38-050 DEMO PERMITS (5) BP-2006-1259
MWOW
GIS#: COMMONWEALTH OF MASSACHUSETTS
4r+°" CITY OF NORTHAMPTON
77
Permit: Buildinq
Category: demolition BUILDING PERMIT
Permit# BP-2006-1259
Project# JS-2006-1865
Est. Cost:
Fee: $1.5.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Groin 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 X978)441-2000 WC
LOWELLMA01854 ISSUED ON:5125/2096 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLITION - BLDG 9 -WOODEN LEANTO
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 Siinature:
FeeType: Date Paid: Amount;:
Building 5/25/2006 0:00:00 $15.00773
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2006-1259
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
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: DEMOLITION-BLDG 9-WOODEN LEANTO
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
T NT
HE FO, OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO
ATION PRESENTED:
V pproved Additional
A _ 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 C13 Architecture Committee
-Permit from Elm Street Corurnis . n
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.
Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway 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 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: (a (� This section to be completed by office
l�
!Prince Street Map j Lot Unit
Northampton, MA ";' !20
e i 4" � Overlay District
Building #9 (Wooden Leanto)
Elm aLDistric' CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORiii)1 GSNT, ;)
2.1 Owner of Record:
MassDevelopment 1 Prince St. Haskell Bld.
Name(Print) Current Mailing Address:
�� rTlr (41 3 ) -587-6314
Signature Telephone
2.2 Authorized 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=0 +2+3+4+5) Check Number
This Section For(Official Use Only
Building Permit Number rt� Irate
�( Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versiont.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ® Demolition❑ '.Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description Enter a brief description here. Demolition of wood leanto
Of Proposed Work: & foundation
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 ( ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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 ❑ 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): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1 sc 1st
2nd 2nd
3rd 3rd
4m
4tn
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: F73ewage Disposal System:
PublicPrivate ElZone Outside Flood Zone❑ cipal ❑ 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
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 0 DON'T KNOW 0 YES 0
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.
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 31t-- 5
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
j�f ( 978 )441 -200
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Signatur 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 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
l � �2 IZA ( 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
-- ------------
A,
- — a
A, ti oizrfar.ra ferrl;i ,� l�c i.K ;'fz. l.z f.
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
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
Commissioner
FROM :S&R.CORP. NORTHAMTON FAX NO. :4135841568 Apr. 08 2006 12:22PM P1
A .
A NiSourm Ot?MPanY
2025 Roosevelt Ave
RO.8ox#2025
SpringlIeld,MA 01102
ltarol!� 31, 2006
90 CORP
706 BROADWAY ST
LOWELL MA 81654
Dear SSR COMP,
The address listed balov hae had the gas pervicele)
disconnected and in nov ready for demolition.
ADDRESS: l PRINCE ST
TOWN NORTHATIPTON 'IIA
STATS Massachusetts
Sincerely
Terri diner
Workforce planning
FROM M :S&R.CORP. NORTHAMTON FAX NO. :4135841568 Apr. 08 2006 12:23PM P2
MAR 32 2006 12 ; 14 PM FR MASS E1..EC CUST 6E'RU 592 7631 TO 9141358415SO
Massaiel usetts Electric
A;Nao aal GMd company
March 30,2006
S and R Corp
706 Broadway'St.
Lowell MA 01854
To Whom It May.Concern,
This is to verify that National Grid has removed the electric scrvicc and meter's at 1
Prince St.,Northampton, -Massachusetts, for wilding Demolition.
ncerely,
4�
�.
Jim Nichols
Supervisor
Distribution Design
3N/ekp
PO box$07
Pdarinampton,MA omoa105w
413.ae2.7200
*A! TOTAL PAGE. r i -k*
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
: 600 Washington Street
Boston, MA. 0211.1
`yam' Workers' Compensation Insurance Affidavit
Name br,Tem r HvSrra/
Job Location.:1, /Z �—i-
City 1V0/ZZ?f�711 W// 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 or my emp oyees working on tUs�o
Company Name: S&R Corporation
Address 706 Broadway Street
City Lowell, MA 01854 Phone# (9-78)441-2000
Insurance Company L,''j6L ,17-;ja/{ Policy# C llt1a57 39o/5Y
t
I am a sole proprieto -general contractor or 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 2SA of MGL152 can lead to the imposition of
criminal penalties ofa tine 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$100.00 per day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage
verification.
I do hereby certify/tnder the pains and penalties of perjur.v*at the information provided above is
true and correct.
Signature ,., �,u�eciccaeye/ Date S`f/f/aQt(
Print Name Z:&,.Mg,s a- 6�,erP,7e Phone_# (978)441-2000
Official use only do not write in this area to be completed by city or town official
City or Town: Permit/license# Quilling Dept
Ucensing Dd-
1 1 check if immediate response is required stiectmen
(tcalth GcpL
Contact person phone 9 Olhcr
t
Commonwealth of'Massachusetts
Ll Notification
Asbestos Nd
tification Form ANF-001 Decal Number
copy
Important:
when filling out A. Asbestos Abatement
p
forms on the
computer,use 1 a. Is this facility fee eempt-city, town, district, municipal housing authority, owner-occupied
only the tab key residence of four uni�s or less?r./ Yes F-1 No
_._
to move your
cursor-do not b. Provide blanket decal number if applicable: - -_.-------
use the return Blanket Decal Number
key. 2. Facility Location:
¢� NORTHAMPTON SATE HOSPITAL [1 PRINCE STREET
a Name of Facilites b.Street,Address
7', orthampton MA 1 01060 413 5 a
N_...�...._._..�..�___.,_ R } 87 6314
f-"- - a City/Town d.State e.Zip Code f_Telephone Number
INSTRUCTIONS 3, Worksite Location:
_
1.All sections of this Bt11LDING#$ t
form must be a..Building Name/Building Location W b Building#µ c.wing d.Floor e. Raam
completed in order
to comply with 4. Is the facility occupied? .m Yes ✓]No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of Occupational 'S & R CONTRACTING 9 706 BROADWAY STREET
Safety(DOS) a Name
b__.__
.Address
notification [LOWELL 01854 9 784412000
requirementsof 453 # .._.� ,.._. ._...__..._.._ .._._A... .._...m... _.._.,., __..___.._.,_�
CMR 6.12 c City/Town� d Zip Code e.Telephone Number
[46000497
g. Contract Type: Written Verbal
SARAH NORTHROP RESIDENT ENGINEER
h Facile Contact Person i.Contact Person's Title
OSVALDO E DE LA CRUZ ! AS03fi170
a. Name of On Smote SupervtsorlForeman b.Supervisor/Foreman DOS Certification Number
_ _ _.
DANIEL DRAGON AM072273
7 — i __. .
a Name of Pralect Monitor b Project Monitor DOS Certification Number
8 a Name of Asbestos Anaiy icai Lab b.Asbestos Anal tical Lab DOS Certification Number
_
---- X0512212006 06/30/2006
9
a Pr9ject Start Date Imrwid-d b.End Date mmtdd/r r r�
o 7 4.00 N1A
c.1Nork hours Mon-Fri. d.Work hours Sat-Sun.
.�0 10. a. What type of project is this?
Demolition Renovation
Repair u Other, please specify: b.Describe -
�� 11. a. Check abatement procedures:
° Lij Glove bag L] Encapsulation
Hca Enclosure Disposal only
LL 1 ; Cleanup Other, specify:
Full containment b.Describe
�a 12. Is the job being conducted . Indoors? I (i Outdoors? ,
® anf001ap.doc• 10102 Asbestos Notification Form•Page 1 of 3
LlCommonwealth of Massachusetts
100032345
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abd ant Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
.0 X40
a.Total pipes or ducts(linear ft) 'b.Total other surfaces{squar'e ff).+
c.Boiler,breaching,duct,tank
surface coatings Lin.ft 5 "ft. d.Insulating cement
. 9 Lin.ftSq,ft
e.Corrugated or layered paper
pipe insulationf.Trowel/Sprayer coatings Lin ft. Sq.ft.
g.Spray-on fireproofing (-- - h.Transite board,wall board
Lin ft Sq fl, Lin ft. Sq.ft
I.Cloths,woven fabrics -- 1 f40
Lin ft Sg S Other,please specify Lin-' Oft. 1 tS.....
k.Thermal,solid core pipe FLASH,RFG40CY
insulation Lin.ft. Sq.f# 1.Specify
14. Describe the decontamination system(s)to be used:
THREE CHAMBER REMOTE DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
IBULK LOAD, OPERTOP CONTAINER, DBL LINED W/10-MIL LINERS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Offiicial
h.. _
c.Date(mmldd/yyyy)of Authorization d DEP Waiver#
e Name of DOS Official f DOS Official Tttle
r
mmtdd/
.N g.Date( yyyy)of Authorization h.DOS Waiver#
0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ✓ Yes 1 }No
B. Facility Description
-----� ISTATE HOSPITAL ANCILLARY BUILDING
�0 1. Current or prior use of facility:
�C)
2. Is the facility owner-opcupied residential with 4 units or less? _;Yes ✓i No
VASSDEVELOPMENT i1PRINCE STREET
3. _. .. w,._ . .._.,
i b Address
NOTH
_. d1060
._. . _.
a.Facility owner Name R060 (4i 3}587-6314
y�.�..�.�. tRAMPTON 01 _ .... _._
o c. City/Town d.Zip Code e Telephone Number(area code and extension)
L 4 SARAH NORTHRUP } �1 PRINCE STREET
a Name of Facility Owner's On-Site Manager b On Site Manager Address
mmmmmmmmnz
�. ;NORTHAMPTON 01060 x(413)587-6314
�Q c.City'/Town' d.Zip Code e.Telephone Number(area code and extension)
anf001ap-doc• 10102 Asbestos Notification Form•Pa e 2 of 3
Commonwealth of';Massachusetts
100032345
Ll Asbestos W tifieation Form ANF-001 Decal Number
B. Facility Description (coat,)
5. iS&R CORPORATION _ _ ? ,706 BROADWAY STREET
a Name of General Cont#actor b Address
LOWELL 1 01854 I (978)441 2000
e pilTown d Zip Coder e.Telephone Number(area code and extension)
;LIBERTY MUTUAL t WC1111257839014 ; 110/0112006
p _ (.. _ �
f.Contractor's Worker's Camp.Insurer g Polic Number h Ex Date mrntddlYyyy)
this facility? �a7Suare Feet_.. ,. _.._.. . s1.. ...__.
6. What i5 the size of t q 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 asbesios-containing waste material from removal/temporary site to final disposal site:
Regulations 310 __,_r
CMR 19.000 RED TECHNOLOGIES, LLC s i0 NORTHWOOD DRiVE
a Name of Transporter b Address
BLOOMFIELD,CT _ ..._...,._ 06002 w_.....i (860)218 2428
$t zip Code e Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address
c City/Town Code e Telephone Number
4. ITURNKEY LANDFiLL(WASTE MGT NH)
_. D�osal$ate Location Owner's Name
a Pmol Disposal Site Location Name bFinal D CHESTER
ROi
7 ROC�HE�TER NEC{ROA a._ _.....-. _ J ,.
d CitytTown
INHnww. _ ._ ._�.� _.1 03839.__
co e.State f.dip Code g.Telephone Number
O
�a D. Certification
.�......�'��� undersigned hereby
states, under the TEVEN PLOOF
penalties pehelyhe
has read the a Name b Authorized Si nature
�o Commonwealth of Massachusetts regulations [TREASURER
for
- G
the Removal,Containment or
c Position/Title d Date(mmldd(yyyy)
Encapsulation of Asbestos,453 CMR 6.00 and qq"�978 441-2000 S&R CORPORATION
310 CMR 7.15,and that the informationt�
contained in this notification is true and correct Telephone Number f Representing
° to the best of his/her knowledge and belief. 706 BROADWAY STREET
p q Address
LOWELL 101'8'54
h.City/Town i.Zip Code
�......Z
anf001ap.doe•10102 Asbestos Notification Form•Paae 3 of 3■
|
|
r[)ER Print 8c�ci[8 '
.
Submittal Summary & Recei0t
Your submission .° complete. /'/m/^ you for using uErsonline reporting system. You can
select "My Homepage" toreview your status.
|
DEP Transaction ID: GS288 �
Date and Time Submitted: :41 PM
User Email : mp|oof@oendroorp.00m|
Form Name: BVVP' Asbestos Notification /onn'ANFO01
Payment Information �
DEP code �
Date !
Amount0N \
Billing Info
Contractor
Contractor Number: AC0004Q7
Name: 8 & RCONTRACTING
Address: 70GBROADWAY STREET, LOWELL, MA 01854
978'441'2008 !
Supervisor |
C}8VALD{} EDELACRUZ
|
Project Monitor �
Lab !
|
'
!
Location �
BUILDING #9
|
Project Start Date �
5u22x2oo6
/
/
-
--- ------ , '100031425
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention — Air Quality Desai Number
L1j Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06 copy
Important: A. Facilit Location
When filling out Y iO n
formson theI �. �. ...,�. W,._.__��. � ._...._.._..... ,-.... . ,.... _ .. _ _. _ _... .. ........ .... .....
NORTHAMPTON S ATE HOSPITAL
computer,use
only the tab key 1.Name of Facility
to move your
11 PRINCE STREET
{
cursor-do not e.____�.____....._ .. .. ., �.-.- .. __ __.. ..... ........: ___ ..__� ._..__. .. _.._.. _ ...
use the return 2 Street Address
key. (NORTHAMPTON
3 City 4.State 5 Zip Code
X4135876314 _
6.Telephone Number
rarr.�
INSTRUCTIONS B. Project Cancelled
1. This form is
only available for ^ Check here if this project is/was cancelled.
online filing of
project date
revisions.
2. Enter project -- — -- -- -- --------- ----------- --- ----- -------
decal number. C. Project Dates
3. Validate that
the project 105/02/2006 05/31/2006
location is correct 1 Or mal Start Date f 2_Or nal End.Date rnm/dd/yyyy)
for the entered 05/02/2006 05/31/2006
decal _ _ e� [ 31/2 .� __.-1
3.Latest Revised Start Date(mm/dd/yyyyj 4.Latest Revised End Date(mm/dd/yyyy)
4. Enter your new
project dates.
5. Certify your ---_----_-----.__.—_—.-
notification. D. Revised Project Dates
Submit date
changes 05/02/2006 i05/05/2006
_ t�
1 Revised Start Date(mrn�d/yyyy) _"�-"-'"�� �� �-��� 2.Revised End Date
E. Other Project Revisions
F. Revision History
EDEP. 05/02/2006 30:37 AM OTHERPROREV: INCLUDE GLOVEBAG METHODS; CHANGE
DISPOSAL SITE TO A&L SALVAGE, LISBON, OHIO; WORK HOURS 7:00 AM-4:00 PM
r
f
3
l
anf06pdrn.doc-rev.2/5/04
Massachusetts Department of Environmental Protection 100031425
-I
Bureau of Waste Prevention —Air Quality Dec aNumber
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
G. Certification
The undersigned here3 y states, under the penalties of perjury,that he/she has read the Commonwealth of
Massachusetts regulations,.for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310
CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
gSTEVEN PLOOF
iTREASURER
2.
IIS&R CORPORATION i (978)441-2000
1706 BROADWAY STREET
6. Address
LOWELL, MA M. "n [01854
7. CityrTown 8, Zip Code
anf06pdrn.doc-rev.2/5104
cD[,--P: Print Rcic° ipj
r,. r itis' r
Submittal Summary & Receipt
Your submission is complete. Thank you for using DEP's online reporting system. You can
select "My Homepage" to review your'sstatus.
DEP Transaction ID: 69179
Date and Time Submitted: 5/5/2006 10:15:02 AM
User Email : mploof@sandreorp.com
Form Name: ANF-001 and AQ 06 Prd)ect Date Revision Notification
DECAL # and Facility information
Form Name: ANF001
DECAL # : 100031425
Facility Name: NORTHAMPTON STATE HOSPITAL
Address: 1 PRINCE STREET, NORTHAMPTON, MA 4135876314
Original Project Dates
Start Date: 5/2/2006 - End Date: 5/31/2006
Revised Project Dates
Start Date: 5/2/2006 - End Date: 5/31/ 006
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`17ORMWATER'MANA03EMENT F-eePatd:
YERMIT Date Paid:
Permit#:
City of Aorthompton APPLICATION Approved Fay;
1lepartment of Public Works .Approval Date-,
(For&PIV use vn v)
1. Project/Site Information
Project 1 Site Name: merhsaerca ErAza' asv;ra/
Project Street/Location: 1- e r
Assessor's Map:,- Parcel(s):
Estimated Area'(,,)he Disturbed(ft): PO 00,0 +�
Total Arca of Impervious Surfaces: Erastin Proposed
(paved. parking, decks. roofs,etc)(ft`) 910 ,010
Project T lie(check one � Permit Revi
S. Application Requirements
The application to the Northampton Department of public Works(DPW) for a Stormwater
Management Permit must include submission of the following:
F1 Completed and Signed Stormwater Management Permit Application
LJ Non-Reftindable Permit Review and Inspection Fee
• Operation,Maintertance,and Inspection.Agreement
• Three complete copies of the Stormwater Management Plan and Erosion and Sediment
Control Plan prepared by a professional engineer licensed by the Commonwealth of
Massachusetts,and including the minimum documentation listed below(see the
Northampton Stormwater Management Ordinance(Chapter 22, Article V) for more
infion-nation):
Pro*ect Documentation:
(Check circles below indicating that you have provided the following minimum information)
Q Identify all operators for the project site and the potions over which each operator has control,
(J All plans submitted have been prepared and stamped by it professional engineer licensed by
the Commonwealth of Massachusetts
CJ The applicant has certified on the drawings that all clearing,grading, drainage,construction,
and development shall be conducted in strict accordance with the plan
0 Locus snap
0 The existing zoning,and land use at the site
0 The proposed land use
Q ]-he location of existing and proposed casements
0 The location of existing and proposed utilities
0 The site's existing&proposed topography with contours at 2 foot intervals
0 Soils investigation(by a Certified Soil Evaluator or Certified Professional Soil Scientist)
including borings or test pits,to a depth greater than 4 it, below estimated seasonal ground
water for areas where construction of infiltration practices will occur.
0 Estimated seasonal high groundwater elevation(November to April) in areas to be used for
storm water retention,detention,or infiltration(by a Certified Soil
Evaluator or Certified
Professional Soil Scientist).
0 A description& delineation of existing?siorinwater conveyances, impoundments, and
wetlands on or adjacent to the site or into which storm water flows.
0 A delineation of 100-year flood plains, if applicable.
0 The existing and proposed vegetation and ground surfaces with runoff coefficient for each.
Cf A drainage area map showing PTC and post construction watershed boundaries,drainage area,
storm water flow paths,and receiving water.
Q A description and drawings of all components of the proposed drainage systern including:
1) the structural details for all components of the proposed drainage systems and storm
water management facilities(including size,inverts,and grade);
2) all measures for the detention, retention or infiltration of water,
3) a]I measures tbr the protection of water quality;
4) notes on drawings specifying materials to be used,construction specification-,,and
typicals:
5) the existing,arid proposed site hydrology with supporting drainage calculations(including
the 1.2,10,and 100 year MRCS design stornis);
Northampton Department of Public Works Page 2
Storinwater Management Permit
6) proposed improvements including location,of buildings or other structures,impervious
surfaces,and drainage facilities,if applicable,
7) location,cross sections,and profiles of all potentially impacted brooks,streams,drainage
swales and their method of stabilization; and
8) proposed ownership of drainage system structures.
0 Estimate of the total area expected to be disturbed by excavation,grading or other
construction activities.
0 A description and location of all measures(i.e.,Best Management Practices)that will be
implemented as par( of the construction activity to control pollutants in storm water
discharges. A description of when each control measure will be implemented in the
construction schedule,which operator is responsible for the impletnentation of each control
measure and a maintenance and inspection schedule for each control measure during
construction.
0 A description of construction and waste material-,expected to be stored on-site,and a
description of controls to reduce pollutatiti from these materials including storage practices to
minimize exposure of the materials to storm water,arid spill prevention and response.
0 l'iming,schedules.and sequence of development including clearing,stripping,rough grading,
construction,final grading,and vegetative stabilization,
6. Application Submission,Review,and Approval Procedures
1. Application Submittal: The application to the Northampton DPW for a Storniwater
Management Permit must be submitted prior to or concurrently with any land use
permit application. Submission of an application should be made to the Northampton
Department of'Public Works, 125 Locust St., Northampton,MA 010601. For more
information and copies of the Nortlitimpton Stormwater Ordinance visit the DPW
,.A,,eb site at %k,-n n", o,ohod -, -rg or contact Doug McDonald at 41-1-587-1582 ext 308 or
(.11 llcdollaU, ivy_Vit?
2. Administrative Review: The Northampton DPW will have 7 days from the receipt of
the application to review the,application for administrative completeness. Incomplete
applications will be disapproved and returned to the applicant based on the
determination that they are administratively incomplete.
3. Review: If the application is round to be complete, the Northampton DPW will
review the application and supporting documents based on the criteria set forth in the
Northampton Stormwater Management Ordinance(Chapter 22, Article V)and will
take final action within 21 days(including the 7 day administrative review period)of
the receipt of complete application unless such time is extended by agreement
between the applicant and the DPW.
4, Final Action: The Northampton DPW's final action will be in writing and will be
sent to the applicant and the appropriate City Department(s)and Board(s).
Northampton Department of Public Works Page 3
Storruwater Management Permit