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24C-151 (2) A"EVV L s, Locp 5cndces 617 Wager Sweet v.ontargetservice5.corn Gardiner,Ddaine 04345 Utility Services ie1800-548-0628 fax U7-588-3302 a-mail: smeniug@cvntugeLservices.com Date/Time :3/26/2014 11:07:42 AM ASSOCIATED BUILDING WRECKERS 352 ALBANY STREET SPRINGFIELD MA 01105 Tel.:(413)-732-3179 ext. This message is being sent 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#: 20141304409 Place NORTHAMPTON, MASSACHUSETTS Address : 29,ARLINGTON STREET 1-NATIONAL GRID ELECTRIC -NE NORTH Ticket Screened on 03!26!2014 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, during normal business hours, Monday- Friday between T00AM and 4:30PM ."eDEP - MassDEP's OnlineFiling System Page 1 of 1 MassDEP Home I t MassDEP's Online Filing System Username:DE Nicknar My eDEP'. Forms1lMl My Profile Help' Notifications Receipt Forms Signature Summary/Receipt print.rec 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: 644061 Date and Time Submitted: 4/15/2014 12:42:28 PM Other Email : Form Name: AQ 06 - Construction/Demolition Notification Payment Information DEP code Date Amount ($) Payment Detail Contractor Contractor Number Name Address, , Supervisor Project Monitor Lab MassDEP Home I C MassDEP's Online Filing System ver.12.6.0.0© 2013 MassDEP https:Hedep.dep.mass.gov/Pages/PrintReceipt.aspx 04/15/2014 t r Massachusetts Department of Environmental Protection eDEP Transaction Copy_ Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: DEMOCOORD Transaction ID: 644061 Document: AQ 06-Construction/Demolition Notification Size of File: 116.98K Status of Transaction: In Process Date and Time Created: 4/15/2014:12:46:49 PM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. Massachusetts Department of Environmental Protection ■ Bureau of Waste Prevention • Air Quality 100196831 w BWP AQ 06 Decal Number LIV 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 ❑ No If yes, who conducted the survey? JAMES BEAUDRY b.Survevor Name AS074322 c.Division of Occupational Safety Certification Number 4115/2014 6/30/2014 7. Construction Or Demolition: 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: ❑ seeding ❑ paving b. If other, please specify: [✓ wetting ❑ shrouding ❑ covering ❑ other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? N/A a.Name of DEP Official N/A b.Title 4/15/2014 c.Date mm/dd/ of Authorization N/A d.DEP Waiver Number D. Certification —��M I certify that I have examined the ANDREW MIRKIN —moo above and that to the best of my a.Print Name °Q knowledge it is true and complete. JAndrew Mirkin The signature below subjects the b.Authorized Signature ��•N signer to the general statutes PRESIDENT ---o regarding a false and misleading c.Position/ e �o statement(s). JASSOCIATED BUILDING WRECKERS d.Re resentin 4/15/2014 , o e.Date(mm/dd/yyyy) �Q ■ ag06.doc•10/02 BWP AQ 06•Page 3 of 3■ Massachusetts Department of Environmental Protection -� Bureau of Waste Prevention • Air Quality 100196831 Decal Number BWP AQ 06 Notification Prior to Construction or Demolition General Statement:If B. General Project Description Cont. asbestos is found during a Construction or 4. General Contractor: ---- Demolition ASSOCIATED BUILDING WRECKERS operation,all a.Name responsible parties must comply with 1352 ALBANY STREET m i 310 CMR 7.00, b.Address 7.09,7.15,and SPRINGFIELD MA 01105 Chapter 21 E of the - - -- General Laws of c.Cit /Town d.State e.Zi Code the Commonwealth. 14137323179 demo @buildingwreckers.com This would include, f.Tele hone Number area code and extension).E-mail Address o tional but would not be ROBERT LOCKWOOD limited to,filing an 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. JASSOCIATED BUILDING WRECKERS a.Name 352 ALBANY STREET b.Address SPRINGFIELD [MA 101105 c. it /Town d.State e.Zip Code 4137323179 demo @buildingwreckers.com f.Telephone Number area code and extension -mail Address o tional ROBERT LOCKWOOD h.On-site Manager Name 2. On-Site Supervisor: WILLIAM BABCOCK On-Site Supervisor Name 3. Is the entire facility to be demolished? ❑ Yes ✓❑ No N 0 4. Describe the area(s)to be demolished: MEo BARN STRUCTURE ONLY N �O °0 5. If this is a construction project, describe the building(s)or addition(s)to be constructed: NIA (0 o ag06.doc•10/02 BWP AQ 06•Page 2 of 3 Massachusetts Department of Environmental Protection _ .._. Bureau of Waste Prevention . Air Quality 100196831 Decal Number BWP AQ 06 Notification Prior to Construction or Demolition Important: Applicability When filling out A. pp . Y 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✓n 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?C✓ Yes ❑ No 1.All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order 2 Facility Information: to comply with the y Department of RESIDENTIAL'BARN"STRUCTURE Environmental Protection a.Name notification 129 ARLINGTON STREET requirements of b.Address 310 CMR 7.09 Northam ton 1 01060 c. i /T wn ate e.Zin Code 4135841224 f.TeleDhone Number(area code and x n i n E-mail Address o tional 500 1 h.Size of Facility in Square Feet i.Number of Floors j. Was the facility built prior to 1980? ❑✓ Yes ❑ No k. Describe the current or prior use of the facility: RESIDENTIAL"BARN" STRUCTURE I. Is the facility a residential facility? ❑ Yes ❑ No o m. If yes, how many units? Number of Units —° 3. Facility Owner: IN CONSTRUCT ASSOCIATES INC. o a.Name 0 136 SERVICE CENTER ROAD b.Address NORTHAMPTON 1 101060 cD i / i 0 14135841224 If.T ele2hone Number(are a de and extension) .E-mail Address o tional ROBERT WALKER h.Onsite Manager Name ag06.doc•10/02 BWP AQ 06•Page 1 of 3 ASBESTOS SAMPLING FORM E I L^BS C0MPANY.C QUIA=J: �RRATIQ ;. . r Com an :Ba state Contracting Services, Inc. Job Contact:James Beaudry Address:352 Albany St. Email/Tel: 413-781-0821 S rin field, MA 01105 Project Name: 29 Arlington St N.Ham ton, Ma. Project lD#Construst Ass Inc. *fir' e� 4,?Ml ,fit v0 wALFd SAMPLE AR "� TEST 1 White Paint Trim-throughout 460 Ift PLM ® TEM 2 Bur and Paint-throughout 18,000s ft PLM ® TEM 3 1 White Window Glazing 8 Ift PLM ® TEM 0 4 Brown Insulation Board 64 s ft PLM ® TEM 0 5 Bie a Covering on sheetrock 32s ft PLM ® TEM 0 6 White Sheetrock 32s ft PLM ® TEM 7 Brown cork style board 64s ft PLM ® TEM 0 8 Black Roofing Shingle 1200s ft PLM ® TEM 9 Black Roofing Shingle 1200s ft PLM ® TEM 10 4 White Window Glazing 2401ft PLM ® TEM 11 12 ex 2nd fl-White Window Glazing 5761ft PLM ® TEM 0 Page-2—of 2_ VERSION CCOC.0214.2/2.LD ASBESTOS CHAIN OF CUSTODY LAL35 LAB USE ONLY: 107 New Edition Court, Cary, NC 27511 CEI Lab Code: Tel: 866-481-1412; Fax: 919-481-1442 CEI Lab I.D. Range: COMPANY-,I. 0 },. PROJECT INFORMATION CEI CLIENT#:1328 Job Contact:James Beaudry Com an :Ba state Contracting Services, Inc. Email/Tel: 413-781-0821 Address:352 Albany St. Project Name#29 Alin ton st Northam ton,Ma Springfield, MA 01105 Project ID#Construst Ass Inc. Email:james@baystatecontracting.com PO#: Tel:800-448-2822 Fax:413-734-6224 STATE SAMPLES COLLECTED IN: Ma. GENERAL11+1 , l '` NS .x... POSITIVE STOP ANALYSIS ❑ PLM DUE DATE: ! / ANALYZE NOB'S BY TEM TEM DUE DATE: IF TAT IS NOT MARKED STANDARD 3 DAY TAT APPLIES. TURN AROUND TIME ASBESTC � .. . 4.: 8 FIR 24 HR 2 DAY 3 DAY 5 DAY PLM BULK EPA 600 (� ❑ ❑ ® ❑ ❑ PLM POINT COUNT(400) EPA 600 ❑ ❑ U ❑ L_l LJ PLM POINT COUNT(1000) EPA 600 E] ❑ ❑ ❑ ❑ ❑ PLM GRAV w POINT COUNT EPA 600 ❑ ❑ ❑ ❑ ❑ PCM AIR NIOSH 7400 ❑ 0 ❑ ❑ ❑ ❑ TEM AIR AHERA EPA AHERA ❑ 0 ❑ ❑ ❑ ❑ TEM AIR NIOSH NIOSH 7402 ❑) 0 ❑ 0 ❑ ❑ TEM BULK CHATFIELD ❑ ❑ ❑ ❑ ❑ TEM DUST WIPE ASTM D6480-05 ❑ ❑ ❑ ❑ ❑ a TEM DUST MICROVAC ASTM D5755-09 ❑ ❑ ❑ ❑ a ❑ TEM SOIL ASTM D7521-13 ❑ 0 ❑ ❑ TEM VERMICULITE CINCINNATI METHOD ❑ ❑ ❑ 1:3 OTHER: ❑ ❑ O ❑ ❑ ❑ REMARKS: ,�- Accept Samples � ❑ Reject Samples i elltii `i>#a ¢ �x1i; jive ° ° Receiv d B Date/Time Jam 'Jamo Beaud /4/2014 � 7 � �� � Sample will be disposq6 of 30 days lafteitanalysis VERSION CCOC.0214.1/2.LD CEILWA�SS LEGEND: Non-Anth = Non-Asbestiform Anthophylite Non-Trem = Non-Asbestiform Tremolite Calc Carb = Calcium Carbonate METHOD: EPA 600/ R93/ 116 and EPA 600/ M4-82/020 The detection limit for the method is <1% by visual estimation and 0.25% by 400 point counts or 0.1% by 1,000 point counts. Due to the limitations of the EPA 600 Method, nonfriable organically bound materials (NOBs) such as vinyl floor tiles can be difficult to analyze via polarizing light microscopy (PLM). EPA recommends that all NOBs analyzed by PLM, and found not to contain asbestos, be further analyzed by Transmission Electron Microscopy (TEM). Please note that PLM analysis of dust and soil samples for asbestos is not covered under NVLAP accreditation. CEI Labs, Inc. can perform positive stop analysis if requested by customer. However, it is the responsibility of the customer to determine if the samples groyped together are in fact the same toe of material and belong,to the same homogeneous area. This report may not be reproduced, except in full, without written approval by CEI LABS. CEI LABS makes no warranty representation regarding the accuracy of client submitted information in preparing and presenting analytical results. This report may not be used by the client to claim product endorsement by NVLAP or any other agency of the U. S. Government. ANALYST. '" APPROVED BY: Taylor B. Metcalf Tianbao Bai, Ph.D. Laboratory Director m V A NVLAP Lab Code 101768.0 CEI Labs,107 New Edition Court,Cary,NC 27511,Phone:(866)481-1412 Page 3 of 3 ASBESTOS BULK ANALYSIS EI By: POLARIZING LIGHT MICROSCOPY LAE35 Client: Baystate Contracting Services, Inc. CEI Lab Code: A14-4137 352 Albany St. Date Received: 04-07-14 Date Analyzed: 04-09-14 Springfield, MA 01105 Date Reported: 04-09-14 Project: 29 Arlington St., N. Hampton, MA; Construct Ass Inc. ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 8 Shingle Homogeneous 25% Cellulose 40% Tar None Detected A1685320 Black 20% Silicates Fibrous 15% Gravel Bound g Shingle Homogeneous 25% Fiberglass 40% Tar None Detected Al 685321 Black 20% Silicates Fibrous 15% Gravel Bound 10 Glazing Heterogeneous 85% Binder None Detected A1685322 White 10% Calc Carb Non-fibrous 5% Paint Bound 11 Glazing Heterogeneous 85% Binder None Detected A1685323 White 10% Calc Carb Non-fibrous 5% Paint Bound Page 2 of 3 ASBESTOS BULK ANALYSIS By: POLARIZING LIGHT MICROSCOPY L/�C35 Client: Baystate Contracting Services, Inc. CEI Lab Code: A14-4137 352 Albany St. Date Received: 04-07-14 Date Analyzed: 04-09-14 Springfield, MA 01105 Date Reported: 04-09-14 Project: 29 Arlington St., N. Hampton, MA; Construct Ass Inc. ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab ID Description Attributes Fibrous Non-Fibrous % 1 Paint Trim Heterogeneous 65% Cellulose 20% Paint None Detected A1685313 White 15% Binder Fibrous Bound 2 Paint Heterogeneous 65% Cellulose 20% Paint None Detected A1685314 Burgundy 15% Binder Fibrous Bound 3 Glazing Heterogeneous 80% Binder None Detected A1685315 White 10% Calc Carb Non-fibrous 10% Paint Bound 4 Insulation Board Heterogeneous 65% Cellulose 20% Binder None Detected A1685316 Brown 15% Silicates Fibrous Bound 5 Covering Heterogeneous 30% Cellulose 40% Vinyl None Detected A1685317 Beige,Green 30% Tar Fibrous Bound 6 Sheetrock Homogeneous 15% Cellulose 70% Gypsum None Detected A1685318 White 15% Silicates Fibrous Bound 7 Cork Style Board Homogeneous 90% Cellulose 10% Binder None Detected A1685319 Brown Fibrous Bound Page 1 of 3 Asbestos Report Summary C E I By: POLARIZING LIGHT MICROSCOPY L_/�C35 PROJECT: 29 Arlington St., N. Hampton, MA; CEI LAB CODE: A14-4137 Construct Ass Inc. METHOD: EPA 600/ R93/ 116 and EPA 600/ M4-82/020 ASBESTOS Client ID Layer Lab ID Color Sample Description % 1 A1685313 White Paint Trim None Detected 2 A1685314 Burgundy Paint None Detected 3 A1685315 White Glazing None Detected 4 Al 685316 Brown Insulation Board None Detected 5 A1685317 Beige,Green Covering None Detected 6 A1685318 White Sheetrock None Detected 7 A1685319 Brown Cork Style Board None Detected _.__._--__ 8 A1685320 Black Shingle None Detected 9 Al 685321 Black Shingle None Detected 10 A1685322 White Glazing None Detected 11 A1685323 White Glazing None Detected Page 1 of 1 CEILA-BS ASBESTOS LABORATORY REPORT Prepared for Baystate Contracting Services, Inc. PROJECT: 29 Arlington St., N. Hampton, MA; Construct Ass Inc. CEI LAB CODE: A14-4137 DATE ANALYZED: 04/09/14 DATE REPORTED: 04/09/14 TOTAL SAMPLES ANALYZED: 11 # SAMPLES >1% ASBESTOS: TEL: 866-481 -1412 www.ceilabs.com Page 1 of 1 Michael Orr From: Ibuckley @nisource.com Sent: Monday, April 14, 2014 10:13 AM To: demo coordinator Subject: Re: Disconnection of service at 29 Arlington Street, Northampton, MA "Barn Only" Hello Michael This is to notify you that there is no gas service line to the Barn on 29 Arlington St. Northampton. No cutoff is needed. Thank you Lisa From: "demo coordinator"<demo @buildingwreckers.com> Tc: <Ibuckley @nisource.com> Date: 03/26/2014 11:17 AM Subject: Disconnection of service at 29 Arlington Street,Northampton,MA"Barn Only" Good Morning Lisa, Attached you will find a request for disconnection of service at one of our new job sites. Thank you, Michael Orr Associated Building Wreckers Demolition Coordinator 352 Albany Street Springfield, MA Telephone: (413) 732-3179 Fax: (413) 734-6224 Demo(a?buildingwreckers.com 04/14/2014 RECEIVED 04/15/2014 14:15 5088726528 02:33:01 p.m. 04-15-2014 DATE: 4/15/2014 FROM:Verizon Engineering 146 Leland St.—Flr.2 Framingham,Ma.01702 RE: 29 Arlington St (Barn only), Northampton, MA This letter is to inform you that the Verizon services involving 29 Arlington St(Barn only),Northampton,MA have been disconnected. VER11ZON Engineer Thank you, Lisa Donovan Central Engineering 508-620-3533 RECEIVED 03/31/2014 13:40 31/03/2014 06:34 (UTC/GMT) National Grid page 1 Associated Building Wreckers, Inc. 35Z Albany St.,Springfield.MA 01105 Tel:(413 73Z 800 448-2822 Date:3124.1 ZOILJ To: National Grid Fax: 888-266-8094 Phone: 800.260.0054 Please cut all services at the following location as it is being scheduled for demolition. ADDRESS: q ,v� -v�n ►re`2 k]at v1 0+n1+.1,.. �Ot intkwt, 11 s Once disconnection has b�eri complateci,please either sign below and fax to 413-734- 6224 or you may fax me Notification on your company letterhead. Thank you very much for your assistance. Sincerely, Associated Building Wreckers,Inc. Service at: 2G( Arltih Aw% S*r-ev* Have been disconnected as oi` Print name: ib�L�eQ IP- signature: Remarks,if any: V i i i i I DIG SAFE SYSTEM, INC. - Create New Quick Ticket Page I of 1 Request Number: 20141304409 Date 03/26/2014 Time 10:58 Latitude: Longitude: State: MASSACHUSETTS Municipality: NORTHAMPTON Address/Intersection: 29 ARLINGTON STREET Nearest Cross Street 1: MASSASOIT ST Nearest Cross Street 2: Additional Information: Nature Of Work: DEMOLITION OF DETACHED Area Of Work: STREET TO BARN Area Is Premarked: Y Start Date: 04/01/2014 Start Time: 09:00 Caller: MICHAEL ORR Title: Return Call: Phone#: 413-732-3179 Fax#: Alt.Phone#: Email Address: DEMO @BUILDINGWRECKERS.COM Contractor: ASSOCIATED BUILDING WRECKERS Address: 352 ALBANY STREET City: SPRINGFIELD State: MA Zip: 01105 Excavator Doing Work: Member Utility List Code Abbreviation Name MC NGRDEL NATIONAL GRID ELECTRIC-MASS ELEC SP VERIZN VERIZON WG 11 CMAGAS