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05-001 (5) Commonwealth of Massachusetts • 100135429 Asbestos Notification Form ANF -001 Decal Number B. Facility Description (cont.) 5 ' a. Name of General Contractor b. Address c. City /Town d. Zip Code e. Telephone Number (area code and extension) ® a _l . f. Contractor's Worker's Comp. Insurer g. Policy Number h. Exp. Date (mm/dd /yyyy) 1 6. What is the size of this facility? a. Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos - containing material from site to temporary storage site (if necessary): [ABSOLUTE ENVIRONMENTAL CONTRACTO 1 1114 KENOZA AVE Note: Transfer a. Name of Transporter b. Address Stations must 'HAVERHILL, MA 101830 9784201492 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 SERVICE TRANSPORT PO BOX 2132 . a. Name of Transporter b. Address 1BRISTOL.PA 19007 1 2158269226 c. City/Town d. Zip Code e. Telephone Number 3. 1 a. Refuse Transfer Station and Owner b. Address c. City /Town d. Zip _Code e. Telephone Number 4. MINERVA ENTERPRISES INC i _ a. Final Disposal Site Location Name b. Final Disposal Site Location Owners Name 19000 MINERVA ROAD - 1 WAYNESBURG c. Final Disposal Site Address d. City/Town OH 1 1 44688 Co e. State f. Zip Code g. Telephone Number MEIVMMEME 0 - o D. Certification N The undersigned hereby states, under the CHRIS MCNULTY J CHRIS MCNULTY 'O penalties of perjury, that he /she has read the a. Name b. Authorized Signature o Commonwealth of Massachusetts regulations PRESIDENT _ 9/30/2011 for the Removal, Containment or c. Position/Title d. Date (mm /dd /yyyy) Encapsulation of Asbestos, 453 CMR 6.00 and 9784201492 ABSOLUTE ENVIRONME 310 CMR 7.15, and that the information contained in this notification is true and correct e. Telephone Number f. Representing - 0 to the best of his /her knowledge and belief. 1114 KENOZA AVE O Address EMIL HAVERHILL, MA 01830 1 mimmoglimisem h. City/Town i. Zip Code Z II anf001ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 II t ,J • Commonwealth of Massachusetts • 100135429 Asbestos Notification Form ANF -OO1 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 260 1100 a. Total pipes or ducts (linear ft) b. Total other surfaces (square ft) c. Boiler, breaching, duct, tank I 100 d. Insulating cement surface coatings Lin. ft. Sq. ft. Lin. ft. Sq. ft. e. Corrugated or layered paper I ! l I pipe insulation Lin. ft. Sq. ft. f. Trowel /Sprayer coatings Lin. ft. Sq. ft. g. Spray -on fireproofing =-..] [- 1 h. Transite board, wall board Lin. ft. _ Sq. ft. Lin. ft. i. Cloths, woven fabrics E -- j. Other, please specify: I 1 1 1 000 Lin. ft. S . ft. Lin. ft. Sq. ft. k. Thermal, solid core pipe 260 1 __1 _ VAT/GLAZING insulation Lin. ft. Sq. ft. I. Specify 14. Describe the decontamination system(s) to be used: 3 STAGE DECONTAMINATION UNIT 15. Describe the containerization /disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET, DOUBLE BAG 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a. Name of DEP Official I b. Title �`- c. Date (mm /dd/yyyy) of Authorization d. DEP Waiver # 1 �� e. Name of DOS Official f. DOS Official Title N g. Date (mm/dd /yyyy) of Authorization h. DOS Waiver # MIIMM 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A —F apply to this project? El Yes p No seilmemmo B. Facility Description N FORMER NURSE'S HOUSE I o 1. Current or prior use of facility: . - Inc) 2. Is the facility owner - occupied residential with 4 units or less? [.1 Yes G No THE OVERLOOK AT NORTHAMPTON 222 RIVER ROAD 3 ' a. Facility Owner Name b. Address ° (LEEDS, MA 01053 413484.8457 ffnac) c. City/Town d. Zip Code e. Telephone Number (area code and extension) , 4 GEORGE SENERNT 222 RIVER ROAD a. Name of Facility Owner's On -Site Manager _ b. On -Site Manager Address Z LEEDSMA 01053 1413- 584 -8457 Q c. City/Town d. Zip Code e. Telephone Number (area code and extension) II anf001ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 1 ...J ,0 Commonwealth of Massachusetts III 100135429 Asbestos Notification Form ANF -001 Decal Number 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? ❑ Yes 0 No to move your cursor - do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: THE OVERLOOK AT NORTHAMPTON 222 RIVER ROAD j a. Name of Facility b. Street Address _ _ r NORTHAMPTON MA - i [01053 r44135848457 _)( c. City /Town d. State e. Zip Code f. Telephone Number INSTRUCTIONS 3 Worksite Location: 1. All sections of this IFRMR. NURSE'S HOUSE - form must be a. Building Name /Building Location b. Building # c. Wing d. Floor e. Room completed in order to comply with 4. Is the facility occupied? ❑ Yes Q No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational ABSOLUTE ENVIRONMENTAL CONTRACTOR 114 KENOZA AVE Safety (DOS) a. Name b. Address notification 'HAVERHILL [01830 9784201492 requirements of 453 CMR 6.12 c. City /Town d. Zip