extension) ■ anfDOlap.doc•10/02 Asbestos Natificetlon Form•Pa a 2p of 3■ Commonwealth of Massachusetts 100050238 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) NIA 5' a Name of General b.Address �c.C /Town Z U d dd e.Tele hone Number area code and extension GRANITE STATE WC698 5513 11/Od/2007 f.Contractor's Workers Comp.Insurer .Poli Number Ih.Fxp. Date((in doM�y) 6. What is the size of this facility? 1600 I2 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): ACCUTECH INSULATION &CONTRAC 1100 STATE ST. P.O.BOX 37fi Note:Transfer a.Name of Transporter b.Address Stations must LUDLOW 01056 (413)583.5500 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 RED TECHNOLOGIES, LLC 10 NORTHWOOD DRIVE a.Name of Trans orter b.Address BLOOMFIELD 06002 860)218-2428 a CRY17. a.Lip Code e.Telephone Number 3. a.Refuse Transfer Station antl Owner b.Atldress =ENTERPRISES /Town d.Zi Code e.Telephone Number 4. MINERVA ENTERPRISES INC a.Final Dis osal Site Location Name b.Final Dis osal Site Location Owner's Name 9000 MINERVA ROAD WAYNESBURG MFinal Di=. osal Site Address c.Ci /room OH 44688 e.State f.Zip Code g.Telephone Number 0 D. Certification N The undersigned hereby states, under the IJUDY CROWLEV penalties of perjury,that he/she has read the a.Name utl ordsol Si nature o Commonwealth of Massachusetts regulations OPFICE MANAGER 0111 /2007 for the Removal, Containment or c.Position/Title d.Date mm/dd/ 310 CMEncapsul 7.1 of Asbestos,453 CMR 6.00 and (413) 583-5500 ACCUTECH 310 CMR 7.15,and that the information contained in this notification is true and correct e.Telephone Number f.Re resenti c to the best of his/her knowledge and belief. 1100 STATE ST. P.O.BOX 376 o q.Address a LUDLOW I 01056 Z h.City/rown i.,Zip Code Q anf001addoc•10102 Asbestos Notification Form•Page 3 of 3 Commonwealth of Massachusetts 100050233 Asbestos Notification Form ANF-001 Dew1N"mbar Important. A. Asbestos Abatement Description When filling out P 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?IJ Yes ❑✓ No to move your cursor-dc not b. Provide blanket decal number if applicable: Blanket Decal rv�mber use the return key, 2. Facility Location: iiii r VACANT HOUSE 81 MAPLE STREET ameaNORT of MP FMA b.St tAedress NORTHAMPTON 01060 C CitylTown d.State e.Zip Code T.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.Allseai°nscfill BASEMENT 1sT&2ND form must be a.Building Name/Building Location b.Building k o Wing d.Floor ee.Room completed in order to comply with 4. Is the facility occupied? []Yes rVJ No DEP nofifi ation requirements of 310 CMR7I5 5. Asbestos Contractor: andthe atoian of Occupational ACCUTECH INSULATION & CONTRACTING 1100 STATE STREET Safety(DOS) a.Name to,Address requitameis of 453 LUDLOW 01056 4135635500 CMR 6 qR 12.12 a C' /Town tl.Zi Cotle e.Telephone Number L l License D 5 Number g. Contract Type: ❑Written El Verbal n.Faciiny Contact Person i.Contact Person's Title DALE A HARDY AS071733 6' ANCmeI= oOn-site Su ervism/Foreman AForeman 005 Genial Number T a.he of Pr°ect Monitor b.Pro ed Monitor DOS Certification Number 8 SCILAB AA000162 a.Name of Asbestos Anal ial Lab b.Asbestos Analytical Lab DOS Cedifieafion Number 01/24/2007 01/26/2007 g' a.Pro so Start Date namlddl b Bad Date(mmlddlyyyy) 0 7:30-4:00 N/A a c.Work hours Mon" d.Wodc hours sat-Sun. 0 10. a. What type of project is this? o Demolition ❑ Renovation ❑Repair ❑Other, please specify: b.Describe 11. a. Check abatement procedures: 0 1❑ Glove bag 0 Encapsulation EnclosureDisposal only a ❑Cleanup ❑ Other, specify: P1 Full containment b.Describe 2 4 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors? anf001ap.dac•10102 Asbestos Notification Form•Page 1 of 3 ( Commonwealth of Massachusetts ■ 100050233 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 enca sulated: 250 1 1295 a. Total pipes or ducts linear oa o er su aces square c.Boiler,breaching,duct,tank surface coatings Lin ft. Sq.ft d Insulating cement Lin Sgft e.Corrugated or layered paper f Trowell5pmyer coatings 7-7 pipe insulation Lin fl Sq ft. Lin ft Sq. g.Spray-on fireproofing h.TrdnsRe board,wall board Lin ft Sq. Lin ft. q. i.Cloths,woven fabrics j.Other,please speciy: 295 Lin ft S ft Lin.ft. S ft. Is.Thermal,solid core pipe 250 FLOORING insulation Lin.ft. Sq.fl. L Speoiy 14. Describe the decontamination systems)to be used: TWO LAYERS OF POLY ON THE WALLS AND FLOOR WITH AN ATTACHED 3 STAGE DECONT 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14 2)( ): ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED INA SEALED 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: NIA a.Name o iiia b. ale c.Date mm/dd of Authorization a.OEP waiver# N/A e.Name of DOS Offidal ua ie g.Date(mmlddlyyyy)of AUWhonzation h.DOS waiver# N ° 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes RI No ° B. Facility Description N 0 1. Current or prior use of facility: RESIDENCE 0 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes Z No MIDDLE HAMPSHIRE DE 1270 EXCHANGE STREET 3' a.Facili Owner Name J.Address ° CHICOPEE 01020 413-746-550 o a Ci !Town d.Zip Code e.Telephone Number area code and extension a 4 MATT MCDONOUGH II� aa.Name of FacilityOwner's On-Site Manager b.In ,,a lana er Address Z 413-537_9109 Q c cr y/rown d.Zip Code e.Telephone Number(area code and extension) ■ mrs)(nap.doc•10102 Asbestos Natifiwfion Form•Pa eq 2 o(9 ■ Commonwealtn of Massachusetts 100050233 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) N/A 5' a.Name of General Contractor It,Address c.Gi Rown tl.Zi Cotle e.Telephone Number area ode and extension GRANITE STATE WC6987513 11/04/2007 f.Contractors Workers Comp.Insurer .Poli Number h.F�c�.Dat Ie�mMdtlNvw7� 6. What is the size of this facility? 2200 1I 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): ACCUTECH INSULATION&CONTRACTING 100 STATE ST. P.O.BOX 376 Note:Transfer a.Name of Trans orter b.Address Stations must LUDLOW 01056 (413)583.5500 comply with the c.Cdy?own tl.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19,000 RED TECHNOLOGIES, LLC 110 NORTHWOOD DRIVE a.Name a/Trans7oher b.Address BLOOMFIELD O6002 (860)218.2428 e Cil d.Zi Ce e.Tele hone Number 3. a.Refuse Transfer Station and owner b.Address c.C /town tl.Zi Code e.Telephone Number 4. MINERVA ENTERPRISES INC a.Final Dis osal Site Location Name b.Final Dis osal Site Location Ovmer's Name 9000 MINERVA ROAD WAYNESBURG o.Final Disposal Be Address d.Ci /town OH 44688 m e.State L Zip Code g.Telephone Number 0 D. Certification N / The undersigned hereby states, under the JUDYJUDY CROWLE� ° penalties of perjury,that he/she has read the a.Name dzed Signature ° Commonwealth of Massachusetts regulations OFFICE MANAGER 01/10/2007 for the Removal, Containment or c.Position/Tit. d.Date mi*Jd Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information 413) 583.5500 ACCUTECH contained in this notification is true and correct s.Tele hone Number f iR ° to the best of his/her knowledge and belief. 100 STATE ST. P.O.BOX 376 resemtlq o Q.Address a LUDLOW 01056 h.City/rawn i.Zip Code Z Q anf001ap.doc•10/02 Asbestos Nogficafion Form•Page 3 of 3 ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 7469 WHITE PINE ROAD -RICHMONN,7xnmT-- 804-2754788 FAX 804-275-4907 FIBER COUNT ANALYSIS SUMMARY CLIENT: AccuTech Insulation& Contracting, Inc. DATE OF SAMPLING: 25 Jan 2007 100 State Street, Bldg.#119 DATE OF RECEIPT: 29 Jan 2007 P. O. Box 376 DATE OF ANALYSIS: 29 Jan 2007 Ludlow, MA 01056 DATE OF REPORT: 30 Jan 2007 CLIENT NUMBER: 22-1056 A EHS PROJECT#: 2007-01-2964 PROJECT: 27-6236; Middle Hampshire Development; 77 Maple St.; Florence, MA EHS CLIENT VOLUMEfJ� SAMPLE # SAMPLE# LITERSW FIBERS/FIELDS FIBERS/CCj_'_� 01 27-6236-01 66.00 0.0/100 <0.045 <- W3 02 27.6236-02 594.00 2.5/100 <0.005 Z'.