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38A-050 (5) „ ''' ""'f} CITY OF NORTHAMPTON, MASSACHUSETTS 'iy � DEPARTMENT OF PUBLIC WORKS 6. +` 125 LOCUST STREET '7���f�:i �� NORTHAMPTON MA 01060 "�' 413-587-1570 FAX 413 -587 -1576 Edward S Huntley, P.E. (Director September 15, 2008 Anthony Patillo, Building Inspector Municipal Office Annex 212 Main Street Northampton, Ma 01060 Dear Mr. Patillo: The buildings that are being proposed to be demolished on the south campus of the State Hospital grounds (Village Hill) have been inspected and it has been determined that there are no active water services in these buildings. Please contact me if you have any questions. • cerely, cl 0,1x/P-9)---- David Sparks Superintendent of Water Cc: Ned Huntley, Director of Public Works Jim Laurila, City Engineer DIG SAFE SYSTEM, INC. - Create New Quick Ticket Page 1 of 2 • 1' • Request Number: 20083209882 Date 08/08/2008 Time 10:38 Latitude: Longitude: State: MASSACHUSETTS Municipality: NORTHAMPTON Address / Intersection: 1 PRINCE STREET Nearest Cross Street 1: LAUREL STREET Nearest Cross Street 2: EARLE STREET Additional Information: FROM INTERSECTION OF LAUREL ST. WORKING DOWN PRINCE STREET FOR 1,400 FEET. FROM INTERSECTION OF EARLE ST. WORKING DOWN PRINCE STREET FOR 1,300 FEET. Nature Of Work: DEMOLITION OF EXISTING STRUCTURES Area Of Work: PRIV PROP Area Is Premarked: Y Start Date: 08/14/2008 Start Time: 07:00 Caller: DOTTY Title: OFFICE MGR Return Call: BET 8 -6PM Phone #: 978- 441 -2000 Fax #: 978- 441 -2002 Alt. Phone #: Email Address: WDUMONT @SANDRCORP.COM, JROSA@SANDRCORP.COM Contractor: S & R CORP Address: 706 BROADWAY ST City: LOWELL State: MA Zip: 01854 Excavator Doing Work: TBD Member Utility List Code Abbreviation Name MC MASSEL I MASS ELECTRIC COMPANY SP VERIZN VERIZON TV COMCAS COMCAST ' WG BSTGAS BAY STATE GAS WT TENGAS TENNESSEE GAS PIPELINE CO ON ONTARG ON TARGET LOCATING RJ IDM INNOVATIVE DATA MANAGEMENT • There may be non - member utilities in the area that you need to notify. • Electric and other companies may not mark lines they don't own or maintain. You may want to contact them for more information. • The excavator is responsible to maintain markings placed by member utilities... http : / /digsafeform.diasafe.com/cai- bin /d1cai.exe 8/8/2008 ON JOE' Loci Services 99 dine Mai Avenue www.ontargetservices.com Utility � � Gardiner, Maine 04345 7 tel 800- 598 -0628 fax 2t]7 -588 -3302 e-mail: screening @onlargetservices.com Date / Time : 8/8/2008 10:50:05 AM To : DOH Cornpany : S & R CORP Tel.: (978)- 441 -2000 ext. Fax: (978)- 441 -2002 ext. This message is being sera in response to your request for underground cable location. The following represents a list of responses for the indicated member. These reponses only pertain to the specific member. Ticket #: 20083209882 Place : NORTHAMPTON, MASSACHUSETTS Address : 1, PRINCE STREET 1- COMCAST GABLE -SEMA AREA Ticket Screened on 0810812008 This ticket is clear of conflict and has been screened by On Target Utility Services If there are questions regarding this transmission or if you arrive at the site and have a question about the markings, please call 1-800-598-0628, extension 3347, during normal business hours, Monday- Friday between 7:00 and 4:30 nationalgrid f { August 8, 2008 Northampton State Hospital 1 Prince Street Northampton, MA 01060 To Whom It May Concern, This is to verify that National Grid has removed the electric service at 1 Prince Street, Northampton, Massachusetts, effective August 7 , 2008 and is safe for Building Demolition. Sincerely, 1461141.1 Jim Nichols Supervisor Distribution Design JN!ekp 548 Havdenville Road, Leeds, MA 01053 • www,nationalgrid.corn e rct tram • uo -lam -uo Uf.1J0 ry. teq eri Bay State Gas Company August 12, 2008 S &R 706 Broadway St Lowell Ma Dear SEAR, The address listed below has had the gas aervicefs> disconnected and is now ready for demolition. ADDRESS: 1 PRINCE ST (26 C,D,R) TOWN : NORTHAMPTON STATE : Massachusetts Sincerely Terri Miner Workforce Planning 2025 Roosevelt Avenue PO. Box 2025 Springfield, MA 01102.2025 413.781.9200 FAX' 413.781.9222 * ./ R • iV s IRPF :kifoi 14tiorl Has the SWPPP been prepared in advance of filing this NOI? Yes [.._ No Location of SWPPP for viewing: is Address in Section II Address in Section III _1 Other If Other: SWPPP Street: I I I I I 1 1 1 1 1 1 I I I I I I I� 11 11 City: 1 111 1111111111111111111 1111 State: 1 I I Zip Code: 1 1 1 1 1 -1 1 1 1 1 SWPPP Contact Information (if different than that in Section II): Name: 'Sl l Iclolglpr;lfdA- li Iol,uf I I I 1 I I 1 I 1 1 I I 1 I I I 5 Phone: I I 1 I -1 1 1_1 - 11 I Fax (optional 11 1 I - III 1 - 1 1 1 1 1 E -mail (optional): 1 1 1 1 1 1 1 1 1 1 1 1 1 Discharge inforttration Identify the name(s) of waterbodies to which you discharge. _AA i If ( R Is this discharge consistent with the assumptions and requirements of applicable EPA approved or established TMDL(s)? Yes { No Agook VI Endar jered Spegies_;tnforrnation Under which criterion of the permit have you satisfied your ESA eligibility obligations? J A Ill B Ec 1 , D [1 E 1 IF • If you select criterion F, provide permit tracking number of operator under which you are certifying eligibility: 1 111111111 VII Gertificatron Information I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Print Name: eS le ■)t40/1.64A1` n_ Print Title: ASStS at ecc IA A - V ie Signature: A , •� , A. Date: f EPA Form 3510.9 (Rev. 6/03) A I This Form Replaces Form 3510 -9 (8 -98) Form Approved OMB Nos. 2040 -0188 and 2040 -0211 Refer to the Following.Pages for Instructions EpA _United States Environmental Protection Agency NPDES Washington, DC 20460 Form Notice e of Intent (N01) for Storm Water Discharges Associated with Construction Activity Under an NPDES General Permit Submission of this Notice of Intent (NOI) constitutes notice that the party identified in Section II of this form requests authorization to discharge pursuant to the NPDES Construction General Permit (CGP) permit number identified in Section I of this form. Submission of this NOI also constitutes notice that the party identified in Section II of this form meets the eligibility requirements of the CGP for the project identified in Section III of this form. Permit coverage is required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in the CGP. To obtain authorization, you must submit a complete and accurate NOI form. Refer to the instructions at the end of this form. i I er mit_Number M IA I 1 1 of 01610101 ti. " :Operator information N L Name: 15 I ICICIRIPIoIKV- r 1 loIiv 1 1 1 1 1 1 1 1 I I I I 1 1 1 IRS Employer Identification Number (EIN): IU I.I - ow 1 L Mailing Address: Street: 11 lo ION 0 kA I w \I1 + Iele - 1 1 1 1 1 11 I I I I I City: IL I 0 IVIQ -1(I t 1 I 1 1 1 1 I I I I I 1 I I 1 1 I I I 1 State: Iri lit I Zip Code: In 11 sly! 1 I 1 1 1 Phone: 11171 1 - 1• ( - 1a10101°1 Fax (optional): la - c' o al E -mail (optional): W t It e I 7 L le $I,/4-1/1/fb IL, o tR i k di4'l I 1 I Itl... Proles /Site 1ihfbrm tion Project/Site Name:HID 1 f (k I 01 YJ ISIA o -- Ho s 1 I 1 • Project Street/Location: R Ib k r e 1 I fG I 1 1 1 1 1 1 1 1 1 1 1 1 City: A 1Ck ► Ip It 1°1+ I 1 l I 1 1 I I I I I I l I State: 0 I Zip Code: P 11 I° I (6 1 0 1 - 1 1 1 1 1 County or similar government subdivision: 1 WA ICI el SIh 111 RI e 1 1 1 1 1 1 Latitude /Longitude (Use one of three possible formats, and specify method) Latitude 1. `Ise J J 51 " N (degrees, minutes, seconds) Longitude 1. t 2-L2_. 3 . k W (degrees, minutes, seconds) 2. _2 N (degrees, minutes, decimal) 2. _ _ _ " W (degrees, minutes, decimal) 3. _ ° N (decimal) 3. _ _ _ ____ (decimal) Method: . U.S.G.S. topographic map F EPA web site I GPS [J Other: • If you used a U.S.G.S. topogr phis map, what was the scale: Project Located in Indian country? I Yes No If so, name of Reservation or if not part of a Reservation, put "Not Applicable ": Estimated Project Start Date: LI / O t I I / 1 4 u J IQ oil Estimated Project Completion Date: / L311_1 / o2I 0 lO P alk' Month Date Year Month Date Year Estimated Area to be Disturbed (to the nearest quarter acre): I 1 1 31 1 EPA Form 3510 -9 (Rev. 6/03) MLR 111 1 Address 706 Broadway Street • Lowell, MA 01854 Telephone 978 -441 -2000 Fax 978 -441 -2002 Web www.sandreorp.com City of Northampton Building Dept. 212 Main Street Room 100 Northampton, MA 09 -26 -08 Re: Demolition Permit of Building # 26 All ACM and Hazardous Material in Building # 26 has been removed as per Tighe & It ; • • survey. _ („ii.z., yr 1 L Paul Darling �� Superintendent S &R Corporation Cell # (603) 231 -3163 Demolition • Environmental • Construction w , Commonwealth of Massachusetts • _ _ _ • x ;100077439 � ��� Asbestos Notification Form ANF- 001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 5219 i ;8780 I a. Total pipes or ducts (linear ft) ' 7 otaI of er sur aces square ft) c. Boiler, breaching, duct, tank , 2 q �� ® M_ d. Insulating cement —7 ' ' q - surface coatings Lin. ft S ft. g Lin. ft S ft. e. Corrugated or layered paper f. Trowel/Sprayer coatings 1 _ pipe insulation Lin. ft Sq ft. g Lin. ft. Sq. ft. g. Spray -on fireproofing ` i h. Transite board, wall board - L. ft Sq. ft _ Lin. ft Sq. ft. 13344 1 ° 8530 i. Cloths, woven fabrics j. Other, please specify t L• — Lin ft S,q ft Lin. ft Sg ft k. Thermal, solid core pipe 1875 5CAULK,TILE,LI E insulation t i _ e.. _. �_ �.. Lin. ft. Sq. ft. I. Specify 14. Describe the decontamination system(s) to be used: 3 STAGE DECON 15. Describe the containerization /disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET 2 LAYER POLY BAGS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: cEE .....:, .�.m......�.�..®,�.�,.,....... �. a.A ... ..�e...f 6.m. 6...,«,. _.....e..m..A «..A ......�.. .........s........,....a.� a,.,_...._.... 3 a Name P O of DEP b. Title c. Date (mm /dd /yyyy) of Authorization d. DEP Waiver # e. Name of DOS Official f. DOS Official Title g. Date (mm /dd /yyyy) of Authorization h. DOS Waiver # 0 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A —F apply to this project? ✓ Yes No B. Facility Description 1FORMER HOSPITAL o 1. Current or prior use of facility: .,. 0 ■■ 2. Is the facility owner - occupied residential with 4 units or less? = Yes , ✓, No MASS DEVELOPMENT 33 ANDREWS PARKWAY 3 ' a. Facility Owner Name b. Address IMMIIIIINIMMEMNIMIM �� DEVENS 01434 978 784 - 2900 0 c City/Town d Zip Code a Telephone Numberkarea code and extension) � � 4 ALAN DELANEY 33 ANDREWS PARKWAY a. Name of Facility Owner's On Site Manager b. On - Site Manager Address z. DEVENS '01434 1 3978 784 - 2900 .� 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 Commonwealth of Massachusetts II, i100077439 Asbestos Notification Form ANF-001 Decal Number Important: out A. Asbestos Abatement Description When 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? 51 Yes 0 No - - to move your [ cursor - do not b. Provide blanket decal number if applicable: i............ Blanket Decal Number use the return key. 2. Facility Location: i 't .!..-4; 1 FORMER NORTHAMPTON STATE HOSPITALj 11 PRINCE STREET ...., aNamp of Facility b. StreeTAddress r _ , 1 ton Northamp I IMA i 01060 , , 1 ,,„ 1 c. City/Town d. State e. Zip Code f. Telephone Number ,.'''" ' ° - -- INSTRUCTIONS 3. Worksite Location: ---- , ,- - 1 : ',BUILDING 26D . . 1 1. All sections of this 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 ll No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division — , of Occupational AIR QUALITY EXPERTS INC ' '23 HALL FARM ROAD Safety (DOS) a. Name b. Address notification f ATKINSON . 03079 ' 16038946465 requirements o 453 CMR 6.12 c. City/Town d. Zip Code e. Telephone Number ,AC000167 --, ' f. DOS License Number g. Contract Type: ill Written , j Verbal „.„... ° - ° - ... h. Facility Contact Person i. Contact Person's Title , . GERALD WHITE , 1A5000782 6. a. Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certifipation Number N/A _____ a Name of Project Monitor b Project Monitor DOS Certcation Number . N/A 8. . . ........,....,.. a. Name of Asbestos AnalyticalLab _ b. Asbestos Analytical Lab DOS Certification Number ....m.,.... , .i- .9/11/2008 ' 110/17/2008 a. Project Start Date (rnm/dd/yyyy) b. E nd Date ( mm/ ddLytyy) -, — ...■ ■ o 7AM-5PM 1N/A IMIIIMINI IMMINIMMI■ .. ■ c. Work hours Mon-Fri. d. Work hours Sat-Sun. .....c\I ............■o 10. a. What type of project is this? ---0 j Demolition Renovation — , Repair ' Other, please specify: b. Describe ..,..,...., ...........—.. .,,.....,- 11. a. Check abatement procedures: o — ./ Glove bag , Encapsulation — . . o : Enclosure i Disposal only — — ..—.......— Il l Cleanup l Other, specify: LL l Full containment b. Describe .......... ■.....,...■ < 12. Is the job being conducted: i Indoors? 1 Outdoors? • anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 r , 0 Commonwealth of Massachusetts 1 100077438 Asbestos Notification Form ANF -001 Decal Number B. Facility Description (cont.) a. Name of General Contractor b. Address I i : c City/Town d. Zip Code e. Telephone Number ,(area code and extension) _ m. f. Contractor's Worker's Comp. Insurer g. Policy Number , „ -w h. Exp. Date mm /dd/yyyy) 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): i a. Name of Transporter b Address W � Note: Transfer - - Stations must I t comply with the P Y 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 GROUP ?PO BOX 2132 a. Name of Transporter b. Address ; BRISTOL,PA 19007 8 779999559 c City/Town d. Zip Code e. Telephone Number 3. a. Refuse Transfer Station and Owner b. Address c City/Town d Zip Code e e Telephone Number 4. MINERVA ENTERPRISES INC ������������ a. Final Disposal Site Location Name b. Final Disposal Site Location Owner's Name 9000 MINERVA ROAD :WAYNESBURG c. Final Disposal Site Address d. CitylTown ;OH ;44688 e. State f. Zip Code g . ele Number ._ M p g. Telephone "'""'''lo ° D. Certification The undersigned hereby states, under the CHRISTOPHER THOMPS i ;Christopher Thompson - o penalties of perjury, that he /she has read the me ” P a Name b. Authorized Signature � o Commonwealth of Massachusetts regulations ;PRESIDENT 308/27/2008 for the Removal, Containment or c Position/Title d Date {mm /di :11m __ Encapsulation of Asbestos, 453 CMR 6.00 and 6038946465 i ,AIR QUALITY EXPERTS . 310 CMR 7.15, and that the information contained in this notification is true and correct e. Telephone Number f Representincf r . , ° to the best of his /her knowledge and belief. 23 HALL FARM ROAD �� o Address � � ATKINSON 03811 h. City/Town i. Zip Code _ ... _.. ..._. � z ............ • anfo0lap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 • Commonwealth of Massachusetts • 1100077438 Asbestos Notification Form ANF -001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: 8938 1241 a. Total pipes or ducts (linen ft) b "Dotal of ie' sui aces (square ft) c. Boiler, breaching, duct, tank 240 surface coatings Lin. ft Sq ft d. Insulating cement • Lin. ft Sq. ft. i e. Corrugated or layered paper € f. Trowel /Sprayer coatings pipe insulation Lin. ft Sq. ft Lin. ft. SRI ft. g. Spray -on fireproofing -- -• h. Transite board, wall board Lin. ft Sq. ft. Lin. ft. Sq. ft. i. Cloths, woven fabrics t� -- j. Other please specify. 6688 , Lin -ft_. _ -Sq�, w s��_..._ Lin. ft N._ Sq ft k. Thermal, solid core pipe ;2250 ;CAULK $ GLAZ insulation ''Lin. ft. ®�� ' S . q ft. — " I. Specify - �� 14. Describe the decontamination system(s) to be used: 3-CHAMBER DECON 15. Describe the containerization /disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET 2 -LAYER POLY BAGS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a. Name of DEP Official b. Title c. Date t mm /dd/ Waiver • ( YYYY) of Authorization d. DEP Waiver # e. Name of DOS Official f. DOS Official Title g. Date (mm /dd /yyyy) of Authorization 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 m ' No B. Facility Description 'FORMER HOSPITAL — o 1. Current or prior use of facility: -� — o 2. Is the facility owner - occupied residential with 4 units or less? x Yes ✓ No MASS DEVELOPMENT 33 ANDREWS PARKWAY 3 ' a. Facility Owner Name b. Address � DEVENS 01434 978- 784 -2900 o c. City/Town d. Zip Code e. Telephone Number (area code and extension) --.... 4 ALAN DELANEY 33 ANDREWS PARKWAY a. Name of Facility Owner's On S ite Manager b On Site Manager Address z DEVENS 01434 978-784-2900 ° ,—..-....Q c. City/Town d. Zip Code e. Telephone Number (area code and extension) • anf001ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 U t • Commonwealth of Massachusetts ■ J 100077438 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? F4 Yes ❑ No ___ ......,,,.. to move your cursor - do not b. Provide blanket decal number if applicable: l, use the return Blanket Decal Number key. 2. Facility Location: ti l l FORMER NORTHAMPTON STATE HOSPITAL i1 PRINCE STREET a Name of Facility bStreet Address N or th amp t on a 1MA 01060 4 a c. City/Town d. State e. Zip Code f. Telephone Number INSTRUCTIONS 3 Worksite Location: 1. All sections of this BUILDING 26C & CONNECT 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 ✓ No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division ._ m m.a__._ of Occupational :AIR _ QUALITY EXPERTS INC ` 23 HALL FARM ROAD Safety (DOS) a. Name _.__ _ _.� b. Address notification ATKINSON '03079 16038946465 requirements of 453 CMR 6.12 c. City/Town d. Zip Code e. Telephone Number AC000167 f. DOS License Number g. Contract Type: I Written : Verbal h. Facility Contact Person i. Contact Person's Title GERALD WHITE 1AS000782 a. Name of On -Site Supervisor /Foreman b. Supervisor /Foreman DOS Ce ification Number N/A 4 a. N ame of froject,Monitor b Project Monitor DOS Certification Number 8. N/A a Name of Asbestos Analytical Lab b. Asbestos Analytical Lab DOS Certification Number 9/11 /2008 1 10/17/2008 0 a Project Start Date mm /dd% b E nd Date mm/ dd/ — o 7AM -5PM 4N /A N c. Work hours Mon -Fri. d. Work hours Sat-Sun. ■ 0 10. a. What type of project is this? 0 ✓ Demolition i Renovation Repair Other, please specify: b. Describe 11. a. Check abatement procedures: 0 ✓: Glove bag Encapsulation o Enclosure ` Disposal only s- _ u ✓ Cleanup :Other, specify: ✓ Full containment b. Describe Z Q 12. Is the job being conducted: ✓? Indoors? '✓ Outdoors? NI anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 eDEP: Print Receipt Page 1 of 1 Submittal Summary & Receipt Your submission is complete. Thank you for using DEP's online reporting system. You can select "My Homepage" to review your status. DEP Transaction ID: 196051 Date and Time Submitted: 8/13/2008 10:14:58 AM User Email : mploof@sandrcorp.com Other Email : Form Name: BWP - Demolition Form for AQ -06 Payment Information DEP code Date Amount ($) Payment Detail Contractor Contractor Number Name Address, , Supervisor Project Monitor Lab print "receipt cancel httnc•/ /Pr1Pr1 r1Pn mace artu/kpctrirtpr1/11/Abnatypeirwintrpop.int , Icr v 5211 l /')ffR2 Massachusetts Departm of Environmenta Protection ■ } Bureau of W aste Preventi • Ai r Quality 100076667 ( B W P AQ 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)? p Yes ❑ No If yes, who conducted the survey? BRIAN DAY b. Surveyor Name A1061695 c. Division of Occupational Safety Certification Number 7. Construction or Demolition: 8/27/2008 M~µ 12127/2008 a. Start Date (mm/dd/yyyy) b. End Date (mm/dd/yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: El seeding , paving 5I wetting shrouding b. If other, please specify: Ej covering ii other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? a. Name of DEP Official b. Title c. Date (mm /dd /yyyy) of Authorization d. DEP Waiver NumberF ".. D. Certification 1 certify that I have examined the 'STEVEN PLOOF o above and that to the best of my a. Print Name o knowledge it is true and complete. [Steven Ploof The signature below subjects the b. Authorized Signature signer to the general statutes 9 9 TREASURER o regarding a false and misleading c F'ositio - rvii a o statement(s). IS&R CORPORATION Represenbn2 '08/13/2008 i..... --.... ..,... ...- ».r..- ...» ». ._ ... _.. .. .. _ __.,.._,..mow, ,.. .a...� e. Date (mmtdd/yyyy) ;d stimmimsom �Q ag06.doc • 10/02 BWP A4 06 • Page 3 of 3 U Massachusetts Department of Environmental Protection • Bureau of Waste Prevention • Air Quality [100076667 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General Statement: If B. General Project Description (cont.) asbestos is found during a ruction or • General Contractor: Const Demolition 'UR CORPORATION operation, all a. responsible parties Name must comply with 1706 BROADWAY STREET 310 CMR 7.00, b. Address.-- .„ roi854 7.09, 7.15, and - Chapter 21E of the rLOWELL General Laws of c. crrown d. State e. Zip Code .„„„. the Commonwealth. 9784412000 This would include, f. Telephone Number (area code and extensi but would not be on) 0. E-mail Address_AitionalL limited to, filing an JOHN PARRINGTON 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. S&R CORPORATION a. Name j70, STREET - b. ress — [[WELL 1 [01854 c:CifFrOWF1 d. State e. Zip Code [9784412000 f Tele•hone NumtierOrea code and extension 9. E-mail Adaresiltoptional) JOHN PARRINGTON . n-elte Wariager 2. On-Site Supervisor: [JOHN PARRINGTON On-Site Supervisor Name 3. Is the entire facility to be demolished? [] Yes [1 No o 4. Describe the area(s) to be demolished: semimEmi mm■ ,o ENTIRE STRUCTURE AND FOUNDATIONS milm 0 === ° 5. If this is a construction project, describe the building(s) or addition(s) to be constructed: NO iiimion= 0 ===== _ 11••■■• 0 • aq06.doc • 10/02 BWP AQ 06 • Page 2 of 3 II Massachusetts Department of Environmental Protection '). ,� Bureau of Waste Prevention • Air Quality L 100076667 II I BWP AQ 06 Decal Number Notification Prior to Construction or Demolition Important: A. A licabilit When filling out Applicability 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 us not use e the (DEP), Bureau of Waste Prevention - Air Quality Control Regulations 310 CMR 7.09. Notification of the return rurn key. Construction or Demolition operations is required under 310 CMR 7.09 (2) ten (10) days prior to any „tr work being performed. The following information is required pursuant to 310 CMR 7.09. . FAA J B. General Project Description MINIM 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner- occupied Instructions residence of four units or Tess? © Yes El No _ _ 1. All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order to comply with the 2. Facility Information: Department of NORTHAMPTON STATE HOSPITAL Environmental _ ._. _ � Protection a. Name notification 1 PRINCE STREE (BUILDING 26D) requirements of b. Address 310 CMR 7.09 -. _ _._ [Northampton MA 01103 c. Ci own d. State e. Zi. Code 4137551341 snorthrup @massdevelopment.com f. Telephone Numbearea code and extension,} _ q._E -mail Addresjoptional) 350 4 h. Size of Facility in Square Feet i. Number of Floors j. Was the facility built prior to 1980? [3 Yes 0 No k. Describe the current or prior use of the facility: VACANT HOSPITAL BUILDING mi I. Is the facility a residential facility? [1 Yes [1 No mimilaimm ° m. If yes, how many units? Number of Units milmis° 3. Facility Owner: MiEnN [MASS DEVELOPMENT _ .,. ;° a. Name a 33 ANDREWS PARKWAY ........ b. Address - DEVENS MA {1434 � ° fin �° X 4137551341 I snorthrup @massdevelopment com , imegamm= }, • _ O e c e Numberr a ta nd )aF t� i rr it Address ( ptional) ;SARA NORTHRUP 'Q h. Onsite Manager Name II ag06.doc • 10(02 BWP AQ 06 • Page 1 of 3 II DEP.. Print Receipt Page 1 of 1 • Submittal Summary & Receipt Your submission is complete. Thank you for using DEP's online reporting system. You can select "My Homepage" to review your status. DEP Transaction ID: 196059 Date and Time Submitted: 8/13/2008 10:39:13 AM User Email : mploof@sandrcorp.com Other Email : Form Name: BWP - Demolition Form for AQ -06 Payment Information DEP code Date Amount ($) Payment Detail Contractor Contractor Number Name Address, , Supervisor Project Monitor Lab print r ece pt a cancel 3 . httne. / /erlen den . magic. pov/ Re: ctricted /wehnauec /nrintreceint_asnx 8 /13/2008 Massachusetts Department of Environmental Protection 1 Bureau of Waste Prevention • Air Quality [100076665 BWP AQ 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)? ✓� Yes 0 No If yes, who conducted the survey? BRIAN DAY b. Surveyor Name A1061695 c. Division of Occupational Safety Certification Number 7. Construction or Demolition: 8/27/2008 12/31/2008 a. Start Date (mmiddlyyyy) b. End Date (mmlddlyyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: Li seeding Cl paving �✓ wetting [] shrouding b. If other, please specify: covering ,IJ other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? a. Name of DEP Official` °°___ b. Title c. Date (mm /ddly alof Authorization d. DEP Waiver Number D. Certification I certify that I have examined the STEVEN PLOOF o above and that to the best of my a. Print Name knowledge it is true and complete. Steven Ploof yossommosiomis The signature below subjects the c■' signer to the general statutes "TREASURER �o regarding a false and misleading c:$osifionlTi e ,..., statement(s). [S&R CORPORATION d. Representing 08113/2008 3m __ (0 e. Date (mmldd/yyyy) TQ ag06.doc • 10/02 BWP AQ 06 • Page 3 of 3 .� Massachusetts Department of Environmental Protection ■ ; ;,W__ Bureau of Waste Prevention • Air Quality 100076665 I, ' \ BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General Statement: If B General Project Description (cont.) asbestos is found during a 4. General Contractor: Construction or ..& _ , _. _ __ _ Demolition SBR CORPORATION operation, all responsible parties P.. ame .., . �_. _ , .. ..... must comply with 1 706 BROADWAY STREET 310 CMR 7.00, b Address _ y _ 7.09, 7.15, and __ .__ _ „„ _ Chapter 21E of the [LOW ELL_ MA 01854 General Laws of c. City/Town, d. State _ e. Zp Qpde , _ - the Commonwealth. 9784412000 _� _ This would include, , 1 . E -mail Address but would not be f. Tele, one _Number (area code and extensions a .'o.tional} limited to, filing an JOHN PARRINGTON n..... _ i i 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. S &R CORPORATION a. Name 70 BROADWAY STREET b, Address _.,,, --,. _,...fw,,, _w _ _____ _e_ „_,_ ._ WELL MA 01854 i c Cny/"row n — F L Mate e Zi , Code 1 978441200 0 f Telephone Number (area and extensions _ mail Address ioptional JOHN PARRINGTON ■ h. • n -site ManagerName 2. On -Site Supervisor: [JOHN PARRINGTON On -Site Supervisor Name 3. Is the entire facility to be demolished? 111 Yes ri No milli m� o 4. Describe the area(s) to be demolished: 2===-_ o ENTIRE STRUCTURE INCLUDING FOUNDATIONS. i i iiimais I O 5. If this is a construction project, describe the building(s) or addition(s) to be constructed: isamis [NO r0 ° i Q U aq06.doc • 10/02 BWP AO 06 • Page 2 of 3 1 Massachusetts Department of Environmental Protection ■ f 'r_.. Bureau of Waste Prevention • Air Quality 100076665 -\t' BWP AQ 06 Decal Number Notification Prior to Construction or Demolition When fll ng out A. Applicability 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 us - not use e th e return (DEP), Bureau of Waste Prevention - Air Quality Control Regulations 310 CMR 7.09. Notification of th 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. ulie, ,..,A 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 Tess? Yes 3 v= No 1. All sections of b. Provide blanket decal number if applicable: L. - 1 this form must be Blanket Decal Number completed in order 2 Facili Information: to comply with the ty Department of . Environmental NORTHAMPTON STATE HOSPITAL Protection a. Name notification 1 PRINCE STRE: (BUILDING 26C) requirements of b. Address 310 CMR 7.09 - _ ----- �°° - Northampton _m.... _ . ,. AMA 01103 c. citviTown 4 ... r io. slate e, 2i Code. 1 4135876314 snorthrup @sandreorp.com s e b «.. grit t .} E -mail Address (optional 35000 E t h. Size of Facility in Square Feet 1 Number of Floors j. Was the facility built prior to 1980? ✓ Yes III No k. Describe the current or prior use of the facility: 'VACANT HOSPITAL BUILDING I. Is the facility a residential facility? , Yes q ✓M % No = m. If yes, how many units? Number of Units 3. Facility Owner: � ...,....•.0.0.0.,,..(4 MASS DEVELOPMENT f =o a. Name , .. ___ MIE= ...............0 X ANDREWS PARKWAY b. Address -- - , DEVENS 1 ; MA 01434 aiiiiiiiiimilim -_ _ . - 4135876314 isnorthrup@sandrcorp.com i MI:22 f. Telephone Number (areal agg.n _._.. E-mail Address tg tIQn I O SARA NORTHRUP lQ h. Onsite Manager Name 1 ag06.doc • 10/02 BWP AQ 06 • Page 1 of 3 1 Client#: 5850 1257839 • ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 3/28/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Helmsman Insurance Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 20 Riverside Rd HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Weston, MA 02493 -2231 617 243 -7926 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: North River Ins. Co. 21105 S & R Corporation, ETAL — INSURER B: 706 Broadway INSURER C: Lowell, MA 01851 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRC DATE (MM /DYY) DATE (MM /DD/YY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRFMISFS (Fa occurrence) $ _ CLAIMS MADE I I OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ — 7 POLICY r7 JECr ri LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ _ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A X EXCESS/UMBRELLA LIABILITY 5520130209 11/02/07 10/01/08 EACH OCCURRENCE $5,000,000 30 OCCUR CLAIMS MADE AGGREGATE $5,000,000 _ $ DEDUCTIBLE $ _ RETENTION $ $ WORKERS COMPENSATION AND WC S TAT U OTH - EMPLOYERS' LIABILITY 1 TORY LIMITS 1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Evidence of Insurance DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTAT VE ACORD 25 (2001/08) 1 of 2 #S294591/M267996 1VMN © ACORD CORPORATION 1988 } • Client#: 5850 1257839 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (M / D/""'"') PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Helmsman Insurance Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 20 Riverside Rd HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Weston, MA 02493 - 2231 617 243 - 7926 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: American International Specialty Lin S & R Corporation, ETAL INSURER B: 706 Broadway INSURER C: Lowell, MA 01851 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRE DATE (MM /DD/YY) DATE (MM /DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PRFMISFS,(FT nrrurrencel $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ n POLICY n s n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ _ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ n OCCUR CLAIMS MADE AGGREGATE $ _ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND AVM S- S OTH- EMPLOYERS' LIABILITY TORY I IMITS 1 I FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ A OTHER Contractors 2044547 10/01/07 10/01/08 1,000,000 Per Claim Pollution 2,000,000 Aggregate Liability DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Evidence of Insurance DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL nn DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ., MA 01854 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001108) 1 of 2 #S261356/M261352 1JIW © ACORD CORPORATION 1988 • This Certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. — BM0069 Certificate of Property Insurance This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend, extend, or alter the • coverage afforded by the policies listed below. This is to certify that (Name and Address of Insured) S & R CONTRACTING CORPORATION ETAL 410. 706 BROADWAY STREET * Liberty LOWELL, MA 01854 U. ra Is, at the date of this certificate insured by the Liberty Mutual Insurance Group at the locations specified under the Policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be used Policy Number YF2 -111- 257839 -097 Eff. Date of Policy 10/01/07 Exp. Date of Policy 10/01/08 Type of Policy Cause of Loss Forms/Insured El Commercial Property ❑ Basic ❑ Broad ❑ Special ❑ Earthquake ❑ ❑ Business Owners ❑ Standard ❑ Special ❑ Earthquake ❑ Inland Marine ❑ Specified Perils Per Form ❑ (All)Risk Subject to Policy Form ❑ ❑ RIM Select ❑ Causes Of Loss Per Policy Form ❑ Earth Movement/Earthquake ❑ Flood ❑ Commercial Business Property ❑ Causes Of Loss Per Policy Form ❑ Earth Movement/Earthquake ❑ Flood ❑ Electronic Data Processing ❑ Causes/Risks of Loss Per Policy Form ❑ Includes Breakdown ❑ Boiler and Machinery ❑ Causes of Loss Per Policy Form ❑ ® Special, all risk Insured Location(s) or Specific Subject of Coverage Evidence of Insurance- Re: 706 Broadway Street, Lowell Description of Insured Property Coin /Contrib % Insured Property ® Building(s)Real Property ❑ $700,000 El Personal Property of the Insured ❑ $310,000 ❑ Personal Property of Others ❑ ❑ Boiler and Machinery Object Definition No: ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 0 Mortgagee (s): Loss Payee (s): Notice of cancellation: (not applicable unless a number of days is entered below) . Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until at least 00 days notice of such cancellation has been mailed to: • Office : Danvers, MA Phone: 800 - 566 -0323 r r ' + r.1 s r Certificate Holder: LAURETTE SZOSTAKOWSKI Evidence of Insurance Authorized Representative 706 Broadway Street Lowell, MA 01854 Date Issued: 10/01/2007 Prepared By: DK • This Certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. BM0069 Certificate of Property Insurance This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend, extend, or alter the • coverage afforded by the policies listed below. This is to certify that (Name and Address of Insured) S & R CORPORATION tA 706 BROADWAY STREET r UL � LOWELL, MA 01854 f��f(� Is, at the date of this certificate insured by the Liberty Mutual Insurance Group at the locations specified under the Policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be used. Policy Number YM2- 111- 257839 -057 Eff. Date of Policy 10/01/07 Exp. Date of Policy 10 /01/08 Type of Policy Cause of Loss Forms /Insured ❑ Commercial Property ❑ Basic ❑ Broad ❑ Special ❑ Earthquake ❑ ❑ Business Owners ❑ Standard ❑ Special ❑ Earthquake ❑ Inland Marine ❑ Specified Perils Per Form ❑ (All)Risk Subject to Policy Form ❑ ❑ RM Select ❑ Causes Of Loss Per Policy Form ❑ Earth Movement/Earthquake ❑ Flood ❑ Commercial Business Property ❑ Causes Of Loss Per Policy Form ❑ Earth Movement/Earthquake ❑ Flood ❑ Electronic Data Processing ❑ Causes/Risks of Loss Per Policy Form ❑ Includes Breakdown ❑ Boiler and Machinery ❑ Causes of Loss Per Policy Form • Contractor's Equipment ® Special Insured Location(s) or Specific Subject of Coverage Description of Insured Property Coin /Contrib % Insured Property ❑ Building(s)Real Property ❑ ❑ Personal Property of the Insured ❑ ❑ Personal Property of Others ❑ ❑ Boiler and Machinery Object Definition No: ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ® Equipment leased or rented from others $485,000 Mortgagee (s): Loss Payee (s): Notice of cancellation: (not applicable unless a number of days is entered below) . Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days notice of such cancellation has been mailed to: Office : WORCESTER, MA Phone: 508- 753 -1840 "zet. " Certificate Holder: LAURETTE SZOSTAKOWSKI Evidenc e of Insuranc e Authorized Representative 706 Broadway Street Lowell, MA 01854 Date Issued: 10/01/2007 Prepared By: DK • This cetificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. BM0068 Certificate of Insurance This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policies listed below. This is to certify that (Name and address of Insured) This voids and supercedes the certificate issued on 10/01/2007. S & R CORPORATION • 706 BROADWAY STREET ' berty LOWELL, MA 01854 is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be issued. Expiration Type Eff./Exp. Date(s) Policy Number(s) Limits of Liability Continuous* 10/01/2007 / 10/01/2008 WCI- 1 1 1 - 257839 -0 17 Coverage afforded under WC law of Employers Liability _ Extended the following states: Bodily Injury By Accident X Policy Term MA, NH $1,000,000 Each Accident Bodily Injury By Disease $1,000,000 Policy Limit Workers Compensation Bodily Injury By Disease $1,000,000 Each Person 10/01/2007 / 10/01/2008 TB2 - 111 - 257839 - 077 General Aggregate -Other than Prod /Completed Operations General Liability $2,000,000 Products /Completed Operations Aggregate Claims Made $2,000,000 X Occurrence Bodily Injury and Property Damage Liability Per $1,000,000 Occurrence Retro Date Personal and Advertising Injury Per Person / $1,000,000 Organization Other Liability Other Liability 10/01/2007 / 10/01/2008 AS2 - 111 - 257839 - 027 Each Accident - Single Limit - B. I. and P. D. Combined Automobile Liability $1,000,000 Each Person X Owned X Non -Owned Each Accident or Occurrence X Hired Each Accident or Occurrence Umbrella Excess 10/01/2007 / 10/01/2008 TH2 -6 1 1- 25 7 83 9 -037 $5,000,000 Evidence of Insurance C 0 M M E N T S Notice of cancellation: (not applicable unless a number of days is entered below) . Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days notice of such cancellation has been mailed to: Office : WORCESTER, MA Phone: 508 - 753 -1840 7 w�"'o` r,,,y;.4 Certificate Holder: LAURETTE SZOSTAKOWSKI Evidence of Insurance Authorized Representative 706 Broadway Street Lowell, MA 01854 Date Issued: 10/02/2007 Prepared By: DK r =. / ,d1l,. =s 706 Broadway Street Lowell, MA 01854 e k h nr, 978 -441 -2000 Fa 978 - 441 -2002 L;/ #i www.sandreorp.com 1 %J4o r ,,a,414 , f / r,XI/;.re ii Board of Building Regulations and Standards Construction Supervisor License License: CS 79011 Birthdate: 5/14/1977 Expiration: 5/14/2009 Tr# 13284 a► a Restriction: 00 WESLEY J DUMONT PO BOX 471 NORTH SALEM, NH 03073 Commissioner 00 - 35,000 cf enclosed space IA - Masonry only IG - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. .. a .•, 1 r 1 r k t f kt v , - - -- •.m+*�+'.nu nwv '+wni4'n'm:' + +xW+'sri�+naawr .. + .... ww.w'ary' ' "sY€- # tG:iMltA'.tiw -5«`°.,s+.. Demolition Environmental Construction The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name (Business!Organization /Individual): — Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. El I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition No workers' comp. insurance comp. insurance. required.] 5. E] 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. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. No workers' 1 • ❑ Other comp. insurance required.] `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r 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. #: Expiration Date: Job Site Address: City /State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sinnature: Date: Phone #: 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 #: • 4 Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, H o S e a 14 ' -11 (CL I) ti(L Uf' MF fii L L ' as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application 7 / Ve P ignature of Owner Date ._..,._ , _�.,, ._,..w.�. .. .. ,_ ,,._. _ _._,....., .. , 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. Print Na 7 _ 26,--., r .‘ - - - 1 t‘ z(;....----c_,.......-, _„,„ „ .„ , ,„,, „ , , Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder • ifr L p,„,,,o,t--- ?, ... Y .. .._ License Number l rf . _ a 7 . . 7Tot _ . .. Address Expiration Date 6 .0.- 23! Signatu a L Telephone 67" y/ " i SEC ION 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 building permit. Signed Affidavit Attached Yes 0 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 ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable 0 Name (Registrant): _... _. Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area Responsibility 53 Sou .ton Rd., Westfield, .MA .01085. , -.__ -{ ?:E.-417 Address / Registration Number 413-562-1600 tf?tcax Signature Telephone Expiration Date Name Area of Responsibility Address RestistrationNumber 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 S&R._Corporation_ Not Applicable 0 Company Name; Wesley Dumont Responsible In Charge of Construction 706 Broadway Street, Lowell, MA--..O1.854-- Address ..�,.-J 1 114.A/A ..t 978 -441 -2000 ignature — Telephone 1 Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _.. Setbacks Front Side L. Rear Building Height Bldg. Square Footage Open Space Footage ° (Lot area minus bldg & paved . v... parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES a IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO CD DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW € YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 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 ® NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 . 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 ❑ Demolitionl Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: Err t`b C� 4 / '1 6, D 4- D SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1 A 1 ❑❑ A -4 ❑ A -5 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ` I" ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional X 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 I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34) _ .. SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 st 1 2 nd l \ ,. .. _ 2 3 4 th 4 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 Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone ,,, Outside Flood Zone❑ Municipal ❑ On site disposal system❑ -14 • e Versionl.7 Commercial Building Permit Mav 15, 2000 Department use only City of Northampton Status of Permit: ,' [ \,,_\ / I 031.1ilding Department Curb Ci.it/Driveway Permit - ' -- - — - ------ .- : 1212 Main Street Sewer/Septic #P8#1aleiii41' S ---- 67' Pko it( 1 . Room 100 Water/Weli uaiiabiiity 5 cot (et SEP 26 2008 N&thampton, MA 01060 Two Sets of Structural Plans Jphone 43-587-1240 Fax 413-587-1272 plot/site pl , .., Other Specify i,_ APPLItATION "r151.6.0.0g ICT,„13.EPAIR, 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 Property Address: / -,R P7Ce__, 'ci-e- Map Lot Unit xidi t ety4f--&-r2 P7/4 Zone Overlay District - - - - - - Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: fi Name (Print) Current Mailing Address: 2.2 Authorized Agent: W t.''"/ 2 5/0, tiLcia,-,.41, le Name (Print) Current Mailing Address: i ,, ) ,t - :- , --e--- Signature Telephone CE(-1- 6 31 t)3 SECTION 3 - ESTIMATED CONSTRUCTION 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 4. Mechanical (HVAC) ..., ,. 5. Fire Protection , 6. Total=(1+2+3+4+5) ft i Z - Check Number This Section For Official Use Only . ,. Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2009 -0343 APPLICANT /CONTACT PERSON S & R CORPORATION ADDRESS/PHONE 706 BROADWAY ST LOWELL (978) 441 -2000 PROPERTY LOCATION 1 PRINCE ST MAP 38A PARCEL 050 001 ZONE PV THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT ee Paid (r Permit Filled out ,Fee Paid # 86) 1 $1_60 ,c1 Typeof Construction: 26C & D COMPLETE DEMOLITION INCLUDING FOUNDATION BLDG New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 061320 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFtMATION PRESENTED: � V 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 Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay 0 y/30/0 z 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. e BP- 2009 -0343 Gs #: COMMONWEALTH OF MASSACHUSETTS 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- 2009 -0343 Project # JS- 2007 - 000677 Est. Cost: $500000.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: S & R CORPORATION 061320 Lot Size(sq. ft.): 226512.00 Owner: HOSPITAL DEVELOPMENT LLC Zoning: PV Applicant: S & R CORPORATION AT: 1 PRINCE ST Applicant Address: Phone: Insurance: 706 BROADWAY ST (978) 441 -2000 LOWELLMA01854 ISSUED ON:9/30/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:26C & D COMPLETE DEMOLITION INCLUDING FOUNDATION BLDG 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 9/30/2008 0:00:00 $200.00807 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo