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31B-004 (29) GAWITH HALL-46 ROUND HILL RD BP-2018-0018 Gis#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-004 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TOTTHE TGUARANTY (FUND D((MGL c 1144/2�A)) Category:demolition B V ILDI G 1 �•uR ISIIT Permit ft BP-2018-0018 Project# JS-2016-002121 Est,Cost: 350000.00 Fee:$200,40 PERMISSION IS HEREBY GRANTED TO: Const. Clans: Contractor: License: use Gmun' TRUCK CRANE SERV INC 074442 Lot Size(sq.8J: 311018.40 Owner: 1924 LLC Zoning: L0RC(10o)t Applicant: TRUCK CRANE SERV INC AT: GAWITH HALL -46 ROUND HILL RD Applicant Address: Phone: Insurance: 20 FAIRFIELD AVE (413) 562-9465 WC WESTFIELDMA01085 ISSUED ON:7/7/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:KITCHEN ADDITION DEMO 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 14 Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Finale Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTyne: Date Paid: Amount: Building 7//7120170:00:00 $200.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Versionl.7 Commercial Building Permit May 15,2000 I, t'' Department use any r- City of Northampton Status of Penrdt 19(}`, Building Department Curt Cut/Driveway Permit - .- - 212 Main Street SewerlSepbc Availapfidy Room 100 Water/Wee AyaiPabiilty Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 'PtouSne 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 7A Property Address: This section to be completed by office H( ' F,aaturo ilia- ° !�- ero Map Lot Unit EA W i j-fi FICA— Zone Overlay District - - .. . -.. .. Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT • 2.1 Owner of Record: /c72 / h C 333 1 swaTL,- s.:5Pace/, .p Name(Print) ♦ t_ .7-h,p)_f'r1Pr 5 763 Ratti' Current Mailing Address Aloe 44 /,_)_ak' 0 :1111111.--_-- yy,, ��^ilY�f' }7�t e `11�.s�l-�e'I 5 signature a _{� __. � �_ Telephone 2.2 Authorized Agent: 'TeLe--.r.{AII3J777cfPrXs 7z5 .Pt. 2v / 79() fh!£.t o,it40 dfr-.'ic Name(Fri Current Mail ng Address -arAL rip,/ Gam-@ 3)52`x. `?t4'S /�YG cru s3/ 67 t Signature _„ � _ 1elephone If TON3- S I : EDCONSTR.CTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant I. Building _,.(a)Building Permit Fee 2, Electrical / (b)Estimated Total Cost of - - Construction from(6) -. 3. Plumbing --A__--,-''' / ,m_ Building Permit Fee 4. Mechantca AC) -Aq�. - / p Ci & -0 60 % 5.Fire Pr. ection ! GOD' 6. Total= (1 +2 +3 +4 +5) CC r f' '� Check Number This Section For Official Use Only Building Permit Number Date Issued Signature. __ 7/7/i 7 Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 'r ION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 C FEET OF ENCLOSED SPACE or Alterations 0 Existing Well Signs ❑ Demolition Repairs 0 Additions 0 Accessory Building 0 for Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other 0 f Description Enter a brief description here. 12 ZL .t. (-2f- 5,-ZLY-7'"21, ic3`°?"'N AS ' roposed Work: Kr i !�1 /^4f3S AnJ fzLYrkvid'?v.G+'iSriic>/7275.�/6l<f3L Ref)L4,ic(Z 5T7}t'(.5. TION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE >sembiy ❑ A-1 0 A-2 0 A-3 0 IA 1 ❑ A-4 0 A-5 01B 0 usiness 0 /"lam 2A 0 ducationai 0 / 28 actory ❑ F-i ...„0 2C ❑ iqh Hazard 0 / \l r 3A ❑ stitutione' 0 I-t 0 i I-2 0 I-3 ❑ _ 30 ❑ Mercantile 0 4 0 Residential 0 --1 ❑ R-2 0 R-3 0 5A 0 Storage 0 S-1 0 S-2 0 58 ❑ Utility ❑ Specify: Mixed Use 11 Specify: Special Use ❑ Specify. COMPLETE THIS SECTION IP EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE fisting Use Group _.. .. .. Proposed Use Group. xisting Hazard Index 780 CMR 34j Proposed Hazard Index 780 CMR 34): IECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY 'bar Area per Floor(sf) 1. Total Area 00 Total Proposed New Construction Of) Total Height(ft) _ _ _. .... .. .. _ . Iola(Height ft 7.Water Supply(MGL.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private 0 Zone _ Outside Flood Zone❑ Municipal 0 On site disposal system❑ Versionl.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 Foota (Lot area minus bid paved parking) #of Par gSpaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES IF YES: enter Book Page and/or Document ft B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O 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 O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO O IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O 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) 91 Registered Architect: Not Applicable ❑ game(Registrant): - - - - Registration Number 4ddress Expiration Date signature Telephone 3.2 Registered Professional Engineer(s): 'lame Area of Responsibility address Registration Number signature Telephone Expiration Date Jame Area of Responsibility \ddress Registration Number signature Telephone Expiration Date Jame Area of Responsibility address Registration Number signature Telephone Expiration Date Jame Area of Responsibility address Registration Number Signature Telephone Expiration Date 11...33 General Contractorct , CLT £' S /e-LF Not Applicable ❑ 1ompany Name: Pic r haPrr i . P ,—c5 Responsible In Charge of Bort'ltiction Zv )'e1( rir A't/t. f � 67pIt f� Y✓1 f} O/OS S lddress � o.- =tore Telephone et Version!.?Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN NOP---- 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 y� Date I, t- r �tP' r "77�'�' '/ 1 -5 ./ £NL si- KE'y SY"L ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application : - true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of • ai Print Name fkIC- TAI ? GIS r-e-3 -7- 7- / '- Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder ? - r LI?m ., 5 'Tc/Cots -617 7i krJ z... License Number _ 20 7gA6CF) 1914 ,1 IFFY p,r 1 o1 e_5 22-IC' ••res Expiration Date Signa • - � / II Telephone SECTION 13-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.P. 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 O No yJ ON AGE 14477/a' TltPf ,P City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a 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 , S150A. L Address of the work: I0 64A) /TI LC PO 111 � , lifr i The debris will be transported by:0742(€_ /SPcoc&_ •SNL The debris will be received by: c O f' 4R Building permit number: ?/9vc TAI? m$-, PRt5 Name of Permit Applicant l/✓r—lam aft Sty�/10E ,-77n,c, p Date Sign- re of Permit Applicant The Commonwealth of Massachusetts e Department of Industrial Accidents ,, -; - ; Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/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): I.❑ I am a employer with 4. 9 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. 9 Remodeling 2.❑ 1 am a sole proprietor or partner- ship and have no employees These sub-contractors have S. 9 Demolition working for me in any capacity. employees and hase workers' Insurance.: 9. ❑ Building addition [No workers' comp. insurance comp. required.] 5. 9 We are a corporation and its 10.9 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required.] t c. 152,§1(4).and we have no employees. [No workers' 13.9 Other comp. insurance required.] 'Any applicant that checks box al must also fill out the section below shovnng their workers'compensation policy inf ation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: lob 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Siimature: Date: Phone#: 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"._every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that`every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 TeL #617-727-4900 ext 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 7-2013 www.mass.gov/dia ® f�nAtyr.. 10 / rvf,I /a/ f/pm,Massachusetts Department of Environmental Protection 100265941BWPAQ06 ._ Notification Prior to Construction or Demolition Asbestos Project# OnC k1/;!..` r Project Revision date d.F/&-19-/7 Z/0„,2d-lig r Project Cancellation A.Applicability A Construction or Demolition operation of an industrial, commercial,or institutional building,or residential building with 20 or more units is regulated by the Department of Environmental Protection(MassDEP),Bureau of Waste Prevention,Air Quality Division,under Regulations 310 CMR 7.09.Notification of Construction or Demolition operations is required under 310 CMR 7.09(2)ten(10)working days prior to any work being performed.The following information is required pursuant to 310 CMR 7.09. 1.Is this a fee exempt notification(city,town,district,municipal housing authority,state facility,owner-occupied residential property of four units or less)? r a.Yes r b.No 2.Blanket Permit Project Approval,if applicable: Approval IDM 3-Non-Traditional Asbestos Abatement Work Practice Approval,if applicable: Approval IDM Instructions: B. Facility Description 1.All sections of this torn must be 1.Facility Information: completed in order to GAWfrH HALL 46 ROUND HILL ROAD comply with the a.Name of facility b.Street Address Department of Environmental NORTHAMPTON MA 010600000 4135316705 Protection c.City/Town d.State a rip Code f.Telephone notification requirements of 310 PAUL T.LIPTAK,PRES.T.CS.,INC AGENT FOR CMR 7.09. g.Facility Contact Person h.Facility Contact Person Tie 2.Submit Original 4135316705 buckcraneservice@comcast.net Foran To: i.Fadlity Contact Person Telephone j.Fadlnta t Person Email Commonwealth of Massachusetts k.Facility Size: P.O.Box 4062 Boston,MA 02211 6400 2 1.Square Feet 2.Number of Floors MSSSDEP Use Only I.Was the facility built prior to 1980? 1.Yes r 2.No m.Describe the current or prior use of the facility: Date Re¢Fred MTp1EN BULDNG n.Is the facility a residential facility? r I.Yes r 2.No 0.If yes,how many units? 2.Facility Owner: r Same address as Facility 1924LLC 333ELMSTREEr a.Facility Owner Name b.Address WESTSPRINGFIE]D MA 010890000 4138969962 c.City/Town d.State e.Zip Code f.Telephone 3.Facility On-Site Manager/Owner Representative: Ir Same contact person as facility r Same address as facility r Same address as owner PAIR T.LITN(,PRES.T.C.S.,INC 20 FAIRFIELD AVE a.On-Site Manager/Owner Representative b.Address Westfield MA 01085 4135316705 c.City/Town d.State e.Zip Code f.Telephone Revised:03/17/2014 Page I of3 Massachusetts Department of Environmental Protection BWP AQ 06 100265941_. Asbestos Project# Notification Prior to Construction or Demolition r project Revision r Project Cancellation C. General Project Description This project is: r New Construction r Demolition r Renovation 2.Project Dates: 6/14/2017 10/20/2017 a.Project Start Date(MM/DD/YY(Y) b.Project End Date(MMDDNVY ) 3.General Contractor: TRUCK CRANE SERNCE,INC 20 FAIRFIELD AVE a-Name b.Address WESTFIEID MA 010850000 4135316705 c.City/Town d.State e.Zip Code t Telephone PAUL T.LIPTAK PRES 4135316705 g.General Contractors On-site Manager/Foreman h Telephone 4.Construction or demolition contractor: Z Same as General Contractor TRUCK CRANE SER4CE,INC 20 FAIRFIELD AVE. a.Contractor Name b.Address WESTFIFlD MA 010850000 4135316705 c.City/Town d.State e.Zp Code t.Telephone PAULT.UPTAK PRES. 4135316705 g.Construction and Demoli0on On-site Manager h.Telephone 5.Licensed Construction Supervisor: PAUL T.LIPTAR.PRES. CS-074442 a.Supervisor Name b.Construction Supervisor License(CSL)Number 6.Is the entire facility to be demolished? ICe a Yes f b.No 7.Describe the area(s)to be demolished: E.flF STRUCM2E 8.Describe the building(s)or addition(s)to be constructed: 9 a.Were the structure(s)surveyed for the presence of Asbestos-Containing I.yes r 2.No Material(ACM)? b. Who conducted the survey? O.T.O.ASSOCIAILS,ROBERT KIRCHER AI-107443 1.Name of Asbestos Inspector 2.DLS Certification ft Revised:03/17/2014 Page 2 of 3 Massachusetts Department of Environmental Protection 100265941 BWP AQ 06 Asbestos Project# Notification Prior to Construction or Demolition r Project Revision I— Project Cancellation C. General Project Description (continued) 10 a-Was asbestos containing material(ACM)found? (—I.Yes lift 2.No General b.If ACM was found during the survey,please provide the Asbestos Statement:If Notification Form(ANF)Project Number. asbestos is found during a Construction 11.For demolition and construction projects,indicate dust suppression techniques to be used: or Demolition operation,all s a.Seeding r b.Wetting r c Coverings d.Paving r e.Shrouding responsible parties must comply with 310 r COther"Specify: CMR TOO,TOR 7.15. and Chapter 21 E of the General Laws of 12.Is this an Emergency Demolition Operation? r a.Yes r b.No the Commonwealth. This would include, c.Name of MassDEP Offidal who evaluated the emergency but would not be9 cY limited to,filing an asbestos removal d.Me notification with the Department and/or a notice of e.Date of Authorization(MM/DDIYYYY) f.MassDEP Waiver Number release/Nreat of release of a D. Certification hazardous substance to the Department,if 1 certify that I have personally PAULT.UP AK applicable. examined the foregoing and am 1.Print Name familiar with the information PAUL-T.UpppK contained in this document and 2.Authorized Signature all attachments and that,based on my inquiry of those PRESIDENT individuals immediately 3.Position/Me responsible for obtaining the TRUCK CRANE SERVICE,INC information, I believe that the 4.Representing information is true,accurate,and 5/31/2017 complete.1 am aware that there 5.Date(MMIDDIYYYV) are significant penalties for 05131/2017 submitting false information, including possible fines and 6.RE# imprisonment.The undersigned hereby states, under the penalties of perjury,that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made" Revised:03/17/2014 Page 3 of3 531/2011 eDEP-MassDEP's OnlineFilirg System MassDEP Home I Contact l Privacy Policy MassDEP's OnEne Filing System Usemame:TCSINC Nickname:LIPPY cm Transaction Overview Trans#929214 ID# 100265941 AQ 06-Construction%Demolition Notification J rAISISIMICEMIVERIalS L Forms Signature Payment Submit Payment print Exit Payment Confirmation Thank you.Your payment has been received. Note_Payment received after 3:30pm will not be posted until the next business day. Next MassDEP Home I Contact I Privacy Policy MassDEP's Online Filing System ver.14.0.2.0©2011 MassDEP https://edep.dep.mass.gov/Pages/PaymenVPaymentConfirmationaspx til 5/31/2017 eDEP-MassDEP's OnlineFiling System MassDEP Home I Contact I Privacy Policy MassDEPN OnAne Filing System Username:TCSINC Nickname:LIPPV an Receipt Forms mature Receipt Summary/Receipt print receipt Exit Your submission is complete. Thank you for using DEP's online reporting system. You can select "My eDEP"to see a list of your transactions. DEP Transaction ID: 929214 Date and Time Submitted: 5/31/2017 12:32:20 PM Other Email : DEP Transaction ID: 929214 Date and Time Submitted: 5/31/2017 12:32:20 PM Other Email : Form Name: AQ 06 - Construction/Demolition Notification Form Name: AQ 06 - Construction/Demolition Notification Payment Information DEP code: 142915 Date: 5/31/2017 12:30:08 PM Amount ($): 100 Payment Detail: LIPTAK PAUL--AccountType -- AccountNumber n**6098 Confirmation Number: My eDEP MassDEP Home I Contact Privacy Poky Mass DEP's Online Filing System ver.14.0.2.0©2017 Mas s DEP 14tpsi/etlep.dep.mass.gov/Pages/PrintReceptaspx 1/1 _ MBWPassachusetts Department of Enonstructionvironmental Protection AQ Notification Prior to Cor Demolition ✓ This is a revision to an existing form. Project ID for existing form to be revised: ✓ This job is being conducted under a Blanket Permit MassDEP assigned Blanket Authorization ID: { ✓ This job is being conducted under a Non Traditional Abatement Work Practice Permit MassDEP assigned Non Traditional Work Practice Authorization ID: ✓ None of the above conditions apply,generate a new form. Revised: 11/13/2013 Page 1 of 1 Massachusetts Department of Environmental Protection eDEP Transaction Copy Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: TCSINC Transaction ID: 929214 Document: AQ 06-Construction/Demolition Notification Size of File: 227.16K Status of Transaction: In Process Date and Time Created: 5/31/2017:12:33:13 PM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page.