&J METHOD: NIOSH 7400, Issue 2, 08/15/94 Intralaboratory Sr=0.205 Interlaboratory Sr=0.450 ANALYST: Aubrey SiSimonds Reviewed By Authorized Signatory: WDI MichaelA. Mueller,MPH, La oratory Director Howard Varner, General Manager Irma Faszewski, Quality Assurance Coordinator NOTE: The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location, description,area,volume, etc.,was provided by the client. The submission of blank samples is required by sampling methodologies. EHS sample results(fibers/cc)are blank corrected,per NIOSH 7400,when the client submits blank samples. If the report does not contain the result for a field blank, it is due to the fact that the client did not include a field blank with their samples. This report cannot be used by the client to claim product endorsement by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full without the written consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY ELAP#11714 Method Level of Detection: Estimated at 7 fibers/mm2. LEGEND L=liters fibers/mm2=fibers per square millimeter _ fbera/cc=fibers per cubic centimeter pcm3.dot/07MAR2006/REV2/MR --PAGE 01 of 01 -- END OF REPORT-- ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 7469 804-275.4788 FAX 804-275-4907 FIBER COUNT ANALYSIS SUMMARY CLIENT: AccuTech Insulation& Contracting,Inc. DATE OF SAMPLING: 24 Jan 2007 100 State Street, Bldg.4119 DATE OF RECEIPT: 29 Jan 2007 P. O. Box 376 DATE OF ANALYSIS: 30 Jan 2007 Ludlow, MA 01056 DATE OF REPORT: 30 Jan 2007 CLIENT NUMBER: 22-1056 A EHS PROJECT#: 2007-01-2965 PROJECT: 27-6236;Middle Hampshire Development; 81 Maple St.; Florence, MA EHS CLIENT VOLUME SAMPLE# SAMPLE# LITERS(L) FIBERS/FIELDS FIBERS/CC54 01 27-6236-03 67.50 3.0/100 <0.044 02 27-6236-04 660.00 1.5/100 <0.005 4,(�J4 METHOD: NIOSH 7400, Issue 2, 08/15/94 Intralaboratory Sr=0.205 Interlaboratory Sr=0.450 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory: Michael A Mueller, H, oratory Director Howard Varner, General Manager Irma Faszewski, Quality Assurance Coordinator NOTE: The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location, description,area,volume,etc.,was provided by the client. The submission of blank samples is required by sampling methodologies. EHS sample results(fibers/cc)are blank corrected,per NIOSH 7400,when the client submits blank samples. If the report does not contain the result for a field blank, it is due to the fact that the client did not include a field blank with their samples. This report cannot be used by the client to claim product endorsement by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full without the written consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY ELAP#11714 Method Level of Detection: Estimated at 7 fibers/mm2. LEGEND L=liters fibers/mm2=fibers per square millimeter fibers/cc=fibers Per cubic centmeter pcm3.dot/07MAR2006/REV2/pd --PAGE 01 of 01 --END OF REPORT-- r ENVIRONMENTAL HAZARDS SERVICES, L.L.C. s 804-275-4788 FAX 804-275-4907 FIBER COUNT ANALYSIS SUMMARY CLIENT: AccuTech Insulation & Contracting, Inc. DATE OF SAMPLING: 29 Jan 2007 100 State Street, Bldg.#119 DATE OF RECEIPT: 31 Jan 2007 P. O. Box 376 DATE OF ANALYSIS: 31 Jan 2007 Ludlow, MA 01056 DATE OF REPORT: 01 Feb 2007 CLIENT NUMBER: 22-1056 A EHS PROJECT#: 2007-01-3280 PROJECT: 27-6236; Middle Hampshire EHS CLIENT VOLUME (' SAMPLE# SAMPLE# LITERS(L) FIBERS/FIELDS FIBERS/CC�,�! 01 27.6236-05 66.0 1.0/100 <0.045 02 27-6236-06 1032.00 0.0/100 <0.005 METHOD: NIOSH 7400, Issue 2, 08/15/94 Intralaboratery Sr=0.205 Interlaboratory Sr=0.450 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory: Michael A.Mueller, MPH,Laboratory Director Howard Varner, General Manager Irma Faszewshi, Quality Assurance Coordinator NOTE: The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location, description,area,volume, etc.,was provided by the client. The submission of blank samples is required by sampling methodologies. EHS sample results (fibers/co)are blank corrected, per NIOSH 7400,when the client submits blank samples. If the report does not contain the result for a field blank, it is due to the fact that the client did not include a field blank with their samples. This report cannot be used by the client to claim product endorsement by NVLAP or any agency of the U.S.Government. This report shall not be reproduced except in full whhout the wntten consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY ELAP#11714 Method Level of Detection: Estimated a1 7 fibers/MM2. LEGEND L=liters fibers/mm2=fibers per square millimeter _ fibers/co=fibers Per cubic centimeter pcm3.dot/07MAR2006/REV2/te -- PAGE 01 of 01 --END OF REPORT— f ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 7469 804-275.4788 FAX 804-275-0907 FIBER COUNT ANALYSIS SUMMARY CLIENT: AccuTech Insulation&Contracting, Inc. DATE OF SAMPLING: 30 Jan 2007 100 State Street, Bldg.#119 DATE OF RECEIPT: 31 Jan 2007 P. O.Box 376 DATE OF ANALYSIS: 31 Jan 2007 Ludlow, MA 01056 DATE OF REPORT: 01 Feb 2007 CLIENT NUMBER: 22-1056 A EHS PROJECT#: 2007-01.3279 PROJECT: 27-6236; Middle Hampshire EHS CLIENT VOLUME r� l SAMPLE# SAMPLE# LITERS(L) FIBERS/FIELDS FIBERS/CCyZ,L, 01 27-6236-07 67.50 2A/100 <0.044 Z.6C3, 02 27-6236-08 510.00 0.0/100 -0.005 lL. { METHOD: NIOSH 7400, Issue 2, 08/15/94 IntralaboraWry Sr=0.205 Interlaboretory Sr=0.450 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory: AMM // Michael A.Mueller, MPH, Laboratory Director Howard Varner, General Manager Irma Flaszewski, Quality Assurance Coordinator NOTE: The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description,area,volume,etc.,was provided by the client. The submission of blank Samples is required by sampling methodologies. EHS sample results(fiberstce)are blank corrected, per NIOSH 7400,when the client submits blank samples. If the report does not contain the result for a field blank, it is due to the fad that the client did not include a field blank with their samples. This report cannot be used by the client to claim product endersemenf by NVLAP or any agency of the U.S.Government. This report shall not be reproduced except in full without the written consent of Environmental Hazards Services, L.L.G. California Codification#2319 NY ELAP#11714 Method Level of Detection: Estimated at 7 fibers/mm2. LEGEND L=liters fibers/mm2=fibers per square millimeter fibers/cc z fibers ter cubic centimeter .._ pcm3notl07MAR2006/RE42te --PAGE 01 of 01 --END OF REPORT-- f ENVIRONMENTAL HAZARDS SERVICES, L.L.C. a 804-275-4788 FAX 804-2754907 FIBER COUNT ANALYSIS SUMMARY CLIENT: AccuTech Insulation& Contracting, Inc. DATE OF SAMPLING: 31 Jan 2007 100 State Street,Bldg.#119 DATE OF RECEIPT: 02 Feb 2007 P. O. Box 376 DATE OF ANALYSIS: 03 Feb 2007 Ludlow, MA 01056 DATE OF REPORT: 03 Feb 2007 CLIENT NUMBER: 22-1056 A EHS PROJECT#: 2007-02-0234 PROJECT: 27-6236; Middle Hampshire Development; 77 & 81 Maple Street EHS CLIENT VOLUME ISP SAMPLE# SAMPLE# LITERSW FIBERS/FIELDS FIBERS/CC'Vj,, 01 27-623609 75 0.0/100 <0.040 L .003'5 02 27-6236-10 225 0.0/100 <0.014 Z-Occ� METHOD: NIOSH 7400, Issue 2, 08/15/94 Intralaboratory Sr=0.205 Interlaboratory Sr =0.450 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory:Michael A. Mueller,MPH, Laboratory Director Howard Varner, General Manager Irma Faszewski, Quality Assurance Coordinator NOTE: The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description,area, volume,etc.,was provided by the client. The submission of blank samples is required by sampling methodologies. EHS sample results(fbers/cc)are blank corrected, per NIOSH 7400,when the dient submits blank samples. If the report does not contain the result for afield blank, it is due to the fact that the client did not include afield blank with their samples. This report cannot be used by the client to daim product endorsement by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full without the written consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY ELAP#11714 Method Level of Detection: Estimated at 7 fibers/mm2. LEGEND L=liters fibers/mm2=fibers per square millimeter fibers/oc=fibers per cubic centimeter pcm3.dot/07MAR2006/REV2/MR --PAGE 01 of 01 --END OF REPORT-- ANAT C 73 William F or De West Springfield, MA 01089 413-781-781-0070 Fax 413-781-3734 AS SO C I ATE s I N C . www.atcassociates.com E 'leering Individual Solutions March 21, 2007 Mrs. Gloria Jenkins AccuTech Insulation State Street, Bldg 119,PO Box 376 Ludlow, MA 0 105 6 RE: Asbestos Air Monitoring 77 & 81 Maple Street, Florence, MA. ATC Associates Inc. Project No. 81-00119-0548 Accutech Project No. 27-6236 Dear Mrs, Jenkins: Enclosed are the air sample results for the above referenced location taken on January 31, 2007. Final Clearance air samples were at or below the EPA Standard of 0.01 fibers per cubic centimeter. If you should have any questions, please feel free to contact our office. Sincerely, AT s ciat s Inc. Sandy Fa Brian Williams Project Manager Administrator Branch Manager SF/rc Enclosure S:Tfed/Cliem Files/Ac= h/00119/0548a.doc \VI llu� VM f •_ ,•.. -AIR SANIP. .GLOG Proicet Name: '77"wn�p Lf-S-I- Collection Dntc: /-3 ("0 7 DD Analysis: 1 , Project 8; Pmject Monitor. ,�/ �tG or TEM(=,me we) Client Q�-�u �' L -7 613b Project Mamlger.�J� / ' r1 I£TEMSpecuf Tumarpuud T' c: Site Location: :+ G�„;n.- F,�m/'Y -'t 1 Rotometer Number: Analyst Signature: / Uv.. Work Area: Send Rosults to: Locntlou Snmple Pump Pump: Time Plow Rate Volume LOD Actual Adjusmd Nmly'st SnmpMft nr Type On OR (Mho). (lYrM (Liters) Count Count Result U) Worker Namc/SSNfTe91t .41`10) (F/flds) . (FlPlds) (P/CC) Initials Iptl {!� Field Blank - Irm ) av Field Blank Field Blank -7 ICA 11 3.D (. 1�. -2, i b.20-2- 'WM-r Y( . .Dei j. 1.230 © `a��j 77in./�. ibIV V3'L `t�2' 30 Reference Slide Duplicate Slide Work Plusses 1)fitiea Dadgmudd 3)During Prep Work 5)During Final Clean: 7)P'ival Air Clearance 9)Associated Work 2)Prc-Abatement 4)During Removal' G)During.Glovebag Removal. S)Personal Air Sample 10) Fla=d Assessment Relinquished By: Date: :Received Ay: Dole: w F a. rq 2 y� CA . d � d^ 8 c9 A J 125 w o I. b K a i"m a�S fig, J o a^� f1 4 4 a } a � \ e•r� O \ n r 1 T laa ABiSA1VIl'. G LOG ProjectNarac; 77 A,y^Ir5 St. r-Lt, -r ALAL ColleWonDatc: D of Analysis: Pmject Il: Pruject Monitor �>tta G 1u�+ A'% 'C ++or TPM(ciree one) Client: -4, 37. LL 3�+ Pmjecc Manager. �� II d"^'S ( TEM Spem, Ttun:}r�ouod Tinto: Site Location: Aotome[crNlunbor... .Analyst SignaNte: t'1CJ�f 2 � — Work Ares u._-.� rr?>�(�.�' Send Resultsto: Lecatlea Sen.ple Pump PumpTime fi7ow Rale Volume LOD Actunl Adjwtcd Analyst Samplers or Type - " On Oft (hlan). (12" (L(ters) _Count Count Result ID worlmrlVamal3SDTl T.,k - (wo). . (r/nds).. (fMds) (F/CC) - Initials wy F"I'lu Field Blank Field Blank Field Blank - 7ws)l.;i. I ( 3S Reference Slide Duplicate Slide Work Phase: 1)I4aca Background 3)During Prep Work 5)During Final Clean. 7)Final An Clearance --9)Associated Wodc 2)Pre-Abatemeti[ 4):During Removal 6)During Glovebag Removal 3)Personal Air.Sample 10) Hazard Assesurneut Relinquished By: Date Received By; Date: ( INV` .., .. AIRSAMPi G.LOG Project Nettie:"7 e. : /vinpa 5J }-5.0o ColleclirntDate: �i I � u7 _ ➢ateo nalysis: �' 3)• Project$: Project momtor. PCM TDM(cii'cc one) Client: Project Manager. ISpecify TuTuner---- Mal �• Analyst Signature: Site Location: ✓�.�' nr;�" RotometerNwnber. Y WorlcArea: 'l:lz ,,�,�..:I--.L .: Send Resullsto: Lacatieu Sample Ptnnp Pump: Time raw Rata Valuue LOD Actual Adlusted Analyst Sample ur Type. On Off (MR,) (LPM) (liters) Count Cutout Result. ID ,. Wedmr Nnmc/s5N/18s1r Elle) /k'lds) . (r/Plde) (P/CC) burials Field Blanlc rl�ld BlRmli: Field Blastic ' 77rn4.37. t._ , ) 5+ ro�.�. o ' �'�, 23'° m�� -�,7. 0e 40..0-2- Reference a.,0vReference Slide Duplicate Slide Work Plrnse: 1)Area Badq;ronnd 3)During Prep We& 5)During rind Clean 7)Final Air Clearance 9)Associated Work 2)Plc-Ab attaneut 4).During Remwd G)During Oftwebag Removal.. 3).Personal Air Sample 10) FLmstrd Assmameat Relinquished Dy: bate: Received By: Date:. ,.. .. wwc DAILY SITE LOG Page__o!__ tjec ie: 1749.1 NtiY�gt YAC/-(p r%e.o a,,.. Date: /,07 / jest N' l 7I, Pmjen Moai[oc c� eat: Z'7- G236 Project Manager. TIME .OBSERVATIONSIACTIONS AV- 04e L ------ ----- � r -- r vr- h.S idA C�,vr - a .,..3�✓ ^ (rv„�,,-�6' j np; r�).c�. . ,Fk •�ewe C�.*Ta..l/�t��rfS ]� 7 / m 1TC Rep resenmtive Signemre �r��'li,r., j--� Title q,thr.7 CertN 'i2f 1 r MAL CLEARANCE CHECKLIST SITE: 7-;1 Sties Du S- e c 2ev.t e- JdtR-, HYGIENIST: y CONTRACTOR: PROI NO.: DATE: /-g SISPERVISORt �yt1 Fa r; t t iw DESCRIPTION: Sprayon_, Plaster_, Boiler—1 Pipe_, GFovebag ABATEMENT: Removal v Delosure Encapsulation_;_ $1�Gtbtu,k. W:aalS I. Contaimmut - Yes No i4.rt Aemarks Giovebag Critical Barriers (Q--r Remaining '-- 3 ' 47�.z. -S�Ucic. Lle.A4S Areas Posted DeeonChambers in Place HVAC Off/Sealed IT. HEPASystetn . Operating. -III. Work Area - All abatement contractor equipment removed Asbestoswaste removed Area vacuumed Wet cleaned i Area is dry Decon unit clean Floor, ceiling&. -� walls clean -. Removed surfaces clean _ Certification of Visual T Insp ction Area surface lockdown (encapsulated) . IV, Final Air;Sampling !I yl Square footage area sampled Volume of area sampled ?!?K7 Number of moms TIL.w.;.° .,- Aggressive sampling Yes '"� N ' No' of samples LC No. of samples O.C. Analysis PCM v ERI— PA-7 / CERTIFICATION OF VISUAL L SPECTION CLIENT: '�wVyJ. rb PROJECT NUMBER. GENERAL LOCATION(bldg.Name,street, etc,) -77 ABATEMENT CONTRACTOR:. METHOD OF ABATEMENT: h^NM .S... TYPE AND QUANTITY OF MATERIAL ABATED L'a SUSPECT MATERIAL REMAINING IN V✓ORK AREA: . Gw 5�i s l.x.�dw cIL- ` SPECIFIC AREAINSPECTED:� CJ/V'r✓-0irJhWWS /' _ a'� <l. d.a +t CiG[�"L �, � tc,b- CERTIFICATION OF VISUAL INSPECTION In accordance with Specification for this project and..any applicable regulations the Contractor hereby certifies that he has visually inspected the work area(all surfaces including pipes, beams,ledges,walls, ceiling and floor, decontamination unit, sheet plastic, etc.) and has found no visible dust,debris or residua - - By: (Signature) -. Date: 1131167 (Print Name) A,e- 1�j o ii em---3 (Print Title) S;!P-Q-( v,`7 Accreditation Number 1S 74 Y17 - State44A OWNEWS REPRESENTATIVE CERTIFICATION The Owner's Representative hereby certifies that he has accompanied the Contractor on visual - inspection and verifies that this inspection has been thorough and to the best of his knowledge and believes the Contractor certification above is true and honest one. By: (Signature) s ww=� Date: � . rJ (Print Name)(Print Title)Title) Jo Accreditation Number _. �/l'Ov` State: Ur�Y" E.P.A. AGENCY # 4036 REDr. pTECHNOLOGIES,MLC .GCT, MA RI,VT, NH, ME NY GENERATORS GENERATORS EPA Region 2 Ri achnologies,LLC EPA New England 290 Broadway, 26th Floor 10 Northwood Drive 1 Congress Street New York, NY 10007-1866 Bloomfield, CT 06002 Boston, MA 0211 4-2 02 3 (212)264-6770 ;860)218-2428 (617)918-1111 rK#40A ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # 27-6236 GENERATOR/BUILDING OWNER Dontractor Acculech Insulation & Cont-racti.ng Middle Hampshire Development Group Address 4ddress 100 State St. P.C.Uox 376 City C' state_270 Hxchanaoe St. _ miry Ludlow State MA Zip 01056 Cinicopee rU1 Z"_01020 telephone Number (413) 583-5500 Phone Number (413) 748-5500 Date Container Del. 1-14-07 Date of Pickup-3-2-07 GENERATING LOCATION vacant House type of Container 100CY Addrass ✓GLUME 19.92 CY Friable d Non-Friable ❑ 81 MapleStreet MUST BE IN CUBIC YARDS city Florence state MA Zip 01060 42Bag 0 6 Drum 13 T-Pack ❑ Wrapped ❑ Other 01 Phone Number certify the above named material does not contain free liquid as defined by 40 CFR part 260.10 or any applicable state law,is not a hazardous waste as defined ry 40 CFR part 261 or any applicable state law,has been properly described,classified and packaged,and is in proper criterion for transportation according to JESHAP standards for asbestos waste disposal found in 40 CFR part 61.150. shipper's Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are aassified, packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national government regulations. 4l IORIZED SIGNATURE - f rransporterl:AtccuT'ech Insulation & Contracting 100 State St. Ludlow,MA 01056 (413) 583-5500 yam_.. Nyne Z s Address Telephone# Driver: �,GC�7.�-L��_ .rh-!r✓C�Registration#: MA F22-383 Date: 1-24-07 Signature State/# Acknowledgement of receipt of materials rransporter2:E,,l Te hnologies LLr' Rlnai ipld� rT (160(12 86U-�l R-�L�A Nam3y. Address �'/� Telephone# Driver: / Registration If YJ -A Date:.'3—.:Z--C�7 r 3c3ng St. Port an - -1022 Permit 1130670-PO Acknowledgement of receipt of mater transporl Swift Transportation 3154 RT. 72 Jonestown, PA 17038 800-523- 099 Namepp�� Address Tele )river:y�_W d/a/lt. W-lV1A/ � Registration th Dater Signature Z State/# Acknowledgement of receipt of materials andfill Name: Minerva Ente-,prises Phone No: (3X) 866-3435 -ocation: 9000 Minerva Rd. Uavnesbur OH 44688 PornI 2005-9 4p timate Volume of Asbestos Received: Discrepancy If Any: Received by: 136ta: 7001 MAR -8 Ce IlfetlPr transfer of materials covered by this mcnifest F� GENERATOR E.P.A. AGENCY # RED TECNNOLDGIES,Vut REMEDIAE N EVE M CT, MA RI, VT, NH, ME NY GENERATORS GENERATORS 4035 EPA Region 2 Ri achnologies, LLC EPA New England 290 Broadway,26th Floor 10 Northwood Drive 1 Congress Street New York, NY 10007-1866 Bloomfield, CT 06002 Boston, MA 02114-2023 (212)264-6770 ;860)218-2428 (617)918-1111 TK# ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # 27-6236 GENERATOR/BUILDING OWNER Dontractor Acculech Insulation & Contracting _ Middle Hampshire Development Group Address 4ddress 100 State St. P.O.Box 376 _ _ _ 970 Exchange Rt _ -ity Ludlow _ State MA Zip . 01056 City Chicopee state MA Zip 01020 Telephone Number (413') 583-5500 _ Phone Number- 413) 748-5500 Date Container Del. 1-14-07 Date of Pickup 3-2-07 GENERATING LOCATION rype of Container 100CY Vacant House ---- Address _- -- VOLUME 5.02 CY Friable O Non-Friable ❑ 77 Maple St. MUST BE IN CUBIC YARDS cry Florence state CA Zip OlObO d Bag Q 4 Drum ❑ T-Pack ❑ Wrapped ❑ Other ❑ Phon,:N°m❑er " certify the above named material does not contain free liquid as defined by 40 CFR part 260.10 or any applicable state law,is not a hazardous waste as defined ,y 40 CFR part 261 or any applicable state law,has been properly described,classified and packaged and is in proper condition for transportation according to JESHAP standards for asbestos waste disposal found in 40 CFR part 61.150. ihipper's Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are aassified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national lovernment regulations. 4L 10RIZED SIGNATURE rransporter 1: AccuTech Insulation & Contracting, 100 State St. Ludlow,MA 01056 (413) 583-5500 Driver. 6me Address WA F22-383 Telephone P (/'-e�T'-r'---��iegistration fi: Date: Signature State/# Acknowledgement of receipt of materials Red Technologies LLC Bloomfield, CT 06002 860-218-2428 rransporter 2: / / Name Address �,` Telephone# Driver L�e,�.G Registration#: G'r j' 7 .'E Date: 3-d-- 07 an�g�tmgl,C 203 Pickering St. Portland CT 06 e g0 342-10 2 Acknowledgement of receipt of material rransporteS ft Transportation 3154 RT. 72 Jonestown, PA 17038 800-523-70 {� Name Address Tele ho e# Driver:d��✓77114it Registration#: Date:30 7 Signature State/# Acknowledgement of Receipt of materials Andfill Name: Minerva Enterprises Phone No: (330) 866-3435 -ocation: 5000 Minerva Rd. Waynesburg, OH 4468E _______?Crmit # 2^05-9 Np ximate Volume of Asbestos Received: Discrepancy If Any: I-tg 3eceived by: MIR'tR aA Ep31 t Date: 1001 NiA&R,lxatfon o transfer of materials covered by this manifest GENERATOR ')MM01 ,E .CHOFA SAC_,SUIS 1 d' nar.ei � abor eno k ro Dec lu.+n n DMA6nofOcesarmt,enal4aCety cA v.nyCc� Sher _tI, FIoc),Fw.tn si08 A4S@:STQS CONTRACTOR LIC.ENSIE aC ;t!T6C ' (ti$Ui,4TiON &CONTRAC f NG. INC. Ctr *ATL SIR_ET FUILNK", LUDLOW VIA OI656 �-T(`WsfE. AC000005 EXPIRE-S, Sunday..tprii 22,200 N ACCORDANCE WITH NCL CH 149§IA AND dH-, CMR 60 I 'HIS CE'RTINCATE S [SSU EU BY THE DLPAR7 KILN f Of LABOR AND WO dk^'ORCE PPYELCTMEN" D!VlblON OP OCCUPATIONAL SAI EYY FOR 'ME PURPOSE OF£NTELING IN J-0 OR ENGAGNG IN'ASBFSTOS WORK. T I'I !CFN'SHIS VALID i°OR A TE%K?t}GF ON@pl YEAR i Reb.(1!. P:czios::.Gan:missinner Ci r ANBD,„ CERTIFICATE OF LIABILITY INSURANCE O7130t2 7) PRQ UCER (413)586-0111 FAX (413)586-6481 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Webber & Grinnell Ins, Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 8 North King Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. rthampton, MA 01060 INSURERS AFFORDING COVERAGE MAIC# 1XsuRRD Accutech ation & Contracting, Inc. INSUA DRA. American Intl Specialty/DVUA PO Box 376 , INSURER-. CRH/Pilgrim _ Ludlow, MA 01036 INSURERC Commerce & Industry/DVUA IrvSVAERD INSURER E'. COVERAGES THIPOLOU S OL MSURANI LISTED BELOW NA%e BEEN ISSUED TO THE INSURED NAN EDABOVE FOR THE FOLICYPERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT',TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AMC)CONDII HONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —_.. —.. IXSR XOD' IS9 OF INS.III POLICY NUMBER ACBI EPFEC IVE POLICY PYPIRAiION UNITS .........m� SAT= XM vom GNC AeaPROP9342961TY � 11/04/2006 11/04/2007 . EACs oc uRRE E $ 5,000,00 X c MERGIIt`CENENALVADY11 . { rDAMn E T.PENTADIT, `= 0090 .� CIAMSLASE MCLC MEn fy.Pl �s 5 00 A naso -CA11 ALLEY s 5,000 AO GEI ai cl ELATE s 5,000,000 cENLAGGEEGATEUMrt?PpUELE.G PRDOUDT -(4WYU`AGS S 5,000, j FOLICY� �L.T _ AUToxoeILE LIABILITY PMC7123414 02/01/2007 ' 02/01/2008 COMBRIEDENGEEL.11' Arn Amo tEa«wn,d i 1,000,000 ALL 06NED AUTOa B.SI-YINIUHY . B X SCGEOG eDAJTG5 EP L. — X HIRED ALYCE BGDILY INJURY X NON-OWMEDAUTDy (P=,acGaenu P>8OPER¢DAMAGE s GARAGE LI4&ULY Au i'C aNty-eFl<caC.rN! 5 ANY G111 aTHERTHAN EAACD s ADTO ONY AGG E EYCESBNMBRELLA UNAUTY '— EACH OCCURRENCE $ OSC.P CLAIMS MADE AGGREGATE S E bEOUCTIBLE S REIENTICH 5 E WORKERS COMPENSATION AND WC69 77513 11/04/2006 11/04/2007WC GTATG EL EACH ACCIDEPo R S,OOg, pNY PRDpWETORiPARiH,$t£%ELUiIK OFFICEGNENBEA EXCLUDEO, EL.DISEASE�GEMPLOYE E 1,DnD,DD RYwe oI -1— smsCIAiPiro'nSIONSeA— E L.DISEASE.POLY LIMIT I E 110001 OF PROP9342961 11/04/2006 11/04/2007 5,000,000 Occurence A OITution for 5,000,000 Aggregate batement Contractors DES..101IOR OF OPERATIO.S I LOCATIONS I VENICLES I ESCL.510NB ADDED BY END7sEMBNTI SPECIAL PROVIm.NS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TEE EX'PIRATION OATS TUNBRIDGE,THE ISSUING IMAEUE WILL ENDEAVOR TO MML p DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE USD. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLWATWN OR GAME TTE Of kHY KIND UPON THE INSURER ITS ASSETS OR REPRESENTATIVES. For Snsuran a Verification Purposes AUTHORIZED REPRESENTATIVE1pi A /i dE Richard Webber CINDY 1b" X& ACORD 25(2001/08) CIACORD CORPORATION 1988 Commonwealth of Massachusetts Division of Occupaf/oml Safety R.qJ R 11 Gnmmsswnsr Asbestos Supery"�sor . BRANDON E, BESAW EH O to IDtl :C6 0 E U t 10il O,% A3OIN09 07 xex rv�.� IIIIIIIIIIG�IN�llll!I�IIInIN�lll�llllQll�l � soa�� INSTITUTE FOR ENVIRONMENTAL EDUCATION, INC. 16 TE Drive, Wilmington, MA OS$87 (Phone) 978,658,5272 This is to certify that I EZ i Brandon E Besaw 1 has completed the requisite training, and has passed 1 an examination for reaccreditation as: jAsbestos SupeMsor Refresher pursuant to Title It of the Toxic Substance Control Act, 15 U.S.C. 2646 + October 3_2006 i COvse Oates IIf �,p�+r�lticatmn ` October 03.2 06 rngtttate ttla Ed�catmn (}CfO�E,y�73 2(107 ( EF.P Ilslel❑ate 16 U'wo Ddve E,,wsWn feta r � WiYmiyon Mr. asAal 06-4641-204-202302 CegHkale Numner Pre9itleoVDU¢Ctoe otRafn�mg (i CERTIFICATE OF ACHIEVEMENT This cert;fits drat Brandon Besaw has successjadly complowd 11:e 40 Hour Asbestos Abatement Supervisor/Contractor Training Asbestos Accreditation Under TSCA Title 11 l 40 GFR Fart 763 S 3 conducted by C;'orr-TestIAfC Ertviranmentut, Inc. .. 39 Spruce SL'ee1 Gast Longmeadow, M4 01028 (413) 525-1198 ��✓��'�" �� 1'rinrtpallum¢ror ReyiannlMnnagrr March 11-I5, 1996 SAR-2413 ee l Ce.rjmie umner - A4arcA13, /D97 Mmch 15. 1996 Nation Os([ h k OCCU-HEALTH OCCUPATIONAL HEALTH AND COMPLIANCE SERVICES 200 North Main Street • East Longmeadow, MA 03028 • (413) 525-600 • FAX (413) 5--15-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORT TO EMPLOYER Employee Name:&,��_ld�y .�` 1_ S54 �ate: l ' Lead Exposure _ P In accordance wish The Department of labor p Industries,I have examined the above nametl person today. Based on the results of my physical examination,there Is no evidence of a medical condition whico would Pace andhyr health at increased ask of impairment die 0 tech exposure- Asbestos Exposure This employee has been informed of the results of this examination and any medical conditions that may result from asbestos exposure and has been wamea of the increased risk attributable to the combined effect of smoWng and asbestos exposure. IT, accordance Mtn O.S.H A.Standard 29 GFR 1928.58,I have examined the above named person inch,arc foilnd hith.`re, Medically qualified with no restrictions: This employes has ro detected measat conditicns that would place himdher at an increased risk of material health mpairment from exposure is asbestos. There is no restrictions on the use of a respirator or personal protective equipment. Modically qualified with the following restrictions: Tis fols+dnp meetcal mnawon e%Iset that places this employee at an increased risk of material health impairment from exposure to asbestos (see Comment). Medically unqualified Respirator Clearance The above named employee's relevant health history and physical examination results were evaluated The reported field conditions of the job were also revlewed. Based on this review,this employee is: Cleared for full respirator use Cleared for restricted respirator use as follows (Circied): lfluscsikun, 11t; tttivj� 058t steels, Glee-isA. Not cleared for respirator use - COMMENT: _.... ----1--x �� _ Medical Examin spa a \\\ rccuTQCh INSULATION & CONTRACTING, INC. \` STATE STREET, BUILDING #119 1-800-244-8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WEE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Brandon Besaw Date: 10/2/2006 License#: AS070407 EMPLOYEE# 145 Company: AccuTech Insulation & Contracting, Inc. B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure Manufacturer: North Model: 7700-30L Approval TC21 C152 Size: Large PAPR: RACAL: Model: Powergow Approval * TC21 C152 ISI: Model: Typhoon Approval #: TC21 C152 Name of Test Conductor: Anthony Roy Employee Signature: C. Test Results i X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes _Employee Fails Expiration Date: 10/2/2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts D'.'sli n of Occupational Safety RMAs esU,,. Co rft so » Asbe5tcs N/a�iwr MIOUFL A REYNOSO ft Lep Dat 0-MIC X nW0 21R � PS�NN y�t �t99 ff ap 54 �. ER 1'I ICA`I'E (� AC`FIILVEMENT Th Z� crrrrn; ihnr � � IVligael I�eynt�sQ �' � � I ' hn v t�cs7irin r 3 +rFlerec+ F'te � � 1 g 1;edr asbestos Rof kcrifl anther RefrcOler Trrinin„Cwtrse Asbestos Accreditation tinder SCA Title 1140 CFR P3rt763 unxf�U t hr �• , � )1 illiivnt 1, ml s hire I(ei Sj>rirn;jicid if 61Of�a t (4N) '8I46'iF 7i ' a' 4 ---- nillX2.y hm _ — I d t _J 7 1 phi �� WNYlNvivlfl uuse W_,W c c c. F Ct�,tl aYtE do U �� b��t�s atcdit,tiunof f�b .isV',esus Esc \hc ccgd�ruii�CIA Ioc & A o6� pacsonat t� �l(}� )) / }LS l6,'�Oi ci 9<) hnr \.7r l�),16, 1is AcnA� Jul,- L?ele� i OCCU-HEALTH _.CUPATIONAL HEALTH AND COMPLIANCE SERVICES 00 North Main Street e East Longmeadow, MA 01028 . (413) 525-6003 . FAX (4!3) 525-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORT TO EMPLOYER Employee Name: (,�,d ` SS#. _ vJ�L'/ Date. , // Lead Exposure t- / in accordance with The oepartment of Labor&industries,i have examined the above named person ieday. Based on the results of my physical examination,there is no evidence of a medical Candlish which would place hisfher health at increased risk of impairment due to lead exposure. Asbestos Exposure This employee has been informed of the results of this examination and any medical conditions that may result from asbestos exposure and has bean warned of the increased risk attributable to the combined effect of smoking and asbestos exposure. In acwrdanc O.S.i Standard 29 CFR 1926.58,f have examined the clove named person today and found hirNher' Medically quallfied with no reetrictli)rl This emplovee has no detected medics conditions that would place himmner at an increased risk of material heann impairment from exposure to asbestos. There is no restrictions on the use of a respirator or personal protective equipment. S C Medically qualified with the following restrictions: iris following medical conaltun exists that places this employee at an increased risk of material health impairment from exposure to asbestos (See Commend). _ Medically unqualified L Respirator Clearance The above named employee's relevant health history and physical examination results were evaluated. The reported field condi4lon f the fob were also reviewed. Based on this review,this employee is. Cleared for full respirator use Cleared for restricted respirator use as follows (Circled): No SCBA use, No heavy exertion, No exposure to high heat stress, Other(See Comment) Not cleared for respirator use 1: COMMENT: CC a� r. edical Examiner ro- .ea \\ fic( ch INSULATION & CONTRACTING,INC. STATE STREET, BUILDING #118 1-800-244.8773 3r P.O. SOX 376 (413) 583.5500 LUDLOW, MA 01056 FAX (413} 583.5555 MASSACHusETi5 CERTIFIED WEE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information i Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Miguel Reynoso Date: 612112006 License#: AW072117 EMPLOYEE# 244 Company: AccuTech insulation & Contracting, Ina B. Respirator Information Respirator Type Selected: 112 Face Negative Pressure Manufacturer: North Model 7700-30M Approval 9. TC21C152 Size. Medium PAPR: RACAL: Model: Powerflow Approval#: TC210152 ISI: Model: Typhoon Approval#: TC21C152 Name of Test Conductor: Anthony Rov _ Employee Signature: C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes _Employee Fails Expiration Date: 6121/2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts Dims:on of Occu�aEionaf W iy Asbestos 5 Fe v+sor 3 fi STEVEN TAVERNI6R 0 late A06fo ... _ f15 0" ( 3?L9 � t rp _�. will i if 1,60dlA<�l 1,2.11 7 •t ,u� .�. so�Saq�X :Q� sat='"Pu`U(1 gO�IBS.i�a� al31 VOSl �pulU}aal olsagsV JnoH 8 G y�ed 21d� Qv usirloo 00/josis aaggaA�a� • „ crti.l t 1 1in(Z jok w A- 0 .. � rlttil H1H 'aQ 44 �n43 YpN- 3� lJ1^� IJ e� i)an `this i erdif � Stephen Tavernier �" �� eanp(eted d,e lly tractor �rainin8 has success.ltt . gatierviso63 �IGAILon-itle It er �1 40 tlonr Asbestos pccred�GCit past d Ns 40 �otld�tGad b1' .t IncA'rc AS."ClOtet' ef g i9 SF'wce JtrA Dlp?8 nacad�w, � � Lust 3'��A 7 3) 525-t t�b R4afoGdM 9 ' 2636 40S—S-_. 2003 -50 Y Y) � e tb�Up3 f„J o p0� t -HEALTH UPATIONAL HEALTH AND COMPLIANCE SERVICES 0 North Main Street • East Longmeadow, MA 01028 . (413) 52S-6003 • FAX (413) 525-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL eY��L_C{_Q__ REPORT TO EMPLOYER (� Employee Nam ,/n,.�rn�Y�G�'7c .7 ssg- - 0 f Date: Lead Exposure ' X In accordance with The Department of Labor 8 Industries, I have examined the above named person to ay. Based on the results of my physical examination,there is no evidence of a medical condition which would place his/her health at increased risk of impairment due to lead exposure. Asbestos Exposure This employee has been informed of the results of this examination and any medical conditions that may result from asbestos exposure and has been warned of the increased risk attributable to the combined effect of smoking and asbestos exposure. In accordance with O.S.H.A. Standard 29 CFR 1926.58, 1 have examined the above named person today and found him/her. Medically qualified with no restrictions: This employee has no detected medical condition=_ that would place him/her at an increased risk of material health impairment tram exposure to asbestos. There is no restrictions on the use of a respirator or personal protective equipment. r Medically qualified with the following restrictions: This following medical condition exists that places this employee at an increased risk of material health impairment from exposure to asbestos . (See Comment). Medically unqualified Respirator Clearance'L' The above named employee's relevant health history and physical examination res, ob were evaluated. The reported field conditions of the job were also reviewed. Based on this review,this employee is ^� Cleared for full respirator use Cleared for restricted respirator use as follows (Circled): No SCBA use, No heavy exertion, No exposure to high heat stress, Other (See Comment) Not cleared for respirator use COMMENT: ar I i Medical Examiner 4 so seIf �CCCITQCh INSULATION& CONTRACTING, INC. STATE STREET, BUILDING #119 1-800-244.8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WBE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Stephen Tavernier Date: 6/20/2006 License#: AS073309 EMPLOYEE# 497 Company: AccuTech insulation &Contracting. Inc. B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure Manufacturer: North Model: 7700-30M Approval TC21C152 Size: Medium PAPR: RACAL: Model: Powerflow Approval#: TC21CI52 ISI: Model: Typhoon Approval#. TC21C152 Name of Test Conductor: Ant n Ro n Employee Signature: C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes _Employee Fails Expiration Date: 6/20/2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commbnweakh of MassachassHs Division ofDaaupaflone sarety j P,ovIJR Awe,C&mmIvxro Asbestos Supervisor TYRONE P. TILLMAN Ul nme iz"2V 5 HMp.1LIP 52l2N07 7/ '—�- A34l53F8 Mo OC.0Ncd. t<. uygq� ��,,pppp ugup �� pp�fererA��'y'tpNttµnq��pppp � �HMp�11 �&RMMIdR)k�� sv.at» .� s�p»yy `111111, 11 11111111ftIg FRT H('.VIT, ( w A(, ' 1111 -YEA417INT r"yrone Tillman has it W111/1 , jrrcicd r)rc a •' g it Hour Asbestos Supervisor/Contractor Refresher " r b Training Course ` Asbestos Accreditation Under TSCA Title H 40 CFR Part 763 .,, nnrcral br f 1(' {nsoadlcd Grr H+lli:uu fi�urf,-� rlrrn a,v�jv-iegfirdd :161 f11OV, 110 f, h �. Ll Iq 0 + ,r :� ie. Ku o�e�iUn'aCt 7ra��tn9 sli 11 supe'vtso7S�p Title II has n LjndeY bateme�t 4o Noot Apsbesto A 40 CFIR Part 763 r d j" r 9 t .1 illcVu i il,t Ji"It ,) v Agg r� occu-HEALTH OCCUPATIONAL HEALTH AND COMPLIANCE SERVICES 200 North Main Street . East Longmeadow, MA 01028 . (4I 3) 525-6003 . FAX (413) 525-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORTTO EMPLOYER J Employee. .._ Daie'_s= C/! Lead Exposure In accordance with The Department of Labor It Industries, haveamirad the above nemaa person lcJ y. Based on Ne results of my physical examination,there is ne evidence or e medical coedition which wolfs place hisrher health at Increased risk of impairment doe to leatl exposure. Asbestos Exposure This employee has been Informed of the results of this examination and any medical conditions that may result from acres^s exposure and has been warned of the increased risk attributable to the combined effect of smoking and asbestos exposuren accordance with 0$.4.A. Standard 28 CPR 1926.58, 1 have examined theabovenamed person, today antl found him/her- =\'' 'Medically qualified with no restrictions: This employee has no arrested medical ccmiuo^s' that would place him/her at an Increased risk of material health impairment from exposure to asbesioe There is no descriptions on the use of a respirator or personal protective equipment. Medically qualified with the following restrictions: This following medical commtar: exists that places this employee at an increased nak of material health impairment from exposera to asbestos (See Comment). Medically unqualified Respirator Clearance The above named employee's relevant health history and physical examination results were evaluated Tne reported eels conditions of the job were also reviewed. Based on this review,this employee is: M Cleared for full respirator use Cleared for restricted respirator use as follows (Circled): No SCRA use, No heavy exertion, No exposure to high heat stress. Other(See Comment) Not cleared for respirator use COMMENT: Medical Examin`_��r dollars 1 *\g%STAT,E uTQch INSULATION & CONTRACTING, INC. STREET, BUILDING #119 1-800-244-8773 P.O. OX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WBE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Tyrone Tillman Date: 7/19/2006 License#: A8071378 EMPLOYEE# 722 Company: AccuTech Insulation & Contracting, Inc. B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure 'I Manufacturer: North Model. 7700-30M Approval#: TC21CJ52 Size: Medium PAPR: RACAL: Model: Powertlow Approval#: TC210152 ISI: Model: Typhoon Approval#: TC21C152 Name of Test Conductor: Anthony Roy Employee Signature: C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes —Employee Fails Expiration Date: 7/19/2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts i Division of occupational safety FOC IJ RObam Corcrmisspre Asbestos Work.* EOGARGQ VERA ETI D.* 0425 0 t L,, Dale WMIQ7 71 wot oes s M« V, lila ,tor Training onip�eis ontr?tis ii riot>SuPender TSCA Ti 4,n` eucce en Asbestos ,r edita Part TAT ti9 Abatem tion 40 Wour Asbestos A 0 SPR i 0 v u x q m ri OCCU-HEALTH OCCUPATIONAL HEALTH AND COMPLIANCE SERVICES 200 North Main Street . East Longmeadow, MA 01028 . (413) 525-6003 • FAX (413) S2S-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORT TO EMPLOYER Employee Name: nb `-Pa SS#: �Za Date: .(_. Lead Exposure In accordance with The Department of Labor&treasures. I have examined the above named person today. Based on the results of my physical examination,there is no evidence of a medical condition wr ch would place his/her health at increased risk of impairment due to lead exposure. Asbestos Exposure This employee has been informed of the results of this examination and any medical ocndfions that may resuii from asbestos exposure and has been warned of the increased risk attributable to the combined effect of smoking and asbestos exposure. In accordance "h O.S.H.A. Standard 29 CFR 1926.58,1 have examined the above named person today and found himlheo Medically qualified with no restrictions: This employee has no detected mescal conditions that would place him/her at an increased risk of material health impairment from exposure to asbestos. There is no restrictions on the use of a respirator or personal protective equipment. Medically qualified with the following restrictions: This following medical condition exists that places this employee at an Increased risk of material health Impalement from exposure to asbestos (Sea Comment)_ Medically unqualified Respirator Clearance The above named employee's relevant health history and physical examination results were evaluated. The reported field ccidifft S of the job vRre also reviewed. Based on this review,this employee is: Cleared for full respirator use Cleared for restricted respirator use as follows (Circled): No SCBA use, No heavy exertion, No exposure to high heat stress, Other(See Comment) _ Not cleared for respirator use COMMENT: fl' t` ",17riP [fo- LSA Medical Examiner 904.98 AccuTech INSULATION &CONTRACTING, INC. STATE STREET, BUILDING #119 1-800-244-8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WSE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Edgardo Vera Date: 4/26/2006 License#: AW074089 EMPLOYEE# 748 Company: AccuTech Insulation & Contracting, Inc. B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure Manufacturer: North Model: 7700-30M Approval#: TC21C152 Size: Medium PAPR: RACAL: Model: Powerflow Approval#: TC21 C152 ISI: Model: Typhoon Approval#: TC21C152 Name of Test Conductor: Anthony Roy Employee Signature: Aa ,, �-w U a—c__, C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes Employee Fails Expiration Date. 4!26!2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts Division of Occupational Safety Asbestos Sunorviser DALE A HARDY ~ Elf Date 0]11&05 Era Date 0711M6 � A50]t]33 �I11111111IINIHIII III III PIIII � s ; � i r Ow :AC 'II11A IA11 "N' l Coale Hardy 4� it-Hour Asbestos Supervisor'Contractor Refresher 8 Training Course Asbestos A .aeditati( n Under TSCA Title 11 40 CM Pait 763 00 f) �Lf f: � �>�q " ' ''a y_ ♦ a o3.a 7 A�.4 F M P -. '4 5 aBt s 8"V, '@F � .l°� 4?'`'4 j � i� ��} �� Y�` � �. "°,..':'"erg '° ��,,. � "p ��."'�,s,�y.. .�;..,,r.3� ;�;... �«e.�,.. � .e'�.-7�p•.mV'� '°'�'' mT"';� CrRTJF1CATF ori A c i I I IN LN Ii" I ho , cI liflea lhol { Bale Hatrtly I hers nlecessfilllp co!Ilple/cd the {� '10 Hour Asbestos .Abatement Supervisor/Contractor Training ��- /Osbestns Accreditation iNnJer T5C/! Title If 40 CfR Part 763 randurrI'd nr A I C Axsacinle.e Inc. 39 Spruce So('P't liar) Long n},mcudm , A 1,1 011)IN 7 A (ala) SIS llIlls, iugust 10-14 199.8 4OSS-2751 rNlb,l� — C r1f- r-h iiG:r August If, 1999 -_ _ Augam 14, 1993 -4sy�i�nrioiilMm 1:rn�o niton OCCUPATIONAL HEALTH AND COMPLIANCE SERVICES ` 200 North Main Street + Ezst Lgnomeadow hiA 01028 ME')!CA, SUR /k,C_LAhIUE EXAM:NA ON -'rr".A- , Lead ExposulIe ' Based on the results ai my pEtpsiGaf exainlaatiore trice is se ttler 't:;m r � ... zP.,veuld nl ^e`ism rn aiFl+et rncr_esep ssk of rmpa �m i= oatirn Asbestos Exposure This It I Ye,has be en i Ifnrmea of the res'its of this evaminatc a,,'ae,—,d ilnd conn,ai, t e' .:I .wnestoI re aao bas tear er ad inaeesed as&at+riSu<.a4ie!a fie ccrrrn r o- ea er sn^ c rssr,. in abcomance witOSHA_Sulntla-d'£S G2 ;928.5$.1 have eraminec.he,Lo a pub oars e _. Medically qualified with no restrictions: -1-a 'hs o h.m=•I NaY would place hlmiher at ar increased dsk of +te-gal hea I p .., ^^r. _. 6W�. TnOre n^^a !s no restriCdions on the use ofa respirahJr or paracnal arota�tive aq�inmen:. Medically qualified with the following rsstriotior�s, _ elders that places Lrds employee at ac intteas"oh cf oIal" 1 he t h:mez (See Comment'. Medica#!v unqualified Respirator Clearance The above named employee's hl health histV and irthectil examinatao results:vara ovuluar=n Tr^_ iiin"M field coni of the job were also reAS,ved. Based On this 2lhsll this dmgta'ea v r Cleared for full respirator use _ Cleared for restricted respirator use as follows (Girded): No SCSA use, No heavy exertion, No exposure to high heat stre9s. Cglne- t hFe Com:nartj Not cleared for respirator use COMMENT'. `— edicai Examen -,^ ___\ FccuT¢ch INSULATION& CONTRACTING,INC. -i STATE STREET BUILDING #119 1-800-244-6773 F.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WEE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee: Dale Hardy Date: 101312006 License#: AS071733 EMPLOYEE # 226 Company: AccuTech Insulation &Contracting, Inc. B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure Manufacturer: North Model: 7700-30M Approval#: TC21C152 Size: Medium PARR: RACAL: Model; Powerflow Approval #: TC21 0152 SI: Model: Typhoon Approval#: TC21CI52 Name of Test Conductor: Anthony-Rov Employee Signature: C. Test Results _ X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jagging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes —Employee Fails Expiration Date: 101312007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts ONision of Occupational5efe�y Asbestos Supervisor ��y.'��A NELSON BERNARDES �?1. FYf 7 0 ,7 107 xp. . 3371 F 530' !'IIIIIIIIIIIIIIIIIIIIIIIflVIILIIIN,Illllilllll':III'� 4 �4n i m�.. ijAy jWan,y Mynd ^£AdF��4 N' v_�' � , Ox- des gernan ,,,,,.00 red lite Refresher c'S-`•1��fiC �` �0�tYaGtor 763 r visor] psbestos 7ra,nir 9 Tp tine it 40 SFR part A � Hour �u�{er , g. . �.et{itatio,� " Asbestos AON , Off U - 4VT"& ; , n� " ® � R;; � �� . 1 SAFE ENVIRONMENT ; OF AMERICA INC ENVIRONMENTAL TRAINING DIVISION SAME ST'ONYBROOK PARK ENVIRONMENT ; 100 MOODY STREET, SUITE 200 .:z LUDLOW, MASSACHUSETTS 01056 ^u (413) 589-1882 -1 t NII OG PI'RN➢I1D1 S S.S. t# 010 62-195[ 0 i 7 .� HAS ATTEhIUIDAN �0 tlGil lFlE6ESlU5 TRAINING COURSE I'OH ASBESTOJ SUPERVISOR/FORC-MAN I' t AND HAS I A,,,,6D A WRIT IFN SEA EXAMINATION 'elldl Nunlh i ASI2uz, ExImation�Date: 11 til m �, IFcoon t Iol Ics r ovLrlt D INCI uuEu � '-, o SLIP=:'IU fW KGI IOUNJ III[OFIMAI ION 111 ALI II HAZARD ], ASRESIU >CONDI HON ASSL MEN]', r R ONfIR 1 1701 CC FIVE ECJI IIPMF(VI 4 EH ONAI 111 GIEN F, COI11 ROt tv1ETHODS,AIR MONRORINB Ay III M ,'A I LANI IMJ(G Af II) I'wmi OMN q I-FDI R3t1 ,W 1-: A ND I O ,AI nLGIJI-AFORY REOUIRLMEJTS, M I I y I� 2a C0UII,E INSIRUC'I-ONS 1 ar R 7k`lS�_C,.. -- .,, �u�11 �1 , I�, FrvGu�cco INATOe oM uli HEALTH '.CUPATIONAL HEALTH AND COMPLIANCE SERVICES 200 North Main Street • East Longmeadow, MA 01028 . (413) 525-6003 . FAX (41 3) 525-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORT TO EMPLOYER n Employee Name_ ,t ��as SS % :] _ LL�;LC _ 7 -65 Lead Exposure In accordance with The 9eoanment of Labor& Lndustriee. I have examined 'Is abc,e Dene- arson today Based on the results of Ty physical examination. ',n Cro Is no evdence of a medlcam Vpo ohim would place his/her health a[mcressed risk ofimpavmenr due to lead exposure. Asbestos Exposure This employee has been informed of the results of this examinatior and any m@dicat conditions that msy res'P from asbestos exposure and has bean warned of the Increased risk attributable to [he combindabeffect of smoking and asbestos exposure. I accordance with O.S.H A. Standar,129 CFR 1926.56, 1 nave examined the abort named person today and found him/her. L/ Medically qualified with no restrictions: This employee has he defected medics conditions that would place him/her at an Increased risk of material health Impalement from exposure to asbestos. There is no restrictions on the use of a respirator or personal protective equipment. _ Medically qualified with the following restrictions: This 'or madion! .nndition exists that places this employee at an Increased risk of material health impairment from exposure to esbes os (See Comment). Medically unqualified Respirator Clearances The above named employee's relevant health history and physical examination results were evaluated. The reported field conal tlt,ons of the job were also reviewed. Based on this review, Iris employee is Cleared for full respirator use ,rh Cleared for restricted respirator use as follows (Circled): No SCBA use, No heavy exertion, No exposure to high heat stress, Other(See Comment) Not cleared for respirator use COMMENT: 1 Medical Exarl�— souse 1 AccuT¢ch INSULATION & CONTRACTING, INC. STATE STREET, BUILDING #119 1-800-2448773 P.O. BOX 376 (413) 583.5500 LUDLOW, MA 01056 FAX (413) 583.5555 MASSACHUSETTS CERTIFIED WOE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee Nelson Bemardes -_Date: 5/2312006 License#. AS072621 EMPLOYEE # 477 Company. AccuTech Insulation &Contracting, Inc;_ B. Respirator Information Respirator Type Selected: 1/2 Face Negative Pressure Mainfacturer: North Model: 7700-30L Approval#: TC21C152 Size: Large PAPE: RACAL: Model: Powerflow Approval #. TC21C152 151: Model: T hoon Approval #: TC21C152 Name of Test Conductor: Anth Er.,. �yee Signature: l r C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes _Employee Fails Expim'.lon Date: 5/231'2007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Cornmonweaffh of Massachusetts Division of Occupational 8ateO, nol+�i J Ndnuac.Cnn,initticm� AstreStos Wwke, J CARMELO MENDRELL "•r4i� t t Jn.1tit s M y r111��C (HHS 07 e ' 9 �9 3 �},lJ tl„� teU catmeto for training ,I flicSuP1orfootitle II i$ ntrac ,l1Iih° �,,;npt' nb8t fol as Under TSCA stos tp Flour As esto sA�o p �Ft2 Part 163 i ( Nr 14 DIC—Et—HEALTH a� OCCUPATIONAL HEALTH AND COMPLIANCE SERVICES 200 North Main Street • East Longmeadow, MA 01028 • (41 3) 525-6003 < FAX (413) 525-9009 MEDICAL SURVEILLANCE EXAMINATION AND RESPIRATOR APPROVAL REPORT TO EMPLOYER / Employee Name' �Z./YV� mdtteG�$q .jDzl€;'�� 1�(p Lead Exposure In accordance with The Depadment o.`Labor 8 edrom'es,;nave examined the aSove named person today. Owed on the results of my physlval ext minaflon,there is no evidence re a medical condition which would place his/her health at increased risk at?T pai,rauh due to lead exposure Asbestos Exposure This employee has been informed of the results of this examination and any medical conditions that may result from asbestos expeaure and has been warned of the increasetl risk attnhutable to the combined ef;ect of smoking and asbestos exposure. In accord anceptith O.5 H A. Standard 29 CFR 1926.58,1 dace examined the above named person todav and found himlher Medically qualified with no restrictions: This employee has no selected medical conditions that would place dimmer at an increased risk of material health impairment from exposure to asbestos. There is no restrictions on the use of a respirator or personal protective equipment. _ Medically qualified with the following restrictions: This following medical condition exists that places this employee at an increased risk of material health impairment from exposure to asbestos (See Conerl Medically unqualified Respirator Clearance The above named employees relevant health history and physical examination results were evaleated. The reported field condition the job were also reviewed. Based on this review,this employee is'. Cleared for full respirator use Cleared for restricted respirator use as follows (Circled): No SCBA use, No heavy exertion, No exposure to high heat stress, Other(Sec Comment) Not cleared for respirator use COMMENT: Medical Examiner e04.ee ii \\ 6CCCIT2Ch INSULATION & CONTRACTING, INC. ` STATE STREET, BUILDING #119 1-800-244.8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSEI"TS CERTIFIED WBE IRRITANT SMOKE RESPIRATOR FIT TEST A. Employee information T! "type: Qualitative Irritant Smoke Rainbow N ne of Employee: Carmelo Mendrell Date. 4126i20G6 Lira; ' #: AW074095 EMPLOYEE# 741 Con:,any: AccuTech Insulation & Contracflnq lnc. B. Respirator Information F _.gator Type Selected. 1/2 Face Negative Pressure N. _cturer: North Model: 7700-30L _ Approval#: TC21C152 Size: Large PARR: RACAL: Model. Powerflow` Approval#: TC21CI52 ISI: Model: Typhoon Approval#. TC2IC152 N- r.e of Test Conductor: Anthony Roy E ra Signature: C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes —Employee Fails Er. .- on Date: _412612007 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. Commonwealth of Massachusetts Divislan of Occupafiaoal S.fah, psbestq Wgrker Jb NC[OR ORTt A Exp nate p42TQ/ 4% mug I . •. 4LYtiS4;i4-0 :tnrn omur.p` i i IIIIIGIIIIIIIIIII�II�II�I�I�N�UINIIiVIII� saw �rtG�a my v��ta� red tl�o oto��rain � 5urrlis°Tso Title ult) hn> yi" ent p,s,. AcG 0 F opart 763 40 Noor A ,t h4 Y 4 9?°� e, x1101�' � by , ti� � OCCU-HEALTH ,fE. p. OCCUPATIONAL HEALTH AND COMPLIANCE SERWES 200 t4+arch Main -greet o Ezst Longmeadow,kA Oi t125 i4i>)S25-SOU3 � FAX(�1�) >?5-9009 MEDICAI- SURVEILLANCE EXAMINATION AND RESPIPUJOR APpRO'h4 REPORI TO EMPLOYER Lead Exposure 1, xa:crdarte with The DepannICII cy caber 8 indutansb, 1 ha' e ezaTinrad the Above nnreetl parson totlay. seeed as the ms.h of:ny physio h etavt can them is w emfeaee of 2 m'EoiCal wildli.h xi+t�would plata blSins,bea t"attn,:eaced riskof mpatanentoue o,lead eyposvia. Asbestos Exposure This emoo ee '!a,seon informed of the ae�suds of tltis examinseon and any medR;at wndittons that may resuitfrom asonstas .Posers feel has nse,1 wametd'I UM rved9atl Ask alimvabid el d+e camolned effect of smoking and astleans esposvra. ac accoNan�vJ"h 0.1&H,A.57inoard 29 Crk 5828.54, I haw examine:the above named 4%erson totlay and fecnd mined[ /_ f�tedica(iV QllBtfied witft np iBtriCtlOflS: This employee has¢c detecf„d mednxi tnndlticas that w.0d{dace hwhow at an incrassed risk of nondnsi eaY,h impelrmeret fra:n exposure to asbestos. There is M+reGelolh na on the use of A respirator er personal prate cove eaopmew, Medical uaiified with the following restrictlans- This roes«m.;medn,ai mr,daroe eyws that D{sdeS th4s employee a,or Nereased risk of vlaoia heath inosetmeir Hom¢sttaewe to asbestos (Soo Comment;. _� fdedical�unpuaiifted Respirator Clearance The above named erdpbyee's relevant healM history and physical dxamJnadon resahs were evaluated. 7*,nporta6 said gacditlen,o"the jot Aero else roYsew2tl. Based an ffis<evlv°.u,thm omployen k: C:sared for full respirator use __. Cleared for restricted respirator use as follows (Circled): ktr SCSA uee, W heavy eXerd0n, NO 80pasum N high heat stress, other i3ee CAhlrtieni) Not cleared for respirator use COMMENT: a ri Medicai Examiner 5hi ,cr,,z Ficcch INSULATION & CONTRACTING, INC, STATE STREET, BUILDING #119 1-800-244-8773 P.O. BOX 376 (413) 583-5500 LUDLOW, MA 01056 FAX (413) 583-5555 MASSACHUSETTS CERTIFIED WEE IRRITANT SMOKE RESPIRATOR FET TEST A. Employee Information Test Type: Qualitative Irritant Smoke Rainbow Name of Employee. Victor Ortega Date: 4126/2006 License#: AW074094 EMPLOYEE# 750 Company: AccuTech Insulation & Contracting Inc. _ B. Respirator Information Respirator Type Selected: 112 Face Negative Pressure Manufacturer: North Model: 7700.30M Approval#: TC21C152 Size: Medium PAPR: RACAL: Model: Powerflow Approval#: TC213152 ISH Model: Typhoon Approval#: TC21C152 Name of Test Conductor: Anthony Roy Employee Signature: C. Test Results X Lateral Head Movement Pass X Deep Breathing Pass X Stationary Jogging Exercise Pass X Rainbow Passage Reading Pass X Employee Reaction to Agent aster Test Pass X Proper Performance of Positive and Negative Pressure Valve X Check and Fit X Employee Passes _Employee Fails Expiration Date: 4126/2007 1 Respirator Fit Test Performed in Accordance with NIOSH and OSHA Methods and Procedures. a/��a� � � » � ^\ 2 � �� © � � : � 2 � ^ V = � . : » . � . . < y� w : ' �� , � yy � < y � . � �� y � . , . �.�g 2 . . : . - a�� » � . & � . \ © : \ �\� � . . \\ ^ � . , : . < \ E /� » � ° \ \��\ j � .\ � ■ : \\ � . : . � � > : : �. . \ yam;L <�� f . . � � . 2. � > �a ^ % . >_ � , :� � \�� 2 a . © �¥. : � .. ��:�} . « : yv . «��\ ~ �» z� � �# � a 2 � _ - - �� f � < . / �y � �� ƒ : . . . > ` 2 � ] § » � d/} < 2 z :2 : ? # aa � >y \ \. �¥ . 4 &�s y :�: : :�- . . a , � < � 2� � : � .�a � » <�� ^ � � ^ � « � . « , . . . , ; �< . . . ^ � � � . . . .