COLUMBIA GAS OF MASSACHUSETTS 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... DIG SAFE ENCOURAGES A COPY OF THIS ELECTRONIC TICKET ON SITE AT ALL TIMES. Create New L Create From Existing Print Ticket Return To Menu Return To Home http://digsafeform.digsafe.com/cgi-bin/dlcgi.exe 03/26/2014 The Commonwealth of Massachusetts Department of Industrial Accidents f 17� - Office of Investi g ations I Congress Street, Suite 100 __ tW Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Bus iness/Organization/Individual): ASSOCIATED BUILDING WRECKERS, INC. Address: 352 ALBANY STREET City/State/Zip:SPRINGFIELD Phone #: (413) 732-3179 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 32 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ■❑ Demolition working or me in an capacity. employees and have workers' g Y P Y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their I L Plumbing repairs or additions 3.❑ I am a homeowner doing all work g P myself. [No workers' comp. right of exemption per MGL 12.[:] Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ' 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 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:GREAT DIVIDE INSURANCE COMPANY Policy#or Self-ins. Lic. #:WCA154516512 Expiration Date:02/01/2015 'ob Site Address: 29 ARLINGTON AVENUE - BARN/GARAGE City/State/Zip: NORTHAMPTON, MA 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 line 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 inhurance coverage verification. I do hereby certi y nder the ai s and penalties of perjury that the information provided above is true and correct. Si nature: Date: A.V%XF4-M i'hone# Lk13) -757-3\7C( Official use only. Do not write in this area, to be completed by city or town official. 1 City or Town: Permit/License # Issuing Authority(circle one): I 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:"4—" y l �—k,fiA V-\ C l>- J�J License Number 70552 V0,J S*t`e'QA S %vxi tck , O1\-Q!2°' ���31� Address Expiration n Date I Signature Telephone 9. Registered Nome Improvement Contractor: Not Applicable ❑ buAcy"v \)J 41 r ii(;O� ComparivAUme Registration Number I Address ��— Expiration Date _Telephone b-Al ?32,-31 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. ..... No...... ❑ 1.1. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2) families and to allow such homeowner to em oe an individual for hire who does not possess a license,provided that the owncr acts as supervisor. CMR 780, Sixth Edition Section 108.3.5,1. Definition of"orneowner: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 larm 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 shrill he 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, durin_v and upon completion of the wort:for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Emplo. ers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for prnonf>) you hire to perform work for you under this permit. 1 he 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. Ilomeowner Signature RECEIVED 04/22/2014 17:59 PAGE 01/01 04/22/2014 17:50 4135847504 CONSTRUCT ASSOCIATES New House U Addition ❑ R iacement Windows Altereuon(s] ❑ Roofing [� r Doors C7 Accessory Bldg, ❑ Demolition New Signs [EM Decks ]C] Siding[t=i] Qther[C9 Brief Des ion of Pro posed Work, �A,a ��::�, -the_ " F Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes o (J Plans Attached Roll -Sheet a, Use of building;One Family Two Family. Other b. Number of rooms in each family unit of Bathrooms c. Is there a garage attached? d, Proposed Square footage of new construction. _ Dimensions e. Number of stories? f. Method of heating? f=ireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? K 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 t S as Owner of the subject property hereby authorize AO! Ah, I P-IS- to act on m behalf,in all matters relative to work authorized by this building permit application, `112-2,Ij rgnature of Owner Date 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 u r the pains 8 d penalties of perjury. Print Na I Signature Agent _ Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Loning This colunui Lo he filled in h\ Buildine Dcrrarfnunt I.Ot Size Frontage ^Setbacks Front Side L:_ R: L:' R: Real' Buildin- Heiolit Bldg. Square Footage Open Space Footage % I Lot veu minus bldg&,paved vlkink�l #Of Parking Spices Fill; (volume&Location) A. Has a Special Permit/Variance/Findin3 ever been issued for/on the site? NO 0 DON'T KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW er YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO (? DON'T KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 Date Issued: C. Do any signs exist on the property? YES 0 NO (-�fp IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO er 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 O NO ��� i IF YES. then a Northampton Storm Water Management;;;Permit from the DPW is required -777 Department use only City of Northampton Status of Permit; i Building Department Curb Cut/Driveway Permit .. .._. APR 8 2014 2 212 Main Street Sewer/Septic,Availability Room 100 Water/Well Availability — - �lectriC,Plumbing&Gas tnspecua^s orthampton, MA 01060 Two Sets of Structural Plans­-- ,_ _ I L,c,rth^mpton,MA 01060 one 413-587-1240 Fax 413-587-1272 PIOUSite Plans __,_--- Other Specify_ j 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 i 9 A6,y -vv) Map-- — Lot_._. _�— ---Unit----- -- IV�%r��/l(1�VYlr� 'r'1 Zone_--- —..._Overlay District.!.__----Elm St.District CB District---.-- ; SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i 2.1 Owner of Record: �IUa 5S e - Name(Print) Current Mailing A ess: ,( �s3) 5Sq- 7331 Telephone { Signature 2.2 Authori A ent: t4=' { Name(Print Current Mailing Address: signature F�V�T � �`,��� . _ 1� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS i Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant Building (a)Building Permit Fee 2 Eloctrical (b)Estimated Total Cost of Construction from 6 3 plumbing Building Permit Fee 4 Mechanical(HVAC) i Fire Protection 6 Total =(1 + 2 + 3+g + g) Check Number This Section For Official Use Only Date Guilding Permit Number: Issued. J i Signature -- -- i Building Commissioner/Inspector of Buildings Date —_ File#BP-2014-1119 APPLICANT/CONTACT PERSON ASSOCIATED BUILDING WRECKERS INC ADDRESS/PHONE 352 ALBANY ST SPRINGFIELD (413)732-3179 PROPERTY LOCATION 29 ARLINGTON ST MAP 24C PARCEL 151 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: DEMOLISH BARN/GARAGE STRUCTURE-PROPERTY CARD 1905 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 063282 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other 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 Signature 5of u ilding 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. 29 ARLINGTON ST BP-2014-1119 GIs#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 24C- 151 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: GARAGE BUILDING PERMIT Permit# BP-2014-1119 Project# JS-2014-001780 Est.Cost: Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ASSOCIATED BUILDING WRECKERS INC 063282 Lot Size(sq.ft.): 8319.96 Owner: NASSER MERRY L Zoning_URB(100) Applicant: ASSOCIATED BUILDING WRECKERS INC AT: 29 ARLINGTON ST Applicant Address: Phone: Insurance: 352 ALBANY ST (413) 732-3179 Workers Compensation SPRINGFIELDMA01105 ISSUED ON.51112014 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMOLISH BARN/GARAGE STRUCTURE - PROPERTY CARD 1905 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: FeeTyne: Date Paid: Amount: Building 5/1/2014 0:00:00 $20.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner