38-050 DEMO PERMITS BP-2007-0002
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: demolition BUILDING PERMIT
Permit# BP-2007-0002
Proiect# JS-2006-1865
Est. Cost:
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: S & R CORPORATION
Lot Size(ss . 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.7/3/2006 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO Main buildings
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 7/3/2006 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2007-0002
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
Fee Paid
2(uilding Permit Filled out
Typeof Construction: DEMO Main buildings
New Construction _
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 11AATION PRESENTED:
pproved 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
Q_ 0
Signature of Buil ing 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.
Versionl.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb CuttDriveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well,Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Roti a �� ---.� ....
Oth; c
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISM A�Y BUILDING
OTHER THAN A ONE OR TWO FAMILY C) �LLIN
x� L UUN
SECTION 1 -SITE INFORMATION L_.
This s to be UO"plgti ;' y offi
1.1 Property Address: i P ,I
IG
1 Prince Street Map Lot x_ `""Unit
Northampton, MA
1st Hall North & South & East Zone Overlay District
Administration Building
_ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MassDevelopment 1 Prince St/Haskell Build.
Name(Print) ,���� Current MailingAddress:
( ) J'X' + jeCfF'7'1teke'Y- (413 )587-6314
Signature t�� / Telephone
2.2 Auth rized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
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) Check Number
This Section For Official Use Only
Building Permit Number pate
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Pen-nit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition q Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. Complete demolition of building
Of Proposed Work: including foundations
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable)' CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 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 ❑ 56 ❑
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)
1st 1 St
2nd 2nd
3rd 3 rd
4th 4t
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❑
Version 1.7 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: R:_ L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
_
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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 ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Tighe & Bond Engineers Z:51--C�"T%-ti
Name Area of Responsibility
53 Southampton Road. Westfield, _MA 01 085 3-7(P34
A Registration Number
fS '11.3-S-Gd-160o . 0 C�
Si tur 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
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
S&R Corporation, Not Applicable ❑
Company Name:
Thomas Guerette
Responsible In Charge of Construction
706 Broadway St. , Lowell, MA 01854
Address
Awe (1978 )441 -2001)
Signature Telephone
Versionl.7 Conunergial Building Pen-nit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 7
Independent Structural Engineering Structural Peer Review Required Yes No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i✓�<tSS�C?c�lc° �e-rT as Owner ofthe subject property
hereby authorize_ ,� (.or,✓ to
act on my behalf, inin all relative to work authorized by this building permit application.
Si ure of Owner Date
I' 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 Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder Thomas Guerette CS 061320
License Number
18 Longwood Ave. , Londonderry, NH 03053 3/19/2007
Address Expiration Date
�-� ( 603 ) 488-5042
Signature 'T Telephone
SECTION 13-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
f.:
Number: CS 061320
Birthdate: 03/19/1967
Expires: 03/19/2007 Tr,no: 11076
Restricted: 00
THOMAS J GUERETTE
18 LONGWOOD AVE
LONDONDERRY, NH 03053 C ��
Commissioner
FROM :S2<R. CORP. NORTHRMTON FAX NO. :4135841568 Apr. 08 2006 12:23PN P2
MAR 32 2066 12 : 14 PM FR MASS ELEC CUST' SERV 533 7631 TO 814135841568 I-'. U1 /u1
Mas,!! a setts Electric
K;Natkag Mid Cofp3ny
Match 30,2006
5
and R Corp
706 Broadway St.
Lowell MA 01854
To Whom It May Concern,
This is to voriliy that National Grid has ramrved the electric servivc and meter's at 1
Prince St.,Northampton, Massachusetts, fbr Building Demolition.
=erely,
t AP&
Jim Nichols
Supervisor
Distribution Dmp
JN/ekp
PO Eos 507
wrinampton.MA 01061.0507
413.U2.72oo
*r' TOTAL FADE. O 1 .�
FROM :S&R. CORP. NORTHAMTON FA ; NO. :4135041568 Apr. 08 2806 12:22PM Pi
way s c%w
A NiSourm Company
2025 Roosevelt Ave
P0.Box 02025
Springifeld,MA avo2
Hared 31, 20M
30 CORP
706 BROADWAY ST
LOWELL Ka 01954
Dear S&R CORP.
The address listed bb16V h&8 had tho gas varvicele)
disconnected and 3a nox ready :for denolition.
ADDRESS: 1 Ptl2RC& ST
TOWN NORTHAMPTON SA
STATE Massachusetts
Sincerely
Terri Miner
Workforce planning
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InVestigatians
600 Washington Street
Boston, MA. 02111
Workers' Compensation Insurance Affidavit
Nacae brc.Tem ,, ,
ffv5l;:r�,1
Job Location.Z Ir'2 r NG S r2 �-
City r Phone (978)441-2000
❑ I am a homeowner performing all work myself.
(] I am a sole proprietor and have no one working in any capacity.
I am an employer providing workers'compensation for my emp ogees wor eng on tis Jo
Company Name: S&R Corporation
Address 706 Broadway Street
City Lowell, MA 01854 Phone# (978)441-2000
Insurance Company olicy#WC !!ll,25783390/y
I am a sole proprieto general contractor or' omeowner(circle one)and have hired the
contractors listedbelow who ave the following workers'compensation policies:
Company Name n/a
address
city Phone#
Insurance Company Policy#
Failure to secure coverage as required under Section 25A of MGL152 can lead to the imposition of
criminal penalties of.a fine up to$1,500.00 and/or one years`imprisonment as well as civil penalties
in the form of a STOP WORK ORDER and a fine of$100.00 per day against me. I understand that a
copy of this statement may be forwarded to the Office ofrnvestigatious of the DIA for coverage
verification.
I do hereby certifympder the pains an�yeualties of perjurv*at the information provided above is
true and correct.
SignaturerE i'rG ?ec ir1.r Date S�/f �2CJC�
Print Name T4c.mqs a- CI er .are Phone_g (978)441-2000
Official use only do not write in this area to be completed by city or to-wn official
City or Town: Permitflicense 0 Building apt
Uctnsing Gd.
check if immediate response is required Sciccuncn
health D? VL
Contact person phone t Other
a
Commonwealth of MassachusettsLl
■
. :100034421_
Asbestos Not' tion Form ANF-001 Decal Number[T
corl' y
Important:
When filling out A. Asbestos Abatement Description
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?[✓ '1 Yes . No _
to move your
cursor-do not b. Provide blanket decal number if applicable: "
use the return Blanket Decal Number
key. 2 Facility Location:
IT—"
$NORTHAMPTON STATE HOSPITAL 1 1#1 PRINCE STREET
a.Name of Facility b.Street Address _
Northampton MA 01060 (413)587-6314
c.City/Town a.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
T L N
1.All sections of this E.AD__MIN.;_1 ST_HA_L &$
a..Building Name/Building Location b.Building# c.Win d.Floor e.Room
form must be 9 9 g g
completed in order
to comply with 4. Is the facility occupied? Yes Na
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division S & R CONTRACTING 706 BROADWAY STREET
ofOccupational �.��....__._._.._,.,..."".�..._....n,,...._._.....___.,k__._.........__,._,..,.__,. .. _._.......___.. ..�.._.,
Safety(DOS) a.Nameb.Address
notification krLOWELL 01854 9784412000 4p
requirements of 453 C __..
CMR 6.12 a City/Town _ _ _ d,Zip Code e.Telephone Number
AC000497
r Qo5"'cense Number" g. Contract Type: Written Verbal
SARAH NORTHROP "µ swMFm RESIDENT IN
ENGEER
h.Facility Contact Person I.Contact Person's Title
OSVALDO E DE LA CRUZ _ _ _._ w AS031170 �
6' a.Name of On-Site Su ervisorlForeman b.Su ervisor/Foreman DOS Certification Number
AN DRAGON AEM07227
7' a.Name of Prct Monitor b Pro'ecj t Monitor DOS Certification Number
$' a.Name of Asbestos Anal ical Lab ��_,� _„"A b.Asbestos Anal 'ticay I Lab DOS Certification Number
—•—+•--� 07/05/2006 _ mm 08131/2006
��0 9. -
a.Project Startate Dmm/ y b.End Date mm/dd/yXM
a 7-4 a_. ,�..._ -1-1-11 N!A
W-N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
o 10. a. What type of project is this?
�C) Demolition _ Renovation
Repair EJOther, please specify: b.Describe
11. a. Check abatement procedures:
Glove bag . Encapsulation
a Enclosure Disposal only
cleanup ✓. Other, specify:LL
DEMOLITION A$ ACM
----- Full containment b.Describe
—d 12. Is the job being conducted: €_] Indoors? ✓ Outdoors?
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3■
Commonwealth of Massachusetts ■
100034421
Asbestos Notification Form ANF-001 Decal Number
Ll
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated
;0 j40000
square ff"
a.Total``i es or ducts linear ft_ wb fi nfai o er surfaces # � �
pP ( �
c.Boiler,breaching,duck,tank 1. L__--i d.insulating cement # f
surface coatings Lin ft Sq ft Lin ft S_q ft
e.Corrugated or layered paper d f.Trowel/Sprayer coatings
pipe insulation Lin ft Sq.ft Lin ft Sq ft
g.Spray-on fireproofing - - ti h.Transite board,wall board - - - --
Lin ft Sq.ft Lin.ft. Sq ft
i.Cloths,woven fabrics i Other,please specify 40000
Lm ft Sq,ft Lin ft „ Sq ft
k.Thermal,solid core pipe1500CY C&D
insulation Lin.ft._ma. Sq.
.ft.
�,.�_..a� .Specify
14. Describe the decontamination system(s)to be used:
REMOTE DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g).—. _ m_—__.
OPEN TOP CONTAINERITRAILER,W/PRE FORMED LINERS; ADEQUATLEY WETTED
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official b.Title _
C.Date(mm/dd/yyyy)of Authorization d.DEP Waiver# _
e.
..._.
e.Name of DOS Official _ f.DOS Official Tit e
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
.�---------�c, 17. Do prevailing wage rates as per M,G.L. c. 149, §26, 27 or 27A—F apply to this project? [✓�Yes W]No
�Q B. Facility Description
N
�0 1. Current or prior use of facility: FORMER STATE HOSPITAL
�o
2. Is the facility owner-occupied residential with 4 units or less? N Yes VINO
--'� MASSDEVELOPMENT #1 PRINCE STREET
3. _ 1
a.Facility Owner Name b Address
oNORTHAMPTON ..... .. . ...... 01060 Lt413)587 6314 ., ......— _ ,.. . _a. a .._.._ _..,..,
o c.CikyJTown d Zip Code e Tele h Done Number(area code and extension)
ISARAH NORTHRUP fil PRINCE ST I HASKELL BUILD
LL 4 tw
a.Name of Facility Owners On Site Manager b On Site Manager Address
�Z INORTHAMPTON 01060 {413}587-6314
d c.City/Town d.Zip Code e.Telephone Number(area code and extension)
■ anf001ap.doc•10/02 Asbestos Notification Form•Pa e 2� of 3■
Commonwealth of Massachusetts
,100034421
Asbestos Notification Form ANF-001 Decal Number
LI
B. Facility Description (cont.)
'S&R CORPORATION 706 BROADWAY STREET
5. a.Name of Genera!_Contractor b Address
_wa
;LOWELL w ... ,n _._ . ,._. _ 854 (978) 41 20QQ
;
c City/Town d Zip Code e Telephone Number area code and extension)
ILIBERTY MUTUAL _._ WC1111257$3901410/Q1/2006
W
f.Contractor's orker's Comp.Insurer Pohg Number h Exp Date(mm/dd/ yyy
40Q00 j4�_
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):
Note:Transfer a,Name of Transporter b Address
Stations must
comply with the c.City/Town d.Zip!Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos containing waste material from removal/temporary site to final disposal site:
Regulations 310 ---.
CMR 19.000 RED TECHNOLOGIES, LLC i0 NORTHFIELD DRIVE
a.Name of Transporter b.Address
($60)
cCit /Town d Z!Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address _
c.City//Tow _ �w m d Zip Code e.Telephone Number _
4. TURNKEY LANDFILL.(WASTE MGT WNH} � � � � .. V��Ra W
a.Final Dis osal Site Location Name m b.Final Dis ossa!Site Location Owners Name
7 ROCHESTER NECK ROAD ROCHESTER
_ � _.. [R M
c.Final Dosal Site Address d Citwn
INH ,. , _. __..u.
M e.State f.Zip Code g.Telephone Nmber
� o
�—° D. Certification
9-N
The undersigned hereby states,under the STEVEN PLOOF i
penalties of perjury,that he/she has read the a.Name _ b Authorized Sianature
c) Commonwealth of Massachusetts regulations TREASURER 06/16/20Q6
for the Removal, Containment or ,
c.Position/Title d Date jmmtddlyy
Encapsulation of Asbestos,453 CMR 6A0 and (978)441-2000 S&R CORPORATION
314 CMR 7.15, and that the information
contained in this notification is true and correct a Telephone Number f Representing
mac' to the best of his/her knowledge and belief. X706 BROADWAY STREET
o g..Address
.�LL
L4WELL i 101854
h_City/Town � i.Zip Code
anf001ap.doc-10/02 Asbestos Notification Form•Page 3 of 3
eV-�EP: Arrint Receipt Page 1 of 1
In
Submittal Summary & Receipt
Your submission is complete. Thank you for using DEP's online reporting system. You can
select "My Homepage" to review your status.
DEP Transaction ID: 74567
Date and Time Submitted: 6/16/2006 9:01:22 AM
User Email : mploof@sandreorp.com
Form Name: BWP -Asbestos Notification form-ANF001
Payment Information
DEP code
Date
Amount ($)
Billing Info
Contractor
Contractor Number: AC000497
Name: S & R CONTRACTING
Address: 706 BROADWAY STREET, LOWELL, MA 01854
978-441-2000
Supervisor
OSVALDO E DE LA CRUZ
Project Monitor
Lab
Location
E. ADMIN.;IST HALL N & S
Project Start Date
7/5/2006
https:Hedep.dep.mass.gov/Restricted/webpages/printreceipt.aspx 6/16/2006
Massachusetts Department of Environmental Protection .. ■,
Bureau of Waste Prevention • Air Quality 100034423 w p
Decal Number
BWP AQ 46
Notification Prior to Construction or Demolition CO
Important: A. Applicability
When filling out 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 unitsis 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.
VC 110
B. General Project Description
1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied
Instructions residence of four units or less?0 Yes E] 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 ofpRTHAMPTON STATE HOSPITAL
Environmental ---- -- ---�—_� ~-- —. —•.— .' —~ -
Protection a.Name
notification 1706 BROADWAY STREET
requirements of b.Address
310 CMR 7.09 Lowell
..�..- ._.W_..-,.,._W..... ....�...e_.... � � INA 01$54 ......._._._...._...e__
c.City/Town __. _ d.State e._Zip Code
(4 13)587-6
314
Lf.Tel Number area code and extension E-mail Address o tionaD_,
40,000 _ W_ - - _ _ .�.._ - 4- ��
h.Size of Facility in Square Feet i. Number of Floors
j. Was the facility built prior to 1980? Z Yes 0 No
k. Describe the current or prior use of the facility:
[FORMER NORTHAMPTON STATE HOSPITAL
I. Is the facility a residential facility? [ Yes [✓j No
m. If es, how many units?
mw � 0 ��..�_..._.__..-,. �. ...._m�_....�._���...�.�...m....�..u...._m�.�.w,.____..
Number of Units
—�—� 3. Facility Owner:
MASSDEVELOPMENT I
9�Cr a.Name
�Q 1#1 PRINCE STREET
b.Address
[NORTHAMPTON.._,,... .. tMA ,.. 01060
c. City/Town d State e Zip Code
(413)587-6314
f.Telephone Number,jarea_code and extensiQn� __ q E-mail A- qq§JQptiQnal�
-C iSARAH NORTHRUP
�Q h.Onsite Manager Name
ag06.doc- 10/02 BWP AQ 06-Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention • Air Quality 1100034423
B W P AQ 06 Decal Number
Notification Prior to Construction or Demolition
WPY
General
Statement:If B. General Project Description cont.
asbestos is found
during a 4. General Contractor:
Construction or
Demolition S&R CORPORATION
operation,all .Name _
responsible parties -- - - - - - — -- —----
must comply with 17_06 BROADWAY STREET
310 CMR 7.00, b.Address � � __
Cha err and 1LOWELL __._._r .. � � �_ � MA �� 01854m_
Chapter 21 E of the
General Laws of c.Cit�/To_wn _ d.State e.Zio Code
the Commonwealth. F978)441-2000 ��^- -��
This would include, f.Telephone Number area code and extension E-mail Address o tional _
but would not be -- - - -- A' —- -�- - --
limited to,filing an PAUL DARLING rn � _��_ _ 1
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
7016130 ADWAY STREET �-
b.Address
[LOWELL [MA � L01854 �
____..._.._.... "
c Citx/Town W � �. �� � _ d. State _ e.Zip Code
f Telephone Number(area code and extension) �� g. E-mail Address(optional)
PAUL DARLING _
h.On-site Manager Name �..�_._"J"`�`
2. On-Site Supervisor:
PAUL DARLING
On-Site Supervisor Name
3. Is the entire facility to be demolished? EI Yes { No
N
° 4. Describe the area(s)to be demolished:
o ;EAST ADMIN. BLD.; 1ST HALL NORTH &SOUTH _
N I
° 5. If this is a construction project, describe the building(s) or addition(s)to be constructed:
N/A
a
=Q
ag06.doc•10/02 BWP AQ 06•Page 2 of 3
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention • Air Quality 1100034423 3
Decal Number
BWP AQ 06
Notification Prior to Construction or Demolition
W IFIT—
U
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)?
FA- Yes [-' No
If yes, who conducted the survey?
DAN DRAGON
�ryvo
gr
1AMU72273
c.Division of Occupational Safety Certification Number
7. Construction or Demolition: 07/0 2006 08/31/2006
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:
[Y] seeding [.] paving
Ev] wetting [1 shrouding b. If other, please specify: __ g
[� covering other ___
9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency?
a.Name of DEP Official
b.Title
II._. 1.1-.."-..-- - �-_.�v.--, --,--,".I.-�.__e—_ _.._�. -. .11.. . ........_. .
c Date(mm/dd �of Authorization
d.DEP
umber
D.
D. Certification
I certify that I have examined the $STEVEN PLOOF
-o above and that to the best of my a.Print Name
�o knowledge it is true and complete. STEVEN PLOOF
The signature below subjects the `'b:Authorized signature
N signer to the general statutesTREASURER
o regarding a false and misleading cPosition/Title
�o statement(s). S&R CORPORATION
d Representm�
06/1_6/2006
eco e�.Date(mm/dd/yyyy)
O
d
Q
■ ag06.doc•10/02 BWP AQ 06•Page 3 of 3
eDEP.Print Receipt Page 1 of 1
Submittal Summary & Receipt
Your submission is complete. Thank you for using DEP's online. reporting system. You can MPYselect "My Homepage" to review your status.
DEP Transaction ID: 74573
Date and Time Submitted: 6/16/2006 9:14:43 AM
User Email : mploof@sandreorp.com
Form Name: BWP - Demolition Form for AQ-06
Payment Information
DEP code
Date
Amount ($)
Payment Detail
Contractor
Contractor Number
Name
Address, ,
Supervisor
Project Monitor
Lab
https:Hedep.dep.mass.gov/Restricted/webpages/printreceipt.aspx 6/16/2006
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