Code e. Telephone Number T DOSUcense _ Number g. Contract Type: ❑ Written ❑ Verbal CHRIS MCNULTY PRESIDENT h. Facility Contact Person i. Contact Person's Title DAVID E. SILVA IAS073035 6 . a. Name of On -Site Supervisor /Foreman b. Supervisor /Foreman DOS Certification Number �MITH & WESSEL AA000161 7. a. Name of Project Monitor b. Project Monitor DOS Certification Number SMITH & WESSEL AA000161 $' a. Name of Asbestos Analytical Lab b. Asbestos Analytical Lab DOS Certification Number r 10/17/2011 10/28/2011 -� 7 0 9 ' a. Project Start Date (mm /dd /yyyy) b. End Date (mm /dd /yyyy) o 7A-4P cv c. Work hours Mon -Fri. d. Work hours Sat -Sun. o 10. a. What type of project is this? =====0 p Demolition ❑ Renovation ❑ Repair ❑ Other, please specify: b. Describe 11. a. Check abatement procedures: 0 IN Glove bag ❑ Encapsulation o ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑ Other, specify: mosimmilan ❑ Full containment b. Describe z ,= 12. Is the job being conducted: Q Indoors? ('I/ Outdoors? 1 anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 1 CITY OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: 0022 e/lrrr V4/ The debris will be transported by: kI■Ii AP ,i hock,,;) The debris will be received at: t VCS cyc l.J 5-6-4-44 Li/n (4, Signature of Permit Applicant ! ���s- e Date /0/320/// Building Permit Number: ) DEMOLITION REVIEW APPLICATION Activity Tracking Sheet Property: Nurse's Quarters at Hampshire Care Map: 05 Parcel: 001 Year Built: unknown Address: 222 River Road, Leeds Received in Building Department: August 31, 2010 Referred from Building Department: September 1, 2010 Action Taken/ Northampton Historical Commission Action Taken By: Entire Commission ✓ Sub - Committee of the Commission Commission Designee/ Staff Date Action Taken: September 15, 2010 Initial Determination Public Meeting held Public Hearing Held Determination Made: ✓_ 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 permit may be issued. Referred by: t '( 2 k- lAVC / � Date S 15 f ;�1 P The Commonwealth ofMassachusetts �... -.. -1: Department of Industrial Accidents Office of Investigations , L. 600 Washington Street 7.4 Boston, MA 02111 .„_ =4-' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 4. v r Alb 1u.—. 1 C_ i GG Address: l 2 lJarrJ .4 City /State /Zip: Sp /} J21 {9 du/ ? Phone #: /3 / 2? --, cPY3/ Are you an employer? Check the appropriate box: Type of project (required): 1. m a employer with 4. ❑ I am a general contractor and I 1/ 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have 8. demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11. 3. ❑ lam a homeowner doing all work ffi h id hi ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other . comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the nacre of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / � , Policy # or Self -ins. Lic. #: b1 C 0 Y? (p ),S- Expiration Date: //1/A2 Job Site Address: all �rr pd. City /State /Zip Aolli pe,i, /Y/ G /o5'? Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations . ' , e DIA for insurance coverage verification. I do hereby , fy unde pains ,f d penalties of perjury that the information provided above is true and correct. Si. nature: ./ , / Date: /doid 1( Phone #: 1/45 -„2 To -7/9 ). Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Version1.7 Commercial Building Permit May 15, 2000 .4 ., SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) 4.. ,.... Independent Structural Engineering Structural Peer Review Required i Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i it771- - a.) 1--- ) — Pet-b-d ■ I, '; , as Owner of the subject property hereby authorize _ _ _ . _ to act c my behalf, in all matters relativ- . ork authorized by this budding permit application. Rt.., „e , • -7 Sig ature of Owner Date / -- htL•- , as Owne Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed und: e pains and •enalties of eu . 4 ..„,r...„, Print Name / o f k L...i v 4.—,.......:1 /0 / / \ Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES / 10.1 Licensed Construction u ervisor: Not Applicable ID ___.. . 6 i 1)2 ..c7 Name of License Holder : e -, 41-04/i License Number Address / .U../. 'Lliff _ :-- z2--- — — Expiration Date Signature Telephone SECTION 13 -WORKERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 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 b • 14ct • m g permit. Signed Affidavit Attached Yes i159 No 0 Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EIJ LOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number } Signature Telephone Expiration Date Name Area of Responsibility _ Address ,...__ __." Ristration Number _ _. __ " Signature Telephone Expiration Date Name _____ _ ,,- _ _ Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor • Not Applicable ❑ Company Na e: ( Responsible In Charge of Construction Address Signatu Telephone t Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning . This column tore filled in by —\\,. Building Department Lot Size Frontage _._. '._.m_.__ ___ .. _M ., _ Setbacks Front _ T i __ / Side L: R_.. L L. _ _.. R. _ _ __ Rear ..__ . 1 j Building Height Bldg. Square Footage _ _.�........ . % .__... Open Space Footage % _ - -°-- (Lot area minus bldg & paved .arking) # of Parking Spaces , " "�' Fill: (volume & Location) A. Has a Special Permit /Variance / finding ever been 'ssued for /on the site? NO 0 DONT KNo' 0 0 IF YES, date issued: IF YES: Was the permit reco '. ed at the Registry of Deeds? NO 0 Do NT KNOW 0 YES IF YES: enter Bo. ' Page and /or Document # B. Does the site contain . brook, body of water or wetlands? NO CO DONT KNOW 0 YES 0 IF YES, has a per it been or need to be obtained from the Conse , tion Commission? Needs to be obtained 0 Obtained 0 , Dat Issued: MNe „ i C. Do any signs exist on the property? YES (3 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the propert ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE-. . ", Interior Alterations ❑ Existing Wall Signs ❑ Demolition. Repairs ❑ Additions ❑ i Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs 0 Roofing ❑ Change of U4 ❑ Other ❑ Brief Description Enter a brief description here. , Of Proposed Work: l7 N1-0 4-(S K N u RS F S + ./4 t5 (S SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A-4 ❑ A - ❑ 1B ❑ B Business ❑ _ 2A ❑ E Educational ❑ 2B - r ❑ F Factory ❑ F - ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential R -1 0 R - ❑ R - ❑ 5A ❑ S Storage L1 S -1 ❑ S -2 ❑ 5B ! tit U Utility ❑ Specify: _ _ _.. ___.W_ ____... _._____ ___..._..,_._.W... __...._ �_.__ M Mixed Use ❑ Specify _ w �,,, __ _ -. _e _._._ S Special Use ❑ Specify. COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: ,_________,__ _ _w . Proposed Use Group: Existing Hazard Index 780 CMR 34): _. w_,._._ mm,,.. Proposed Hazard Index 780 CMR 34): ?._ ,,_____ ._w__ ___._a SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 st r _ l . , --..... —...- 2 nd 2 _... ...... .... ..__,..__.._ .._... ....._... ., t 3rd 3 4m -..___.__..M_.......,_ ....._., -.____ 4 th 9 _ ________ Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) ____ _ _____ .___.._. Total Height ft _ _.,.__. 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood_ZoneInformation: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone ___ _ __, Outside Flood Zone El Municipal ❑ On site disposal system Version1.7 Commercial Building Permit May 15, 2000 �+ ` ' Departmefit use only, City of Nc CE! Y ED S t c rs � g f tT ,ittlt � ,d € f*M 1 s :,4,*' ?. , 4001 �`h ei �a , ,v ia u° as z Building Gepa ment G + t/Driveway P2 tTitt ' k �aa it - r At 212 Ma n Si e kt ,(-, ') fl S e r ls e p tle A va ( r Vet �. L. U LV a�,� }��` cam, ,3�" "r a as ,, % ROOM 1 1 1 erpe[ AySila Ji .� , Northampto 1, G 1 1.1 T •l ets ; t�,�Sti`uc ula F'I A _ _ °° ` Y phone 413- 587 -1240 F..` . -it • 7". � i tlStte Flans g other -Spec y ,.. ,.> - :.....: APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Pro a Addre s: )a, - � j _ - ___._ : Map Lot Unit • `+�., X14 Zone Overlay District w.M. ,_ _ .� M .. _a ... w EIm.St: District CB District SECTION 2 . PROPERTY OWNERSHIP /AUTHORIZED =AGENT 2 1 Owner of Record .._____.„,.,,.._ ........__________ .._________,,. 0 ttl- 2 --- --- - : Name (Print) Current Mailing Address: signature _ e , Telephone . 2.2 Authorized Agent: ip , _._., _... ,,,-,.. i,- ,..,.1fritt . --- 7-J.7 ------ ,xkits -------:,-:_ :: ,.. _ . . ..,./. / 7E _ Name (Print) Current Mailing Address 1/.:- _9/ y6 -/1_. Signature Telephone 1 SECTION 3 - ESTIMATED CONS - UCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ; (a) Building Permit Fee 2. Electrical — — (b) Estimated Total Cost of Construction from (6) _. _ ____ ......_,___ ._. _ 3. Plumbing Building Permit Fee pF rr d 4. Mechanical) (HVAC) �,� 5. Fire Protection " , _ . 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Permit Number Date Issued • Signatur 7' "-.' 'in / O / f 2-0 /r I Building Commissioner /Inspector of Buildings Date /// 222 RIVER RD BP -2012 -0418 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 05 - 001 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit # BP- 2012 -0418 Project # JS- 2012- 000663 Est. Cost: Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CHARLIE ARMENT TRUCKING INC 017764 Lot Size(sq. ft,L Owner: HAMPSHIRE COUNTY LTC FACILITY Zoning: Applicant: CHARLIE ARMENT TRUCKING INC AT: 222 RIVER RD Applicant Address: Phone: Insurance: 42 WAREHOUSE ST (413) 739 -8431 Workers Compensation SPRI NGFI ELDMA01118 ISSUED ON:10/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMO NURSES QUARTERS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/24/2011 0:00:00 $200.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner S