38B-068 OrderID: 041532059
Asbestos Chain of Custody
EMSL Order Number(Lab Use Only):
PHONE'
EMSL ANALYTIGAL.ING..
FAX:
Company Name: CARDNO ATC EMSL Customer ID:
Street: 73 WILLIAM FRANKS DRIVE City: WEST SPRINGFIELD 5tatelProvince: MA
Zip/Postal Code: 01089 :USA Telephone#:4137552128 Fax#: 4137841149
Report To(Name): JOHN D.MORIARTY Please Provide Results: Fax ✓ Email
Email Address: JOHN.MORIARTY @STATE.MA.US Purchase Order.
Project Name/Number: MASSAC"UsE''SDEPART'ENror ENVIRONMENTAL PROTECTION EMSL Project ID Infemal Use Only):
U.S.State Samples Taken: MASSACHUSETrs CT Samples:❑Commercial/Taxable ❑Residential/Tax Exempt
EMSL-Bill to: Sam@ Different-If BIII to Is Different note instructions in Comments~
Third Party Billing requires written authorization from third party
Turnaround Time TAT Options*–Please Check
3 Hour 1&6 Hour ❑24 Hour ❑48 Hour ❑ 72 Hour [] 96 Hour I ❑1 Week I ED 2 Week
'For TEM Air 3 hr! rough 6 hr,please cell ahead to schedule.`There is a pre mium charge for 3 Hour TEM AHERA or EPA Level 11 TAT You will be asked to sign
an authorization form for this service. Anal ms corn leted in accordance with EMSL's Terms and Conditions located in the Anel ical Pnce Guide.
ECM-Air Check if samples are from NY TEM–Ai 4.4.5hr TAT(AHERA only) TEM-Dust
❑ NIOSH 7400 ❑ AHERA 40 CFR, Part 763 ❑Microvac-ASTM D 5755
❑ w/OSHA 8hr TWA ❑ NIOSH 7402 ❑Wipe-ASTM D6480
P -Bulk(reporting limit ❑ EPA Level II ❑Carpet Sonication(EPA 600/J-93/167)
"MELM EPA 600/R-93/116(<1%) ❑ ISO 10312 Soil/RockNemticulite*
❑PLM EPA NOB(<1%) TEM-Bulk ❑PLM CARB 435-A(0.25%sensitivity)
Point Count ❑TEM EPA NOB ❑PLM CARB 435-13(0,1%sensitivity)
❑400(<0.25%)❑1000(<0.1%) ❑NYS NOB 198.4(non-friable-NY) E]TEM CARB 435-B(0.1%sensitivity)
Point Count w/Gravimetdc ❑Chatfield SOP ❑TEM CARE 435-C(0.01%sensitivity)
❑400(<0.25%)F-1 1000(<0.1%) MTEM Mass Analysis-EPA 600 sec.2.5 []TEM Qual.via Filtration Technique
[] NYS 198.1 (friable in NY) TEM–Water:EPA 100 2 9,TEM via Drop-Mount Technique
n not accept t N Nee w York State Loose Fill Vennkvilte Samples
❑ NYS 198.6 NOB(non-friable-NY) Fibers>10pm ❑Waste []Drinking Other:
❑ NYS 198.8 SOF-V All Fiber Sizes ❑Waste ❑Drinking
NIOSH 9002(<1%)
Check For Positive Stop–Clearly Identi Homogenous Grou Filter Pore Size Air Samples); ❑0.8 m 00.45pm
Samplers Name: a �� �.aY� Samplers Signature:
e/Area(Air) Date/Time
ample# Sample Description HA# Bulk { Sam le
d
� a>
N
P �-
Client Sample#(s): -- 03 - (� O� Total#of Samples:
Relinquished(Client): .���, , �:� Date: Time: I,6
Received(Lab): a U 0 6 Date: I C �J Time:
Comments/Special instructions: S�
Controlled Document-As besto.COG-R9-1013 00014
Page 1 of A—pages
Page 1 Of 1
EMSL Analytical, Inc. EMSL Order: 041532059
200 Route 130 North,Cinnaminson,NJ 08077 CustomerlD: ATC62
Phone/Fax: (800)220-3675/(856)786-5974 CustomerPO: 11-81-0030
http://www.EMSL Corn dnnasblab(oD.EMSL corn ProjectlD:
Attn: John D. Moriarty Phone: (413)781-0070
Cardno ATC Fax: (413)781-3734
73 William Franks Drive Received: 10127/15 9:30 AM
West Springfield, MA 01089 Analysis Date: 10/2712015
Collected: 10126/2015
Project: Massachusetts Department of Environmental Protection 1243 South St,Noho
Test Report: Asbestos Analysis of Bulk Materials via EPA 600 1R-931116 Method using
Polarized Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance % Fibrous % Non-Fibrous % Type
10/26-03-Skim Coat -Plaster Tan 100% Non-fibrous(other) None Detected
041532059-0001 Non-Fibrous
Homogeneous
10/26-03-Base Coat -Plaster Gray 5% Synthetic 95% Non-fibrous(other) None Detected
041532059-000IA Fibrous
Homogeneous
Analyst(s)
Alexis Kum(2) Benjamin Ellis,Laboratory Manager
or other approved signatory
EMSL maintains liability limited to cost of analysis, This report relates only to the samples reported and may not be reproduced,except in full,without written approval by EMSL. EMSL bears no
responsibility for sample collection activities or analytical method limitations. Interpretation and use of test results are the responsibility of the client. This report must not be used by the client to claim
product certification,approval,or endorsement by NVLAP,NISI or any agency of the federal government. Non-friable organically bound materials present a problem matrix and therefore EMSL
recommends gravimetric reduction prior to analysis. Samples received in good condition unless otherwise noted. Estimated accuracy,precision and uncertainty data available upon request.Unless
requested by the client,building materials manufactured with multiple layers(i.e.linoleum,wallboard,etc.)are reported as a single sample.Reporting limit is 1%
Samples analyzed by EMSL Analytical,Inc.Cinnaminson,NJ NVLAP Lab Code 101048.0,AIHA-LAP,LLC-IHLAP Lab 100194,NYS FLAP 10872,NJ DEP 03036,PA ID#68-00367
Initial report from 10/2712015 10:49:10
Test Report PLM-7.28.9 Printed: 10127/2015 10:49:10 AM THIS IS THE LAST PAGE OF THE REPORT. 1
EMSL Analytical, Inc. EMSL Order: 041532059
200 Route 130 North,Cinnaminson,NJ 08077 CustomerlD: ATC62
Phone/Fax: (800)220-3675 1(856)786-5974 CustomerPO: 11-81-0030
http://www.EMSL corn annasblab(a)EMSL.com ProjectlD:
Attn: John D. Moriarty Phone: (413)781-0070
Cardno ATC Fax: (413)781-3734
73 William Franks Drive Received: 10/27/15 9:30 AM
West Springfield, MA 01089 Analysis Date: 10/27/2015
Collected: 10/26/2015
Project: Massachusetts Department of Environmental Protection/243 South St,Noho
Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using
Polarized Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance % Fibrous % Non-Fibrous % TyRe
10/26-03-Skim Coat -Plaster Tan 100% Non-fibrous(other) None Detected
041532059-0001 Non-Fibrous
Homogeneous
10/26-03-Base Coat -Plaster Gray 5% Synthetic 95% Non-fibrous(other) None Detected
041532059-000IA Fibrous
Homogeneous
Analyst(s)
Alexis Kum(2) Benjamin Ellis,Laboratory Manager
or other approved signatory
EMSL maintains liability limited to cost of analysis. This report relates only to the samples reported and may not be reproduced,except in full,without written approval by EMSL. EMSL bears no
responsibility for sample collection activities or analytical method limitations. Interpretation and use of test results are the responsibility of the client. This report must not be used by the client to claim
product certification,approval,or endorsement by NVLAP,NIST or any agency of the federal government Non-friable organically bound materials present a problem matrix and therefore EMSL
recommends gravimetric reduction priorto analysis. Samples received in good condition unless otherwise noted. Estimated accuracy,precision and uncertainty data available upon request.Unless
requested by the client,building materials manufactured with multiple layers(i.e.linoleum,wallboard,etc.)are reported as a single sample.Reporting limit is 1
Samples analyzed by EMSL Analytical,Inc.Cinnaminson,NJ NVLAP Lab Code 101048-0,AIHA-LAP,LLC-IHLAP Lab 100194,NYS ELAP 10872,NJ DEP 03036,PA ID#68-00367
Initial report from 10/27/2015 10:49:10
Test Report PLM-7.28.9 Printed: 10/27/201510:49:10 AM THIS IS THE LAST PAGE OF THE REPORT. 1
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
I accordance of the provisions of MGL c 40, S54, I acknowledge that as
condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
r
Address of the work:
The debris will be transported by:
2
The debris will be received by:
Building permit number:
i
Name of Permit Applicant
i
to Signature of Permit Applicant
City of Northampton
X Massachusetts
L ,
L y r• DEPARTMENT CF BUILDING INSPECTIONS
212 Main Street • Municipal Building .Jj•,., lb�'"
n.� Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be i
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
4andd pectio ns are made
understand the above.
e o ne /resident's signature requesting exemption)
schedule all required building inspections necessary for the building permit issued to me.
Date-W W/ I
4ddress of work location Ca)q '\Jylyr /n
R
�'� t �`i'U�� �CG�r'�►,Cr ,111
The Commonwealth of Massachusetts
Department of Industrial Accidents
' -
Office of Investigations
600 Washington.Street
r Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contr actors/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.❑ 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
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are:a corporation and its 10.❑Electrical repairs or additions
3rI am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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:
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 he y certi under the pains and penalties of perjury that the information provided above is true and correct.
S' atar . Date: 1� �
Phone#: I c1 �G' I i 0" Z ZZ . Vj 2
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 87 ONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 Rea�sfeced-Home Irrmprovemenf Confraetor „_ ` __; 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....... £ 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. CNM 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
r-thampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature.
s
i
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [[--3] Decks [0 Siding [0] Other[CO]
rAttached tion of Proposed
�P.nl C(✓(',FiYhj _ (°( r r,�t 2� (.�)! �s�G.Y f 7f�.�C�
existing bedroom Yes No Adding new bedroom Yes � No
rative Renovating unfinished b asement Yes No
Plans Attached Roll -Sheet
6a If. New house artd orad:dltlon to existlndhousincr, cornpfete=fhe followtnci:
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
I 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.
Signature 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 der the pains and penalties of perjury.
f C'f A_
Print me �
D12-
� f
igna re of Owner/ en Date
t
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 l
Setbacks Front F-
Side L:= R:= L:i i R:t
' 1
Rear i 1 t--
Building Height
BIdg. Square Footage j — %
Open Space Footage
(Lot area minus bldg&paved
arkin )
#of Parking Spaces l--
Fill: r
(volume&Location) t I I I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES Q
IF YES, date issued: —J
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book j� Page --? and/or Document#i i €
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q 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 O NO O
IF YES, describe size, type and location: j
E. Will the construction activity disturb(clearing, grading, excavation, or fifiing)over 1 acre or is it part of a common plan
that will disturb over i acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• i
J f
,a
-- ^c'1, pepa. ent use only
(rC V�� 1J a t I r
ity of Northampton Staf`us ofPermtt -
uilding Department Curb CuvDrl�e�iahy Perrot# "
OCT 2 8 ?�!►�� 212 Main Street wNgRSepticAvailaS�Irty
� R yin f
Room 100 a/Vatere7�Rua�la6{hty J DeUr.CF - N rthampton, MA 01060 MEE=[�s�one 41 -587-1240 Fax 413-587-1272 r' .r� e r`r,�_'r -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S CTION 1 -SITE INFORMATION
-_ =_ J__ Thts secfiorrfo be completed by offiice
1.1 Property Address: -- - -
Lot Unit
M nn � rtct___ __
..........
_EI"m�St District r=- .CB District _, ., .--.
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED:AGENT:::.
2.1 Owner of Record:
Ted C: ct 6,k 26 l
Name( •nt) Current Mailing Address:
X13 , 2-z2 Z-
Telephone
Si atur
2.2 AuTgorized Aqent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS. .
Item . Estimated Cost(Dollars)to be Official Use Only
e_ L, , completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost bf
Construction from(8)'7
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
-5. Fire Protection
6. Total=(1 +2+3+4+5) C Check Number
This Section For Official Use Only
ate
Building Permit Number. Issued:
i
Signature
Building Commissioner/(nspector.'of Buildings: Date
243 SOUTH ST BP-2016-0585
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-068 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-0585
Project# JS-2016-000973
Est. Cost: $3600.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot size(sq.ft.): 10410.84 Owner: LUNDQUIST FELICIA R
Zoning: URB(100)/ Applicant. LUNDQUIST FELICIA R
AT: 243 SOUTH ST
Applicant Address: Phone: Insurance:
243 SOUTH ST
NORTHAMPTONMA01060 ISSUED ON:1012812015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SHEETROCK CEILING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Date Paid: Amount:
Building 10/28/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner