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38-050 DEMO PERMITS (2) I PRINCE ST BP-2007-0461 GIs #: COMMONWEALTH OF MASSACHUSETTS MapBlock: 38A-050 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-0461 Project# JS-2007-000677 Est. Cost: Fee: $35.00 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 WC LOW ELLMA01854 ISSUED ON:10/25/2006 0:00:00 TO PERFORM THE FOLLOWING WORK.-COMPLETE DEMOLITION INCLUDING FOUNDATION 2ND,3RD,4TH HALL NORTH & TUNNELS 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 10/25/2006 0:00:00 $35.00795 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2007-0461 APPLICANT/CONTACT PERSON S&R CORPORATION ADDRESS/PHONE 706 BROADWAY ST LOWELL (978)441-2000 pavi PROPERTY LOCATION I 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 Building Permit Filled out Fee Paid Typeof Construction: COMPLETE DEMOLITION INCLUDING FOUNDATION 2ND,3RD,4TH HALL NORTH &TUNNELS 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INlf0y4ATION 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 Cominittee —Permit from Elm Street Co s on 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. . r Version 1.7 Commercial Building Permit May 15,2000 Department use only ity of Northampton Status of Permit: ` �.4jilding Department Curb Cut/Driveway Permit - _-�` 2,12 Main Street Sewer/Septic Availability Room 100 Water/Well Availability '>,'Northqlppton, MA 01060 Two Sets of Structural Plans p hoh ' �'S- 8 1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 1 Prince Street Map Lot Unit Northampton, MA 2nd Hall; 3rd Hall; 4th Hall; Zone Overlay District North & Tunnels Elm St.District cB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: MassDevelopment 1 Prince St/Haskell Build. Name(Print) Cam %��� 1y�4SS ,�Zrla,?,-4oF�urrent Mailing Address J /1y� -mly 'j (413 ) 587-6314 6-Y✓z-" Signature 7 Telephone 2.2 Authorized Agent: ca/ 0 Name(Print) Current Mailing Address: i3 i - 3I (03 _ het L Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS ; Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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 I,Us- This - This Section For'Official Use Only Building Permit Number Date [issued Signature: Building Commissioner/Inspector of Buildings Date Version 1.7 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 P Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other[:1 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 E] 1 B F-1B Business ElA-4 ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C El High Hazard 133A ElInstitutional El1-1 El1-2 ❑ 1-3 El3B ElM Mercantile ❑ El Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 4 4 ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ 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): -F- 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 1st 2nd 2nd 3 rd 3rd 4 t 4m 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 systemE] Versionl.7 Commercial Building Pen-nit 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: I. 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 YES 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 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. F Version 1.7 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 Name Area of Responsibility 53 Southampton Road. Westfield, MA 01 085 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 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 ( 978 )441 -2001) Signature Telephone Versionl.7 Commercial Building Permit May 1.5,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 140—''; as Owner of the subject property hereby authorize /l `F/��'` �ry `tet to act on my behalf, in all matters relative to work authorized by this building permit application. 2 C? 5 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 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 Number: CS 061320 rz' Birthdate: 03/19/1967 . Expires: 03/19/2007 Tr.no: 11076 Restricted: 00 THOMAS GUERETTE 18 LONGWOOD AVE LONDONDERRY, 0305' Commissioner f FROM :S& .CORP. NORTHANTON FRX NO. :41;35641568 Apr. 08 2006 12:22PN P1 BayftftGas A NSovrm Company 2025 Roosevelt Ave P,O.Box#2025 Springfield,MA 01102 )tarais 31, ��6 S&R CORP 706 BROADWAY ST LOWELL KA 01854 Dear SSR CORP. The address listed bblow hae had tho gas VeroiCel6) diacamnected and is now ready for deualition. ADDRESS: i PRINCE ST TOMH NORTHAMPTON IIA STATS haesachunetts Sincerely Terri Miner Workforce planning a ' The Commonwealth of Massachusetts r Department of Industrial Accidents a Office of Investigations ' 600 Washington Street r .= Boston, MA. 02111 Workers' Compensation Insurance Affidavit Name bc,r-em e /1Gw,ra Job Location.1 �'/< rNL City__A/6.��/d/� �7-c„v 1 42213 Phone (978)441.-2000 Q I am a homeowner performing atl work myself (� 1 am a sole proprietor and have no one working in any capacity. I am an employer providing workers'compensation or my employees working on this to Company Name: S&R Corporation Address 706 Broadway Street City Lowell, MA 01854 Phone# (9.78)441-2000 Insurance Company. flTytc/ Poticy#i!✓G iitl.2sx15390/y I am a sole proprieto .general contractoror omeowner(circle one)and have hired the contractors listed below who have the fallowing workers'compensation policies: Company Name n/a address city Phone# Insurance Company Policy# Failure to secure coverage as required under Section 25A of NMGL152 can lead to the imposition of criminal penalties of-a fine up to$1,500-04 and/or one years'imprisonment as welt 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 of Investigations of the DIA for coverage verification. I do hereby certify a#der the pains and�yenatties of perjurv*at the information provided above is true and correct_ Signature�, �- i'rG;e4, 111C4,1c ye1- Date Print Name T,�ur�us r , Phone—# (978)441-2000 Official use only do not write in this area to be completed by city or town official City or Town: Permit/license# Building NP( Ucensing ffd- 1 1 check if immediate response is required sel " F'f�DM :S2:R.CDRP. NORTHRMTDN FAX NO. :4135841568 Apr. 08 2006 12:23PM P2 —,. MAP 32 3066 13: 14 PM FR MASS ELEC COST SERI) 532 7631 TO 914135341568 F. U L 101 Massae ljusetts F-lectric A 46a g Gid Company Mauch 30,2406 S and R Corp 706 Broadway St. Lowcll MA 01954 To Whom It May Concern, This is to vorify that National Grid has removed the electric servicc and meter's at 1 Priaco St.,Northampton, Massachusetts, for Building Demolition. 'ncerely, Jim Nichols Supervisor Distribution Design JN/etcp PO bas SD7 wnnampwn,MA(20$10507 413.U2,72oo TOTAL PAGE. e1 -t� corporation 706 Broadway Street Lowell, MA 01854 City of Northampton Building Dept. 212 Main St. Room 100 Northampton, MA 01060 Re: North Halls and North Tunnels All ACM/Haz have been removed as per Tighe & Bond's survey and all areas have passed air clearances. h Paul R. Darling Superintendent S&R Corp. Cell 603-321-3163 Tel. 978-441-2000 - Fax 978-441-2002 AM-17-2006 17:24 FROM:AIR QUALITY DTIERI' 0:9784412002 P.2/4 Commonwealth of Meewmhusetts ' �'_ - 100f7rt71 Asbestos Notification Form ANF-001 Decal Nurn A. Asbestos Abat+ment Deswiption toms on the 1- a is this faaffRy flee exempt CitXlown, eanp�r,use amp - district,municipal housing authority.owner Ted orgy the tab key residence of four units or Tess? Yes 0 No to MwM ywr cursor-do not b.Provkfe blanket decal number if applicable: t nfaet DPW Number U"the retu► `' 2. Facility Location: NORTHAMPTON STATE HOSPITAL PRINCE ST or Frial; Add NorthacryitonMA 01060 9711 T12-634 a citytrorwn C e.4PCoft ne rN TRUCTIONs 3. Worksite Locatlon: U�~j I AP seaiwa or We T rHot7'I term must be a.Burma N*nWf0uGdftL4xan b. a.V ftv d Fbor e.Room In ordw yly vn'M a. Is the facTty occupied? Q Yes No taquinumCMR 7AS rusor310 Asbestos Contractor. and @r!Oivisien of 00x+06661W JPJR QUALITY 9XPFR1"S INC 140 WYYELL RID UMT 1 $may CDWI Name nooka*w requirements ot4$$ SALEM Q8099 8Q38948486 CMR 8.12 4L zo 9996 e.Tdwhorw f wlm acama Nut<,ber g.Contrail Type: ®Written ❑Verbal 6. GIERMAN POSADA ZWlQA AS032679 b. bsr DWB IAAOM77 7. a. WA I IWA 8. a cs A- � 11J9Q1/2A06 a b.Fnd o.ae o ?AM-SPM tv a houf8 !r um 0 10. a.What type of project Is this? cRration Renovation LE Rmew �Other,please specify: b.oeacrum 11. a.Check abaternent procedures: do Encapsulation onlyn a Ent k Other,specify. 2 Full oontafrtntent b.Dacufbe d 12. Is the job being conducted-acted: Indoors? Q Outdoors? S enWIRPAW-low Asbestos Notiticabon 0 -Page i of 3 Y/ 2096 17:24 FROM:AIR QLFL.ITY EXPERTS 6038947044 TO:8784412092 Commonwealth of Massachusetts ' 1tX10371 Asbestos Notification Form ANF-001 Decal Nu B. Facility Description (cont.) S&R CORP I IMBROADWAY $, a.Neem of General Con mam b.Address ILOWELL C.20nZIP ownCode Toppowmw Numberivnscode and ex s*on) f.Coniracrbors Wortcer•e Comp,Ineuterpot��y Number h. mm!`� t3. What is the size of this faciGiar� ��--�Feet b_rvum r at floors C. Asbestos Transportation and Disposal 1. TransporWr of ssbe0=-contairang materia!fmm sEte to tempmry sforage site(if nec ary): IR quALrry EXPERTS Note:Trandw a nre of Trans o b. stadorm must c0ml*YAM rhe G OtyRpam d.Zip Code e.Teleph"Nwnber fond Waste DM90 t 2. Transporter of arcs-aontaWng waste materisi f m reffmatRemporsy site to fim I psposal site: Reptadmu 310 CMR IS.W0 SERVICE TRANGPORT GROUP i IPO BOX 2132 a Name of Transporter b.Addmn t3RISTOL � 1StiU7► {BTIj 699.85 own T Nrarrber 3. a.ROUSS Transfer' and Ownw � nrss a awnag Code s.Tafthow Number 4. JA&L SALVAGE INC a. SdsLoodion No Site Owner's I um 11225 STATE ROUTE 45 1 JUSBON ON f t2isacreal slte A „� d.awnam s.State f.Ztp Code a. Nurdw co 0 ° D. Certification a Yhs undewswed hereby states,under the ICHRISTOPHM T"OMpej peneldes of perjury,that helshe has reef the a.Nwo nature o Comrrrommewth of Mamchuselts vegulalbion8 IPMMDEW for the Racnoval.CoMainmut or Elcap310 C ul 7.1 of Asbestos. ird t2AR 6A0 s1Rd I")8A4.64$6 � AIR G1UA EXPERTS .. 310 CMR7.15,and that the irrfomfaUon ....,� contaklad in this nofif�ion is trate and ooaaat Tet t. ° b the gest of NOW b owtedge and belief. 40 LOWELL RD aa.AxIckem %"F Oft 0=79 h.CwTown I.Zip cocoa Q i♦ antoolepiJoc•low ABb9QW Nodticatlon •pow 3 of 3■ •2006 17:24 FROM:RIR QOA-ITY EXPERTS 6&-JO947044 T0:97844120W- P.3/4 ;r► Commonwealth of Massachuseft 1000371 } Asbestos Notification Form ANF-001 A. Asbestos Abatement Desedption (cont.) 13. Totem Omcunt of OaCh b"of Asbeq Cvntalmng Materials(ACM)to be removed,et losW,or e L! i pas or UUM(MMW �o a BOW,bresol ID,&xt tw* 1$40 hreWanng pfxrs�sc surface votatlng6 e. UnAt 000O*ffugmd or layered Pam fWOO&M UL it . flnsats@Sprsyar coatings 1�itf g.Spray-on ftw Oft n,Tru Oft Ow d,WO bwd L Cloths,www fabdw ).Olhw.please speo4 3 low k.Thermal.SOW care pipe WND% ";3,VAT,MST WoWedon tt. 1. 14. Dawdbe the detmntaminttltion syst n(s)to be used: 8 CHAMOM DEO MSI 1a. Describe the contakumizabonklisoosal matt"s to comply with 390 CMR 7.15 and 40,3 CMR 6-142) WET 2 PLY POLY 16. For Bnew9ency Asbestos Open oft,the DEP anal COS oMokk who evaluated the gar►cy: a.Fw—ft of to MW a DEP w o.1"" a ? 111111111ma 17, Do prmft wage rates as per M.10-L c.149,§26,27 or 27Ar-F apply to this ( Yes 0 No B. Facility Description 0 1. Current Of prior USO of faClIlty: STATE HospirAL ,std 2. Is the facility oww-occupied sesirienthd vAh 4 unfs or kw? ❑Yes RIM mAss oEVEttAPMENT 11 PRINCE ST 3` F b Arwrsss ° NORTHAMPTON O a erns d.rw e. 4. F QWnefs Oa-3se MsaraMr b.On-3tee R tr'�tyRG1M1 f M e_TMBPWM ( 4`ttd4 Aad ) t I Massachusetts Department of Environmental Protection Bureau of Waste Prevention•Air Quality 1100042646 BW- - P AQ 06 Desai Number Notification Prior to Construction or Demolition Important: Applicability. When filing out A 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-et not Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09.Notification of use the rattan (DEP), Y 9 key. Construction or Demolition operations is required udder 310 CMR 7.09(2)ten(10)days prior to any work ging performed.The following information is required pursuant to 310 CMR 7.09. 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 ❑No 1.All sections of b.Provide blanket decal number if applicable: this form must be Blanket Decal Number completed in order to comply with the 2. Facility Information: Department Environmental NORTHAMPTON STATE HOSPITAL.NORTH HALLS 1 THRU 4 Protection a.Name notification JONE PRINCE STREET requirements of b.Address 310 CMR TD9 [NorthamlAon 1 101060 Q.cit frown State e.Zip Code 1(413)587-6314 t Te r id .E-mail Address loptionat 73,000 3 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: FORMER STATE HOSPITAL I. Is the facility a residential facility? ❑ Yes ❑✓ No m. If yes,how many units? �.—.-.�,.....o Number of Units " 3. Facility Owner: MASSDEVELOPMENT �,.o a.Name ONE PRINCE STREET/HASKELL BUILDING b.Address NORTHAMPTON 1 IMA 101060 gra ChyAUwn d. e. ode 99= o (413)587-6314 f.ieftph2ne Number lama gft and "on - alt d oml O SARA NORTHRUP �d h.Onsite Manager Name agO6.doe•10/02 B1NP AO 06-Page 1 of 3 0 �t VE C =[D V Massachusetts Department of Environmental Protection Bureau of Waste Prevention«Asir Quality 100042646 t.. Decal Number BWP ACS 06 Notification Prior to Construction or Demolition l e statemment:!f �B. General Project Description cont. stat asbestos is found during a Construction or 4. General Contractor: Demolition SM CORPORATION operation,all a,Name responsible parties must comply with 1706 BROADWAY STREET 310 CMR 7.60, b.Address Cha 7.15,and Cha �pter 21E of the LOWELL MA 101854 General Laws of c.Ci /Town d_State e.Zip Code the commonwealth. (97$)441-2000 This would include, f.Telephone Number area code and g.E-mail Address(optional) but would not be limited to,filing an IPAUL DARLING asbestos removal h.©n-site Manager Name notification with the Department and/or a notice of releaseiofa of release of a C. General Construction or Demolition Description hazardous substance to the 1. Construction or demolition contractor: Department,if applicable. SAME a.Name GAME b.Address LOWELL MA_ _ 01854 ^� c. ownd.state- e.Zip Code (978)441-2000 f.Telephone Number area code and extension) 9.E-Mail Address trona PAUL DARLING h.On-site Manager Name 2. On-Site supervisor: PAUL DARLING On-Site Supervisor Name 3. Is the entire facility to be demolished? Yes ❑ No acv o 4. Describe the area(s)to be demolished: a COMPLETE DEMOLITION OF BUILDINGS&FOUNDATIONS i 0 �" 5. If this is a construction project,describe the building(s)or addition(s)to be constructed: �'• �r NIA C �4 a406.doc-10/02 BWP AQ 06-Page 2 of 3 Massachusetts Department of Environmental Protection Ll Bureau of Waste Prevention-Air Quality 1100042646 BDecal Number W- P AQ 0 6 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)? n�l Yes E] No It yes,who conducted the survey? JCLAN DRAGON b.Su[Myor Ngme JAM07223T3 c,Division of Occupational Safety Certification Number 1 1 7. Construction or Demolition: ri(V19M06 12/2912006a.Start Daft(mmlddlyyyy) b,End Date(mmtddfyyyy) 8. a.For demolition and construction projects,indicate dust suppression techniques to be used: El seeding C] paving b. If other,please specify: wetting shrouding ❑ covering other 1 1 9. For Emergency Demolition Operations,who is the DEP official who evaluated the emergency? a.Name of DEP Official b.Title c.Date(mmIdd6y no of Authorization d.DEP Waiver Number D. Certification I certify that I have exarnined the ISTEVEN ALOOF above and that to the best of my a.Print Nam knowledge it is true and complete. ISTEVEN PLOOF The signature below subjects the I b.Auft- Ftmd ftnature N signer to the general statutes ITREASURER 0 regarding a false and misleading c.Position/rift 0 statement(s). S&R CORPORATION d.Repr esentin 11010412006 e.Date(mnvddtyyyy) aqO6.doc-10/02 13WP 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 select"My Homepage"to review your status. DEP Transaction ID:95683 Date and Time Submitted: 10/4/2006 7:02,13 AM User Email : mploof@sandreorp.com Form Mame: BWP-Demolition Form for AQ-06 Payment Information DEP code Date Amount($) Payment Detail Contractor Contractor Number Name Address„ Supervisor Project Monitor Lab hops://edep.dep.mass.gov/Restricted/webpages/printreecipt.aspx 10/4/2006 3