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37-002 (2) Massachusetts Department of Environmental Protection • Bureau of Waste Prevention • Air Quality 1100143824 1 ':'• B P Acs 06 Decal Number Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project, were the structure(s) surveyed for the presence of asbestos containing material (ACM)? 0 Yes ❑ No if yes, who conducted the survey? STEVE NIEC b. Surveyor Name A1072378 c. Division of Occupational Safety Certification Number 7. Construction or Demolition: 3/2012012 _ 3/2612012 a. Start Date {mmlddlyyyy) b. End Date (mmlddlyyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: seeding ❑ paving 19 wetting -] shrouding b. If other, please specify: ] covering l other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? r a. Name of DEP Official b. Title c. Date (mmlddlyyyy) of Authorization d. DEP Waiver Number D. Certification � "' I certify that I have examined the {CHRIS HOPPER o above and that to the best of my a. Print Name knowledge it is true and complete. t - Ti - 1 oppp�er The signature below subjects the b. authorized Signature signer to the general statutes MANAGER o regarding a false and misleading c. Position/Title statement(s). [COMPASS RESTORATION SERVICES LLC * — d. Representing -- -M^^ 316!2012 e. Date (mmlddlyyyy) .�.. a Q 1111 ag06.doc • 1 0102 BWP AQ 06 • Page 3 of 3 It Massachusetts Department of Environmental Protection __ __. -__ A.. ..._,,...:.„.:‘ Bureau of Waste Prevention • Air Quality 1100143824 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General B. General Project Description (cont.) Statement: If p l ) asbestos is found during a 4. General Contractor: Construction or Demolition [COMPASS RESTORATION SERVICES LLC operation, all •.. , responsible parties a. Name must comply with 1 76 PINEVALE STREET 310 CMR b 7.00, Address ...___.. ` ����` 7.09, 7.15, and . ))MA f 01151 f Chapter 21E of the F .__._ _ �_ ___.� 1 L. ...._._.1 L ._., ___...! General Laws of C. City/Town _ d. State e. Zip Code , ,_, the Commonwealth. 4132651569 _ _ Lcompassrestoration@yahoo.com would include, - _. •_••- °.- .. -.- ...,w._.....� co @yahoo.com L ----- -- �_ ....._. — - - -• but would not be f_ Telephone__ . Number (area code and" nd extensionf mm T o w E —mail Address Jpptional _ ___ _ _ limited to, filing an 'VICTOR RODRIGUES _� ^_� _ _j asbestos removal h. On -site Manager Name notification with the Department and /or a notice of release /threat of C. General Construction or Demolition Description release of a hazardous substance to the 1. Construction or demolition contractor: Department, if �. _ __._ ..___-____ applicable. IH.M. NUNES & SON CONSTRUCTION INC. a. Name _ _ 82 CARMELINAS CIRCLE _� -— _.1 b. Address LUDLOW MA uvY II 01056 c. Cityrrown d. State _ e. Zip Code 4135476488 _ _ _ _ __ armandn@nunesconst.com ^ f. Telephone N mber (area code and extension) g. E -mail Address (optional) ARMAND NUNES w.. h. On -site Manager Name 2. On -Site Supervisor: ARMAND NUNES 4 On -Site Supervisor Name 3. Is the entire facility to be demolished? ID Yes fl No MON■Www■I..NI 04 ° 4. Describe the area(s) to be demolished: o 700 SF WOOD FRAMED HOUSE AND FOUNDATION ■ N ••,,.■••■0 ............. ........ .__...,......-- ,,,..__. ------ _....•.W_ �° 5. If this is a construction project, describe the building(s) or addition(s) to be constructed: •. NONE MMEo 0 - IN ag06.doc • 10/02 BWP AQ 06 • Page 2 of 3 II L 1 Massachusetts Department of Environmental Protection . 's.,. :\,:: Bureau of Waste Prevention • Air Quality [100143824 1 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition Important: A. Applicability VVhen filling out forms on the computer, use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building, or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor - do not use the return (DEP), Bureau of Waste Prevention - Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09 (2) ten (10) days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. r,„3 "N. IFFAll B. General Project Description 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner-occupied Instructions residence of four units or less? 0 Yes n No 1. All sections of b. Provide blanket decal number if applicable: L.. - -, -- anket De Number this form must be completed in order to comply with the 2. Facility Information: Department of DENNO RESIDENCE Environmental - _ Protection a. Name — notification [559 FLORENCE ROAD i requirements of b. Add ---- — 310 CMR 7.09 „.._ _____.-- -------- Northampton I [MA] 1_9060 — j c. City/Town f4135840852 [ - , f. Telephone Number (area code arid extensiorkz„ ... _ q. E-mail Address(optional) [700 ' 1 L 1 h. Size of Facility in Square Feet ------ --- i. Numb of Floors j. Was the facility built prior to 1980? Ed Yes Ej No k. Describe the current or prior use of the facility: [SINGLE FAMILY RESIDENCE I. Is the facility a residential facility? R Yes 0 No IMIIMIIMINIMMIN IMNI■■ 1 ••••••••• m. If yes, how many units? MIN•11111111 Number of Units ■1•1111.12=101•1•1101•1•11.1 wallilliM111••••11111MOIMI 10111111■1•••••■• o 3, Facility Owner: 1.■,.......... 04 ------ RICH DENNO 1 ---- 0 a. Name _ _ 111■••■■•■■ 0 559 FLORENCE ROAD , ,......„,...,. ,...,,...... . . — ----- b. Address .-- 1■101■■■■••••■ I N 0 RT Fl AM PT 0 N MA j [01060 1 ..--- —.- 1■11.•■•11■11111111111M to c Gity/Town _ d_Sat e. Zip Code IMINIIIIINOMP•MR■ MO1011■1111•1 4135840852 r 11V■IIIMMI1 0 .^,■- ■■••■•■•••1•11 i f. Telephone Number (area code and extensiOn) Q. E-mail Atidre55 (optional) G RICH DENNO 1 — - -----‹ h. Onsite Manager Name • aq06 doc • 10102 BWP AQ 06 • Page 1 of 3 a eDEP MassDEP'sOnlineFiling System hops: / /edep.dep.mass,gov /pages /PrinlReceipt,aspx MassDEP Home 1 Contact 1 Feedback 1 Tour 1 Privacy Policy MasSDEP's Online Filing System Username:HUNTER331 Nickname: ZACHARY emaa My eDEP Forms My Profi !etas Help L Receipt J Forms Signature Receipt Summary /Receipt . print receipt. Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select "My eDEP" to see a list of your transactions. DEP Transaction ID: 455889 Date and Time Submitted: 3/6/2012 12:30:14 PM Other Email : Form Name: AQ 04 - Asbestos Removal Notification Form ANF -001 Payment Information DEP code Date Amount ($) Billing Info Contractor Contractor Number: AC000695 Name: COMPASS RESTORATION SERVICE SERVICES LLC Address: 16 PHEASANT RUN, BELCHERTOWN, MA 01007 4132651569 Supervisor JACK D. RODRIGO Project Monitor Lab Location DENNO RESIDENCE Project Start Date 3/20/2012 My eDEP MassDEP Home 1 Contact 1 Feedback 1 Tour 1 Privacy Policy MassDEP's Online Filing System ver.11.4.10.10 2011 MassDEP 1 of 1 3/6/2012 12:30 PM Cl. Commonwealth of Massachusetts Asbestos Notification Form ANF-001 [10_T3821 - --- Decal Number _Ai B. Facility Description (cont.) .._.._... _ - • — COMPASS RESTORATION [176 PINEVALE STREET i 5. a. Name of General Contractor b. Address 'SPRINGFIELD 1 01151 _1 1413-265-1569 1 c. qtylTown d. Zip Code e. Telephone Numberiarea code and extensionL [ATLANTIC CHARTER _I [WCV0082630 1 1812812012 I f. Contractors Workers Comp. Insurer . Polio Number h. Exp. Date (mmidd/Dryy) 1 1 6. What is the size of this facility? 700 a. Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos material from site to temporary storage site (if necessary): , [COMPASS RESTORATION 1 1176 PINEVALE STREET Note Transfer a. Name of Transporter b. Address : Stations must SPRINGFIELD 1 101151 j [4132651569 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 1 [10 NORTHWOOD DRIVE 1 a. Name of Transporter b. Address [BLOOMFIELD CT — 1 116002 — 1 0 2182 42 81 c. City/Town d. Zip_Code e. Telephone 3. CHARLES M. GORDON & SONS 1 [203 PICKERING STREET 1 a. Refuse Transfer Station and Owner b. Address !PORTLD AN C [0 8603421022 - _I cSArroCin --- d. Zi Code e. Telephone Number 4. rii-A' INERVA ENTERPRISES INC lylINERVA --] a. Final Disposal Site Location Name b. Final Disposal Site Location Owner's Name _ 19000 MINERVA ROAD WAYNESBURG 1 Final Disposal Site Address __ d. Cityrf own OH j 1:14688 3308663435 .... .. e. State f. Zip Code g. Telephone Number ............, or) .......m...■ ° D. Certification s....w.i......... The undersigned hereby states, under the [ HOPPER 1 Chris Hopper I '') penalties of perjury, that he/she has read the a. Name b. Authorized Signature 0 Commonwealth of Massachusetts regulations [MANAGER 1 [3/6/2012 _ 1 for the Removal, Containment or c. Position/Title _ d. Datejmm/ddiyyvy) `-- Encapsulation of Asbestos, 453 CMR 6.00 and ,- 310 CMR 7.15, and that the information [413_50_3_7919 __[ ;COMPASS RESTORATiol — _ — _--- .................. contained in this notification is true and correct e. Telestione Number f. Representing o to the best of his/her knowledge and belief. 176 PINEVALE STREET 1 ............. o q. Address ........................ IMMINIMINIIIIN111•1•11111•111.1 ____ _ [SPRINGFIELD j 101151 u. _____ h. City/Town i. Zip Code —,...........—... ...—,....< $ anfOOl ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 II , Commonwealth of Massachusetts 1 ' • • IL.. • Asbestos Notification Form ANF-001 15eTaTNTaber - — A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: Lo a. Total pipes or ducts Pear fir TTOTal other surfaces (square c. Boiler, breaching, duct, tank r 1 d. Insulating cement r I F surface coatings Lin. ft. Sq. ft. - Lin. ft. — e. Corrugated or layered paper L_ —I f. Trowel/Sprayer coatings Li _ 1 T I pipe insulation Lin, ft, Sq. ft. n. ft . Sq. ft. g. Spray-on fireproofing 1 -----_-] h. Transite board, wall board r _ F1200 i Lin. ft. Sq. ft. Lin. ft. , - WIT— 1. Cloths, woven fabrics L _I r _i j . Other, please specify: L 1160 ---- - I Lin. ft S .ft. lin - ft - . - _ ._,:gg rm k. Theal, solid core pipe r 1 L , [- DAMPPROOFING 1 insulation Lin, ft. Sq. ft. I. Specify 14. Describe the decontamination system(s) to be used: REMOTE 3 CHAMBER DECON PER OSHA 1926.1101 1 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): [DOUBLE WRAPPED AND SEALED IN 6 MIL POLY SHEETING OR EQUIVALENT 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: 1 I_ 1.."%iife b. 1 L _ 1 c. Date (mm/dd/yyyy) of Authorization ------ i d. DEP Waiver # e. Name of DOS Official . 1 0 • icier Titre L J _ 1 VIIIMIIIINSININIMONMIIIMIN . ----- g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver # ..... 01 ..i.,..--ii..— o 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A-F apply to this project? Ell Yes LE No o B. Facility Description cNi RESIDENCE 1 - o 1. Current or prior use of facility: --- . 2. Is the facility owner-occupied residential with 4 units or less? [a Yes fl No M H DENNO [559 FLORENCE ROAD '---- j IIMMINIMOI■ . — ■ ■1•1111PE a. Facility Owner Name b. Address ---- ______ 11 MINIIINEINI 0 1NORTHAMPTON - 1 101060 7 [4135840852 _ ---- o CTdity/Town d. Zip Code e. Telephone Number (area code and extensionT .. RICH DENNO 1559 FLORENCE ROAD ____ j ...■......■■ LL A . ' a. Name of Facility Owner's On-Site Manager Con-Site Manager Address .----z [NORTHAMPTON j 01060 R1 .1 MMIININIIIIMMOVNIMMI < C. City/Town — d. Zip Code e. Telephone Number (area code and extension) IN anf001 ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 1 i 04A. cli Commonwealth of Massachusetts III [ 00143821 ______......................__ . , Asbestos Notification Form ANF-001 Decal Number ,• . . . Important: out A. Asbestos Abatement Description VVhen filling 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? III Yes 0 No to move your r i cursor - do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: IDENNO RESIDENCE ---- 559 FLORENCE STREET _I . ... a. Name of Facility b. Street Address Northampton 1 IMA O Xii c. cit;City/Town n i I. State I loj N 4135840852 e. Zip Code ,-- -- I] f. Telephone Number INSTRUCTIONS • Worksite Location: 1. All sections of this DENNO RESIDENCE =---._ 1 1 1 ] 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? 0 Yes 0 No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational [COMPASS RESTORATION SERVICE SERVIC] [1 - 6 PHEASANT RUN 1 Safety (DOS) a. Name b. Address notification requirements of 453 friELCHERTOWN 1 101007 4132651569 CMR 6.12 c. City/Town d. Zip Code_ e. Telephone Number rAC000695 j g. Contract Type: 2 Written Li Verbal f. DOS License Number DENN . . 0 - — j OWNER — h. Facility Contact Person i. Contact Person's Title 6 IJACK D. RODRIGO j AS061983 . _.., . a. Name of On-Site Supervisor/Foreman b. Supervisor/Foreman DOS Certification Number STEVE NEIC 1 [A 7. a. Name of Project Monitor b. Project Monitor DOS Certification Number TRC ENVIRONMENTAL AA000052 8. a. Name of Asbestos Analytical Lab b. Asbestos Analytical Lab DOS Certification Number ---- 3/20/2012 3/26/2012 ----„0 9 - ■M a. Project Start Date (mriiiddiyaz) b. End Date (mmfddiny m ■ yl 1groi 11111M101.111111110MMI■ o I 7AM-5PM _...... j ................. _______ 1 c. Work hours Mon-Fri. . Work hours Sat-Sun. ...................... Cs/ ■ CD 10. a. What type of project is this? MINIIIIMIIII■ 0 0 Demolition 0 Renovation -,-. [I Repair 0 Other, please specify: b. Describe 10■111111111■111•11.1 •■■• 11. a. Check abatement procedures: ---.-. o —._. o Fi Glove bag [] Encapsulation o 1::] Enclosure El Disposal only — Nm■ m 0 Cleanup E Other, specify: woo LL ■■■■ Ei Full containment b. Describe ----. — 12. Is the job being conducted: 0 Indoors? ril Outdoors? 16■10...161.1■VIMINIVM < • anfOOlap.cloc • 10/02 Asbestos Notification Form • Page 1 of 3 111 Massachusetts Department of Environmental Protection 100143821 Li 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. [CHRIS HOPPER Chris Hopper 1. Name — Authorized Signature [MANAGER j [3119/2012 2. PositioW/Title_ 3. Date (mmidd/yvyyl, [COMPASS RESTORATION 4135837919 _ "a. Representing 5. Telephone 1176 PINEVALE STREET 6. Address [SPRINGFIELD [01151 7. City/Town 8. Zip Code anfO6pdrn.doc • rev. 2/5/04 �- --- _.....W 0 L ia. Massachusetts Department of Environmental Protection 110143821 _.._ _._.._....._._...... Bureau of Waste Prevention — Air Quality Decal Number Project Revision Notification 1 - -0, '1 For Asbestos Notification ANF -001 and AQ 06 Important: A Facility Location When filling out y forms on the DENNO RESIDENCE computer, use I E ___.__- ._..__ - .._- __. —____ __, ____ .___ only the tab key 1. Name of Facility to move your (559 FLORENCE STREET cursor - do not i .___. ,____..,........... .__ .,_ 2- Street Address 1 use the return key. [NORTHAMPTON i [MA { 3. City -� -�- 4. State 5. Zi p Code ' ` � 4135840852 - 6. Telephone Number 1NA1 INSTRUCTIONS B. Project Cancelled 1. This form is only available for _I Check here if this project is /was cancelled_ online filing of protect date revisions. 2. Enter project decal number. C. Project Dates 3. validate that ( 312012012 _�_ __ 3 __ the project L _...._.__ 1 � !2612012 _ -._-_ location is correct 1_ Original Start Date (mm /ddlyyyyl _„ . „ � 2. Original End Date (mm/ ________� for the entered decal. 3. Latest Revised Start Date (mm /ddlyyyy) 4. Latest Revised End Date (mm/ddlyyyy) 4. Enter your new project dates. 5. Certify your - -- - notification. D. Revised Project Dates Submit date changes. 3123!2 4!212012 [3 �012 _.l 1 ._. - _ l 1- Revised Start Date (mm /dd /yyyy) 2. Revised End Date Date (mm /dd /yyyy) E. Other Project Revisions F. Revision History — __ _ _..._ _ anf06pdrn.doc • rev. 2/5/04 .• R \W HEELER P.O. Box 1337 Environmental Scientists FORBES YY Tj� HEELER 413-221-8 331041 Hea lndu t Safety al Hygienists A Massachusetts Corporation www.forbeswheeler.com Demolition Management Alternate Work Plan ("AWP ") Request March 21, 2012 Mr. Brian Bordeaux Massachusetts Department of Environmental Protection (DEP) tl p �✓ Bureau of Waste Prevention Western Region 436 Dwight Street MAR 2 2012 Springfield, MA 01103 RE: Alternate Work Plan ( "AWP ") Denno Residence 559 Florence Street, Northampton, MA 01062 Dear Mr. Bordeaux: On behalf of the demolition contractor, Forbes & Wheeler, Inc. is requesting review and approval of the following Alternate Work Plan ( "AWP ") for the removal of presumed asbestos - containing materials as special waste in conjunction with demolition procedures at the above - referenced Site. The following proposed AWP incorporates alternative work practices with regard to certain asbestos regulations. The 559 Florence Street, Northampton, MA residential building is presumed to be severely damaged in the interior floors, and interior areas may be structurally unsound and unsafe for conventional asbestos retnoval activities. An asbestos survey report is unavailable, and we are assuming that all building materials contain asbestos. We propose to utilize procedures to (1) remove the entire building and its contents and components (except where noted) as special waste via live- loading in conjunction with whole building demolition procedures. We suggest that no individual enters any portion of the building due to potential health and safety hazards. The specific regulations regarding the removal of asbestos - containing materials and to which the altemate work practices will apply are: 310 CMR 7.15(1)(c)1. — Requires the removal of any asbestos - containing material from a facility prior to demolition/renovation operations. 310 CMR 7.15(1)(c)3.d. — Requires the capture and containment of fugitive dust by utilizing sealed work area with air cleaning during asbestos removal operations. 310 CMR 7.15(1)(c12.c.ii.: When a facility component covered or coated with asbestos — containing material is being removed as units or in sections ensure no release of asbestos to the ambient air space during removal of asbestos from these units or sections handled by sealing the work area and using a local exhaust ventilation and collection system designed and operated to capture particulate asbestos material. Page 1 of 7 Forbes &3 Wheeler, Inc. NOTICE _ =- NOTICE ' •w TO 1 .0 TO V FW YII Sfi f � EMPLOYEES ' r:. - EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617 - 727 -4900 - http: / /www.mass.gov /dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above - mentioned chapter by insuring with: Union Insurance Company NAME OF INSURANCE COMPANY • 290 Donald J. Lynch Boulevard, Marlborough, MA 01752 ADDRESS OF INSURANCE COMPANY WCA 0305007 -12 08/13/2011 to 08/13/2012 POLICY NUMBER EFFECTIVE DATES T.P. Daley Insurance Agency, Inc. 1381 Westfield Street, West Springfield, MA 01090 NAME OF INSURANCE AGENT ADDRESS PHONE # H.M. Nunes & Sons Construction Co Inc 82 Carmelinas' Circle, Ludlow, MA 01056 EMPLOYER ADDRESS' EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts Prim Forall ' Department of Industrial Accidents „ , 1 : Office of Investigations l 1 Congress Street, Suite 100 �. Boston, MA 02114 -2017 .5 y www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): H . M . Nunes & Sons Const. , Inc . Address: 82 Carmelinas Circle City /State /Zip: Ludlow, MA 01056 Phone #: 413.547.6488 Are you an employer? Check the appropriate box: Type of project (required): 1. © I am a employer with 25 4. ❑ I am a general contractor and I employees (full and /or part-time).* have hired the sub contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have 8. © Demolition working for me in capacity. employees and have workers' g any p Y . 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Acadia Insurance Co. Policy # or Self -ins. Lic. #: WCA 0305007 -12 Expiration Date: 8/12/12 Job Site Address: 559 Florence Road City /State /Zip: Northampton, MA 01060 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif under the pains and penalties ofperjury that the information provided above is true and correct. Signature:: _4 -1 . l31,ti..1- Date 4 k a _ Phone #: 4 1 3 'S4R 4- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit /License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Jeffrey Henriques CS102023 License Number 32 Michael Drive, South Hadley, MA 01075 04/21/2012 Address , Expiration Date 4 41 C,` fi�,(v( =� 413.426.1794 Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- 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 building permit. Signed Affidavit Attached Yes Il No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not 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 Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition © New Signs [O] Decks [lD Siding [0] Other [0] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT l6 I i 4R , as Owner of the subject property hereby authorize Armando M. Nunes of H.M. Nunes & Sons Const . , Inc . to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date Armando M. Nunes of H . M .Nunes & Sons Const . ,Inc . , as Owner /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 under the pains and penalties of perjury. Armando M. Nunes Print Na e Si ature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0 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 0 NO 0 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 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. c ` Department use only er G V ity of Northampton Status of Permit: 9141 : ilding Department Curb Cut/Driveway Permit VNS) • 12 Main Street Sewer/Septic-Availability P Room 100 Water/Well Availability: oFew N� °'� I orthampton, MA 01060 Two Sets of Structural Plans • one 413 - 587 - 1240 Fax 413 587 - 1272 PiotiSit Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 559 Florence Street Map Lot Unit Northampton, MA 01060 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Richard Denno 559 Florence Street, Northampton, MA 01060 Name ( C 413.584.0852 ^ ress: Telephone Signature 2.2 Authorized Agent: Armando M. Nunes, H.M.Nunes & Sons Const.,Inc. 82 Carmelinas Circle, Ludlow, MA 01056 Name t ( Print) Current Mailing Address: 'A/ ∎ (- c%i ,AJ A (LOA ,C) 413.547.6488 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee Demolition $ 8,000.00 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 3_5 b y 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number /5/7/ This Section For Official Use Only Date Building Permit Number: Issued: r Signature � r Building Commissioner /Inspector of Buildings Date 559 FLORENCE RD BP- 2012 -0874 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 002 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 -0874 Project # JS- 2012- 001364 Est. Cost: $8000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: H M NUNES & SONS CONSTRUCTION 102023 Lot Size(sq. ft.): 26440.92 Owner: DENNO KAREN H & RICHARD Zoning: Applicant: H M NUNES & SONS CONSTRUCTION AT: 559 FLORENCE RD Applicant Address: Phone: Insurance: 82 CARMELINA CIRC (413) 547 -6488 WC LUDLOWMA01056 ISSUED ON:4/9/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMOLISH HOUSE 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 4/9/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner