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BP-2022-1410 196 COOKE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18-022-001 CITY OF NORTHAMPTON Permit: Demo PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1410 PERMISSION IS HEREBY GRANTED TO: Project# 2022 DEMO LODGE Contractor: License: ASSOCIATED BUILDING Est. Cost: 64000 WRECKERS INC 062382 Const.Class: Exp.Date: 10/31/2023 CITY OF NORTHAMPTON CONSERVATION Use Group: Owner: COMMISSION CITY HALL Lot Size (sq.ft.) Zoning: RI/RR Applicant: ASSOCIATED BUILDING WRECKERS INC Applicant Address Phone: Insurance: 352 ALBANY ST (413)732-3179 WCA154516521 SPRINGFIELD, MA 01105 ISSUED ON: 11/02/2022 TO PERFORM THE FOLLOWING WORK: DEMOLITION OF THE MOOSE LODGE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: tlAk Fees Paid: $ 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner SCE f �' = 7 The Commonwealth of MasSac us®ts E0 Office of Public Safety and Ins ecti., s 2 8 21 ; Massachusetts State Building Code 80 C , : Building Permit Application for any Building other thah_a(Sni'or. , , 1,it Dw ling (This Section For Official Use Only) �1•2'�`�N,r�q Ti NS Building Permit Number:2 .- /'/1 Date Applied: Building Official: _ SECTION 1:LOCATION 7 196 Cooke Avenue Northampton 01060 Smith Voc. &.Ag. High School Bldg E No.and Street City/.T,pwn Zip Code Name of Building(if applicable) 18 -022-001 l a -0 ?,2_ Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or�check all that apply in the two rows below Existing Building Repair 0 Alteration 0 Addition 0 Demolition ® (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Is an Independent Structural Engineering Peer Review required? Yes 0 No Brief Description of Proposed Work Machine demolition of former Moose Lodge structure including slab and foundations. Use water for dust control via tanker. Live load debris onto ABW trailers for disposal at licensed facility. Leave site slant graded with onsite soils. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) see attached 0 0 Total Area(sq.ft.)and Total Height(ft.) property card 0 0 SECTION 5:jYSE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 M A-4 0 A-5 0 B: Business ❑ E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as ap licable) IA 0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB1i IV 0 VA 0 VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supp : Flood Zone Information Sewage Disposal: Trench Permit: Debris Removal: A trench wiel not be Licensed Disposal Site sr Public Check if outside Flood Zone Indicate municipal required NI or trench or specify:USA Recycling Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 120 Old Boston Rd, Wilbi aham Railroad right-of-w Hazards to Air Navigation MA Historic Commission Review Process: Not Applicable 1! Is Structure within airport ap oach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No SiYes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner City of Northampton Planning Department 210 Main Street Northampton, MA 1060 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Nathan Chung 413 _ 587_ 1262 - nchung@northamptonma.gov Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Associated Building Wreckers, Inc. 352 Albany Street Springfield MA 01105 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 1( Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Associated Building Wreckers, Inc. Company Name Andrew Mirkin CS-062382, Type U HIC-169969 Name of Person Responsible for Construction License No. and Type if Applicable 352 Albany Street Springfield MA 01105 Street Address City/Town State Zip 413-732- 3179 - - demo@buildingwreckers .com Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the ' suance of the building permit. Is a signed Affidavit submitted with this application? Yes Eir No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor 64,000.00 and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 69, 000.00 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 69,000.00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. I Andrew Mirkin, Associated Building Wreckers, Inc. President. 413 _732 3179 10/27/2022 Please print and sign name Title Telephone No. Date 352 Albany Street Springfield MA 01105 demo@buildingwreckers.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date City of Northampton '��' \s . ' S C Massachusetts ��?�' �•- << I. ,?�j yy W 4J�f DEPARTMENT OF BUILDING INSPECTIONS S z Y=�' 212 Main Street • Municipal Building 0 �a� 1iv Northampton, MA 01060 rSN1y ;7‘1 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 120 Old Boston Road, Wilbraham, MA The debris will be transported by: Name of Hauler: Associated Building Wreckers, Inc. (/) Signature of Applicant: Ar drew Mirkin, President Date: 10/27/202,2 The Commonwealth of:11assachusetts i r j4r- .--,: Department of Industrial Accidents 1 Congress Street.Suite 100 fl Boston, AMA 02114-201 7 i•j WWW. iass.govidirt IIorkers'('untprnsation Insurance Aftidasit:Builders/('ontractors/Ekctricians!rl'Iuin hers_ SO HE FILE!)N ITII'il1E PERMITTING At''1'IiOIll'I!. Applicant Information Please Print l..eeihh Name(Business fN tnts.iUrm individual): Associated Building Wreckers, Inc. Address: 352 Albany Street City/State/Zip: Springfield, MA 01105 Phone#: (413) 732-3179 Ante rec ce enllpbyeM'Cheek dtr,ppwptrtole htltt: Type of project(required): 1.5(1 am a employ ca with 3 0 employees(tali aad,or part-trope 1" 7. 0 New construction 1.0 I am a sole proprietor or partncrhnp and have no employ ere working tun me in IL odeling ' any capacity (tit,workers'comp.insurance nwutred.l 9. Weinkmolition )0 I am a krnKl"w110 dumy all work in)self ltio u orkarx'comp_I, urance required"" /� n-m 100 Building addition (.F t I am a hinneou and skill b.hiring clnrtr .at9�rr.to conduct all work un no groped). I w ill LJ ensue.that all contractors either ha%.worker'uamrgacnsalrut insurance or an:sole I i.Q Electrical repairs or additions prupri.tur w ith no crnploy.as. 12.0 Plumbing repairs or additions i ant a general contractor and I kite hued the orb-cuntractun listial un the attached xhec1. 130ROOf repairs The sub-contractor hate clnpluy.e.and lute workers'dump.msuraoce.^ 6.0 We are a corporation and its officers hate exercised their nyht of cx.rfrptiun per hfltiL c. la'0011ltt 152 414 41.and we hate no employees.INo workers'cutup.inatnraoce required.' *Any applicant that chocks b.x?I mint also fill out the section below showing their workers'compensation policy infonnatian. Hnmwvrwnem who submit this atualatit indicating they arc dully all work and then hire outside contractor.rnrut xuhmr►a new aItidal.it rfrdicaarnc such 'Contractor that check this box must attached an additional sheet show my the name of the sub-coraractrrx and xtat.w Iretner In not those aortic,hat: anplut'ccx. II the sub-euf trretum%kr4..eitplutiex.tier must pru%ii.then workers'.xnnp-p t iiii. uwuber. l am an employer that is providing w+orAers'compensation insurance"fur my employees. Below is the policy and job site Information. Insurance Company Name: Great Divide Insurance Co. Policy#or Self-ins.Lic.#: WCA1545165-21 Expiration Date: 2/1/2023 ' job Site Address: 196 Cooke Avenue City State `lip: Northampton, MA 01060 Attach a copy of the workers"compensation policy declaration page(showing the policy number and ertpi lion date). Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishable by a fine up to$1,500.00 and'or ane-y• imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up $250.00 a day against iulatur_ 't copy of this statement may be forwarded to the Office of investigations of the DIA fo insurance c'o%4:rage%C a on. 1 do hereby i i,un I the pains and penalties of perjury that the information provided d above is true and correct. *nature: Andrew Mirkin, President Date: 10/27/2022 Pltonr : (413) 732-3179 Official use only. Do not write in this area,to be completed by city or town official t'ity or Town: l'ermit.I.icense 4_ Issuing Authority(circle one): I.Board of llealth 2.Building Department 3.city(loon Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone k: Scope of Work and other Contractor Requirements All work must be completed within 120 days of the contract award and signing.The contract signing shall not start until the Contractor has a valid federal Unique Entity Identifier.The awarded Contractor shall: 1. Comply with all applicable contractor requirements and laws,including but not limited to chapters and sections of Massachusetts General Laws(M.G.L.)included in this list. Full texts of Massachusetts General Laws can be found at https://malegislature.gov/Laws/GeneralLaws. 2. Attend a post-contract, pre-construction conference prior to the demolition arranged by the City.At that time,the Contractor shall be expected to present to the City and its consultants a plan for the execution of every phase of construction. 3. Perform remediation of Asbestos and proper disposal from the building at 196 Cooke Ave in accordance with the Commonwealth's standards and the attached "196 Cooke Ave, Northampton, Massachusetts, Section 02 81 13,Asbestos Abatement" specification.ANY other method of asbestos MUST be approved by the City's asbestos consultant.The City is NOT condemning the building and asbestos must be remediated prior to building demolition. 4. Perform demolition, removal, and proper disposal of the building, its foundation,and its contents at 196 Cooke Ave within 50 feet of the building, including manmade structures, an oil tank,air conditioning units, an ice maker,fixtures,and loose items. Fixtures and loose items include but are not limited to furniture,fluorescent lights, household chemicals, and animal remains. 5. Backfill all foundation holes with clean fill,fill ruts and rough grade all disturbed areas, seed and mulch and ensure a cover crop comes up to stabilize the site. 6. Provide coordination and notice to ensure that the City's asbestos abatement and environmental consultant can monitor and inspect asbestos abatement work and the oil tank removal with inspections as established by the environmental consultant. 7. Comply with all contractor requirements in the attached "Wetland Protection Act Form 2— Determination of Applicability."Contractor requirements include implementing erosion controls and responsible disposal of soil and other materials as specified in Attachment A of Form 2. 8. Obtain all necessary permits: a. Demolition permits(from the Northampton Building Department b. DigSafe approval and City Trench permits-fee waived for City projects c. All other permits, if any,and compliance with all OSHA(Occupational Safety and Health Administration) regulations are the Contractor's responsibility. 9. Pay employees of the Contractor and its subcontractors the state prevailing wage according to the attached prevailing wage schedule per MGL C149 526. 10. Maintain eight-hour work days between 7:00 a.m.and 4:00 pm unless otherwise approved per M.G.L. Chapter 149, Section 34. no laborer,workman, mechanic,foreman or inspector working within the commonwealth, in the employ of the contractor,sub-contractor or other person doing or contracting to do the whole or a part of the work contemplated by the contract,shall be required or permitted to work more than eight hours in any one day or more than forty-eight hours in any one week, or more than six days in any one week, except in cases of emergency 11. Contact all utility companies to ensure compliance with all utility cutoff requirements. Page 3—Request for Bids Application 1 fie C�/lZ�ll '/rll'F'fl 1V C .,' �%Clr%,..)-a rllT%f' �*1 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation ASSOCIATED BUILDING WRECKERS,INC. Registration: 89962 Exxpp 0iration: 8/24/2023 352 ALBANY ST. SPRINGFIELD, MA 01056 11 Update Address and Return Car . SCA 1 0 20M-0511, HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration 0 ice of Consumer Affairs and Business Regulation 169969 08/24/2023 #i# Washington Street -Suite 710 ASSOCIATED BUILDING WRECKERS,INC. .n,MA 0 118 I ANDREW H.MIRKIN. i _ 352 ALBANY ST. ,(r✓7.•R G,/.w/(v.0 SPRINGFIELD,MA 01056 Undersecretary Not Illr without signature Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617)727-3200 or visit www.mass.gov/dpl Commonwealth of Massachusetts ®J Division of Occupational Licensiue Board of Building ``Re ulations and Standards COnstoitilOn S rvisor CS-062382 spires: 10l31/2023 ANDREW H MIRKIN 299 TANGLEWOOD DR LONGMEADOW MA 011 ;•r Commissioner doeK, Du►'fcbut„ THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT DEPARTMENT OF LABOR STANDARDS 19 STANIFORD STREET,BOSTON,MASSACHUSETTS 02114 ASBESTOS CONTRACTOR LICENSE ASSOCIATED BUILDING WRECKERS,INC. 352 ALBANY STREET SPRINGFIELD MA 01105 LICENSE: AC000898 EXPIRES: Friday,August 18,2023 IN ACCORDANCE WITH MGL CH. 149 §6B AND 453 CMR 6.04 THIS CERTIFICATE IS ISSUED BY THE DEPARTMENT OF LABOR STANDARDS TO T CONTRACTOR ABOVE FOR THE PURPOSE OF ENTERING INTO OR ENGAGING IN ASBESTOS WORK. THIS LICENSE IS VALID FOR A PERIOD OF ONE(1)YEAR L FLANAG CTOR • Please detach this mailing tab and keep your license certificate in an accessible location.A copy of this license must be maintained at each worksite. ASSOCIATED BUILDING WRECKERS,INC. 352 ALBANY STREET SPRINGFIELD,MA 01105 10/28/22,8:49 AM Ticket (DIG SAFE SYSTEM, INC - MA) 10/14/2022 13:50:05 -BB -HK11 -MC -WB -WG *** INTERNET TICKET *** RENEWAL ***** REGULAR ***** TIME. .13:50 DATE..10/14/2022 REQUEST NO...20224114161 PREVIOUS REQUEST NO..20223804222 STATE MASSACHUSETTS MUNICIPALITY NORTHAMPTON ADDRES5..196 STREET...COOKE AVE NEAREST CROSS STREET 1..PINES EDGE DR DEMOLITION OF FORMER MOOSE LODGE, INCLUDING SLAB AND FOUNDATION NATURE OF WORK..DEMOLITION EXTENT OF WORK STREET TO BUILDING AREA IS PREMARKED..YES START DATE 10/19/2022 START TIME..14:00 CALLER JOHN JEFFRESS TITLE RETURN CALL PHONE # 413-732-3179 FAX # ALT. PHONE # 800-448-2822 EMAIL ADDRESS DEMO@BUILDINGWRECKERS.COM CONTRACTOR ASSOCIATED BUILDING WRECKERS ADDRESS 352 ALBANY ST CITY SPRINGFIELD STATE MA ZIP 01105 EXCAVATOR DOING WORK..ASSOCIATED BUILDING WRECKERS https://exactix.d igsafe.com/tickets/view/a2dd8644-4be8-11 ed-b9a0-0658baf3b56b#tab2 1/2 10/28/22,8:49 AM Ticket ervlce Area UtilityJypg(5) Contact Alternate Contact Emergeng Coniadt VERIZON TELEPHONE (800)624-9675 *Principal COMCAST-WESTERN CABLE TV USIC LOC MA (800)778-9140 *Principal NATIONAL GRID ELECTRIC USIC LOC ELECTRIC-MASS ELEC (800)778-9140 *Principal BERKSHIRE GAS GAS (800)292-5012 WB HIT GAS LINE NUMBER *Principal (413)445-0286 EVERSOURCE GAS OF GAS (800)688-6160 WG HIT GAS LINE MA NUMBER (800)525-8222 *Principal This Dig Safe ticket expires on: 11/13/2022 There may be non member utilities in the area that you need to notify. Electric and other utilities may not mark lines they don't own or maintain.You may need to hire a private company to locate these lines. The excavator is responsible to maintain marks placed by the member utilities. https://exactix.digsafe.com/tickets/view/a2dd8644-4be8-11 ed-b9a0-0658baf3b56b#tab2 2/2 nationaigrid 55 Bearfoot Rd Northborough MA 01532 Aug 23rd, 2022 RE: Service Removal for Building Demolition 196 COOKE AVE NORTHAMPTON MA To Whom It May Concern, This letter is to confirm that, per your request, National Grid has confirmed the electrical meter# (11030820) and service have been removed from 196 COOKE AVE,NORTHAMPTON, MA The work was processed on work request#30644436. If you have any questions or need further assistance, please feel free to contact Andrea Hache@ 508-691-6552. Sincerely, X. tilist)M&4g/ Andrea Hache Customer Connections Representative MyConnections NE nationaigrid EVERS=URCE October 28, 2022 John Jeffress Demolition Coordinator Associated Building Wreckers, Inc. E-Mail: demo@buildingwreckers.com Re: 196 Cooke Avenue Northampton MA To Whom It May Concern: This is to inform you that there is no Eversource Gas Service at 196 Cooke Avenue Northampton MA. Sincerely, Cynticut,a/2we tcv pp Eric Lent Eversource Gas )Demo Coordinator 0 1e" d co From: Romito, Jeff <Jeff_Romito@comcast.com> Sent: Tuesday, August 23, 2022 8:28 AM To: Demo Coordinator Subject: RE: Demolition Disconnect Request - 196 Cooke Avenue, Northampton, MA All set From: Demo Coordinator<demo@buildingwreckers.com> Sent: Friday, August 19, 2022 4:06 PM To: Romito, Jeff<Jeff_Romito@cable.comcast.com> Subject: [EXTERNAL] Demolition Disconnect Request- 196 Cooke Avenue, Northampton, MA Good afternoon - Attached please find our request to disconnect services at 196 Cooke Avenue in Northampton, MA. The abandoned commercial structure is scheduled for demolition. Thank you in advance for your help. John Jeffress Demolition Coordinato Associated Building Wreckers, Inc. (413)732-3179 www.buildingwreckers.com A:. ASSOClALCO hem owe iau cilia' Confidential(C) 1 verizoni NYS-NE OSP CENTER 1-866-686-1195 NYS-NE.OSP.CENTER@VERIZON.COM TO: Associated Building Wreckers, Inc. Date: 8/24/2022 RE: Facility Removal for Demolition This Letter confirms that Verizon's facilities have been disconnected and removed from the address below. 196 Cooke Avenue, Northampton, Ma Thank you, Tyrell, Ralph Patrick OSP Engineer Associated Building Wreckers, Inc. 352 Albany Street,Springfield,Massachusetts 01105 Tel:(413)732-3179/(800)448-2822 Fax:(413)734-6224 www.buildingwreckers.com AA/EOE MUNICIPAL WORK INSPECTION SIGNOFF SHEET 1616 coo o AVL M 6 o_ cb1= (address/location) MUNICIPAL WATER / SANITARY SERVICE DISCONNECTION HAS BEEN �t�►�.. (circle one) INSPECTED AND APPROVED ON I 0—Za —Z4) ZZ (2� (date) BY: w''IL1 J), 4 (print na/lie) SIGNATURE: PHONE#: �17 - s y} - I S 3() n Cf;`t (please indicate mobile or office) REMARKS, IF ANY: �(AT SCfon �; i> i/ver WAS CfccI, in ac,Vt.w^y e oxi ILO -771 ffUN\ N:\DEMO\Disconnects\Water-Sewer-Inspect ion-S ignoff.docx Associated Building Wreckers, Inc. 352 Albany Street,Springfield,Massachusetts 01105 Tel:(413)732-3179/(800)448-2822 Fax:(413)734-6224 www.buildingwreckers.com AA/EOE MUNICIPAL WORK INSPECTION SIGNOFF SHEET :mot:( 4'1 *Yv' to (dress/location) MUNICIPAL WATER / SANITARY SERVICE DISCONNECTION HAS BEEN (circle one) �7 INSPECTED AND APPROVED ON I 0 ' Z (date) BY: ) -e i h S✓1stp{ (print name) SIGNATURE: 1)\)(3 PHONE#: ")3-S 7- /0 8 (please indicate mobile or office) REMARKS, IF ANY: der be(cr 5,1()Ir e er G4 &l t 1 v a(kVe-1-42/. �� N:\DEMO`,Disconnects'W ater-Se«er-Inspect ion-Signoff.doc x O' Reilly,Talbot & Okun i- NGINEER ING ASSOCIATES October 14, 2022 J285-39-03 Mr. Nathan Chung, Grants Administrator Office of Planning & Sustainability City of Northampton 210 Main Street Northampton, Massachusetts Re: Asbestos Abatement Clearance Documentation Former Moose Lodge 196 Cooke Avenue Northampton, Massachusetts Dear Mr. Chung, Please find attached visual clearance inspection forms and final air monitoring report for asbestos abatement activities conducted October 2022 at the above- referenced address. The abatement of resilient flooring materials (asbestos containing sheet flooring, tile, and associated mastics) in top floor areas was performed using the full containment removal methodology by Baystate Contracting Services, Inc. The regulated area was cleaned using HEPA vacuums and wet methods. The negative pressure enclosure was inspected and found to be free of visual debris. The final visual inspection and associated post air sample results for the area were below established regulatory limits. The abatement of asbestos roofing and exterior caulking was performed in an established regulated area according to MassDEP methodologies. The regulated areas were cleaned using HEPA vacuums and wet methods; regulated areas were inspected and found to be free of visual debris. Thank you once again for the opportunity of providing these industrial hygiene services to the City of Northampton. Please do not hesitate to call should you have any questions. Sincerely, O'Reilly, Talbot & Okun Associates, Inc. 014,..u,e,,s, 464, Andrew P. Rolinger Sr. Project Manager Attachment: Limitations, Visual Clearance Forms, PCM Laboratory Results 293 Bridge Street Suite 500 Springfield MA 01 103 I 413.788.6222 I www.OTO-ENV.com LIMITATIONS 1. The observations presented in this report were made under the conditions described herein. The conclusions presented in this report were based solely upon the services described in the report and not on scientific tasks or procedures beyond the scope of the project or the time and budgetary constraints imposed by the client. The work described in this report was carried out in accordance with the contract Terms and Conditions. 2. In preparing the report O'Reilly, Talbot, Okun & Associates, Inc. relied on certain information provided by state and local officials and other parties referenced herein, and on information contained in the files of state or local regulatory agencies at the time of the file review. Although there may have been some degree of overlap in the information provided by these sources, O'Reilly, Talbot, Okun & Associates, Inc. did not attempt to independently verify the accuracy or completeness of all information reviewed or received during the course of this assessment. 3. Observations were made of the site and of the structures on the site as indicated within the report. Where access to portions of the site or to structures on the site was unavailable or limited, we render no opinion as to the presence of asbestos containing materials, lead based paint, or hazardous, or to the presence of indirect information relating to asbestos containing, lead based paint, or hazardous materials in that portion of the site. In addition, we render no opinion as to the presence of asbestos containing, lead based paint, or hazardous materials, where direct observations of portions of the site where obstructed by objects or coverings on or over these surfaces. 4. Unless otherwise specified in the Report, we did not perform testing or analyses to determine the presence or concentration of additional potential hazardous materials, oil, or polychlorinated biphenyls (PCBs) at the site or in the environment at the site. 5. Our report was prepared for the exclusive benefit of our client. Reliance upon the report and its conclusions is not made to third parties or future property owners. 2 O'Reilly,Talbot & Okun // O'REILLY,TALBOT&OKUN ASSOCIATES 293 BRIDGE STREET SUITE 500 SPRINGFIELD, MA 01103 413-788-6222 Asbestos Abatement Visual Clearance Inspection Project Number: OZ B S ' 3 9 - 03 (. // Site Surveyed: t c. m-wr /vID�S-G- C�o Project Name: G� Address 1 / (0 Cooke. 4ti-c iwL/ /VOi +awtioJ),1/ /4 0/06O Location of Containment: -1 0 p 1 oar Date Inspected: IO /3- l 2- L Asbestos Abatement Contractor: DA y r/' 74_ C€ 4" /✓►5 c v;_e_ J Asbestos Supervisor: RI,-Ai ,S 11- r+, , Visual Clearance Result (circle one): (--Pas ) Fall Reason for Failure: Description of Asbestos Abatement /L -,1.c in / Or '- / 5 0 0 Sg . F�- The above asbestos abatement regulated area has been visually inspected by the asbestos abat- i ent supervisor and asbestos abatement project monitor. The regula -d - : wa dr and all surfaces were free of visible debris. Asbestos Supe isor LS # Asbestos Project Monitor/ DLS # Phase Contrast Microscopy(PCM) Fiber Count NIOSH 7400 Method, Revision 3, Issue 2, 8/15/94 PROJECT NO: 0285-39-03 PROJECT: Former Moose Lodge CLIENT: City of Northampton, Office of Planning & Sustainability 196 Cooke Avenue ADDRESS: 210 Main Street Northampton, MA 01060 Northampton, Massachusetts ATTN: Mr. Nathan Chung, Grants Administrator Date: 10/7/22 Scope: —1500 Sq. Ft of Flooring PHONE: FAX: Sample ID Location Sample Date # # Volume Fiberslm Fibers/cc= LOD (less than) Fibers Fields (L) m2=E C ACR-10072022-01 Top Floor Containment 10/7/2022 8 100 1200 10.19 0.003 0.004 ACR-10072022-02 Top Floor Containment 10/7/2022 9 100 1200 11.46 0.004 0.004 ACR-10072022-03 Top Floor Containment 10/7/2022 13 100 1200 16.56 0.005 0.004 ACR-10072022-04 Top Floor Containment 10/7/2022 13.5 100 1200 17.20 0.006 0.004 ACR-10072022-05 Blank 10/7/2022 0 100 ACR-10072022-01 10% Recount 10/7/2022 7.5 100 1200 9.55 0.003 0.004 QC Checks: ACR Analyst Name: Alec Robinson Analyst Signature: AP---- __....-- O'Reilly,Talbot&Okun Associates,Inc. - 293 Bridge Street,Suite 500 - Springfield,MA 01103 Phone: (413)788-6222 - Fax(413)788-8830 O'REILLY,TALBOT&OKUN ASSOCIATES 293 BRIDGE STREET SUITE 500 SPRINGFIELD, MA 01103 413-788-6222 Asbestos Abatement Visual Clearance Inspection Project Number: Qz$ S -- 3 9 - 0 3 Site Surveyed: )-o,-v-u-e- JlooSe, Zoc-i `, �.- Project Name: d Address 19 Le COOK4— ,4✓t,,,A.v 1 JVc,-.4 LEA rn p 4'o' i , ./14/4- Location of G t: (X f t„r.•nor" Are A.. Date Inspected: i b i)Z/Z 2- Asbestos Abatement Contractor: gv�s 14 /c 6:Z41 1r-01- (PI � r '�S e- v I c I J Asbestos Supervisor: � v.•dy JG ti A.-, . Visual Clearance Result (circle one): Pass Fail Reason for Failure: Description of fAsbestos Abatement Z,4 K.LC� U(/-OG44-r tl 1140) r‘ G. /S Olvl of 611;w►".e.y G41-t.Xi1 The above asbestos abatement regulated area has been visually inspected by the asbestos abatement supervisor and asbestos abatement project monitor. The ted area was dry and all surfaces were free of visible debris. _____VC /,t,, c £Q1r..^ico./4yi, 10�7-.9 Asbestos Supervisor/ DLS # Asbestos Project Monitor/ DLS # 1 L Massachusetts Department of Environmental Protection 100371925R4 BWP AQ (ANF— Asbestos Project# Project Revision04 Notification001) w Project Revision Project Cancellation A. Asbestos Abatement Description 1.Facility Location: FORMER MOOSE LODGE` 196 COOKS AVENUE Instructions 1.All a.Name of Facility b.Street Address sections of this form NOR11-W FTON must be completed in MA 01060 4135871262 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification NA.TMAN CHUNG GRANTS ADMINISTRATOR requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: MOOSE LODGE Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2.Blanket Permit Project Approval,if applicable: CMR 6.12 Approval ID# 3.Non-Traditional Asbestos Abatement Work Practice Approval, MessDEP use ' if applicable: Approval ID# Date Received 9/29/2022 10/12/2022 , a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7:OOAM-3:30PM N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday B. Other Project Revisions: Note:Temporary storage of Asbestos containing waste material is only allowed at the place of business of a DLS licensed Asbestos contractor or a transfer station that is permitted by MassDEP and operated In compliance with Solid Waste Regulations 310 CMR 19.000 Note:Contractor must sign this form for DLS notification purposes Revised: 11/13/2013 Page 1 of 2 Massachusetts Department of Environmental Protection 100371925R4 BWP AQ 04 (ANF-001) Asbestos Project# {1 Project Revision Notification }, (.7 Project Revision r Project Cancellation C. Certification JAMES BEAUDRY JAMES BEAUDRY "I certify that I have personally P Y 1.Name 2.Authorized Signature examined the foregoing and am PROJECT MANAGER 10/7/2022 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 4137323179 ASSOCIATED BUILDINGtRECxERS I on my inquiry of those 5.Telephone 6.Representing individuals immediately 352 ALBANY STREET SPRINGFIELD responsible for obtainingthe P 7.Address B.City/Town information, I believe that the MA 01105 information is true,accurate,and complete. I am aware that there 9.State 10.2ip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 2 of 2 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: BAYSTATEI Transaction ID: 1435868 Document: AQ 04-Asbestos Removal Notification Form ANF-001 Size of File: 225.37K Status of Transaction: In Process Date and Time Created: 10/7/2022:8:09:30 AM 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. ILL ---wi Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) PreForm j Asbestos Notification Form i P This is a revision to an existing foram. Project ID for existing form to be revised: 100371925 r 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: r This job does not require the use of an asbestos contractor licensed by the MA Department of Labor Standards because(please check one box below): r This job involves breaking,shearing or slicing ofnon-friable asbestos-containing material only(e.g.cement shingles/panels,cement pipe,asphalt roofing or siding,vinyl floor tiles,etc.)in a manner that does not generate asbestos dust or render the material friable,as allowed by the Department of Labor Standards(DLS)at 453 CMR 6.13(2Xa)5.All work must be done in compliance with the applicable regulations at 310 CMR 7.15;or r This job involves work on asbestos containing material that is classified by the Department of Labor Standards (DLS)as a`Small-Scale Asbestos Project,' an`Asbestos-Associated Project',or an`Asbestos Response Action' by qualified`in-house'personnel as allowed by the Department of Labor Standards(DLS)at 453 CMR 6.00,and will be performed in accordance with all the requirements of 453 CMR 6.13(1)(a),453 CMR 6.13(2)(a)1.and 3., and 453 CMR 6.14(1)(a),as applicable.All work must be done in compliance with the applicable regulations at 310 CMR 7.15. ✓ None of the above conditions apply,generate a new form. Revised: 11/13/2013 P.:e 1 of 1 1 MassDEP Home I Con act I Privacy Policy MassDEP's Online Filing System Usvmame• STATE' Nldmame:BAYSTATE CO TINE GM Receipt Forms §ign ure Receieipt Summary/Receipt print Ipt 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: 1435868 Date and Time Submitted: 10/7/2022 8:07:18 AM Other Email : DEP Transaction ID: 1435868 Date and Time Submitted: 10/7/2022 8:07:18 AM Other Email : Form Name: AQ 04 - Asbestos Removal Notification Form ANF-001 Form Name: AQ 04 - Asbestos Removal Notification Form ANF-001 Payment Information DEP code Date Amount($) Billing Info My eDEP MassDEP Home I Con .ct I Privacy Policy MassDEP's Online Filing System ver.15.22.2.0©07/15/2022 MassDEP 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: DEMOCOORD Transaction ID: 1423965 Document: AO 04 - Asbestos Removal Notification Form ANF-001 Size of File: 231.03K Status of Transaction: In Process Date and Time Created: 8/29/2022:4:50:03 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. Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) PreForm Asbestos Notification Form f This is a revision to an existing form. Project ID for existing form to be revised: r This job is being conducted under a Blanket Permit. MassDEP assigned Blanket Authorization ID: r This job is being conducted under a Non Traditional Abatement Work Practice Permit. MassDEP assigned Non Traditional Work Practice Authorization ID: r This job does not require the use of an asbestos contractor licensed by the MA Department of Labor Standards because(please check one box below): r This job involves breaking,shearing or slicing of non-friable asbestos-containing material only(e.g.c- ent shingles/panels,cement pipe,asphalt roofing or siding,vinyl floor tiles,etc.)in a manner that does not generate asbestos dust or render the material friable,as allowed by the Department of Labor Standards(DLS at 453 CMR 6.13(2)(a)5.All work must be done in compliance with the applicable regulations at 310 CMR 7.15;or r This job involves work on asbestos containing material that is classified by the Department of Labor '.tandards (DLS)as a `Small-Scale Asbestos Project,' an`Asbestos-Associated Project',or an`Asbestos Res onse Action' by qualified`in-house'personnel as allowed by the Department of Labor Standards(DLS)at 453 C ' 6.00,and will be performed in accordance with all the requirements of 453 CMR 6.13(1)(a),453 CMR 6.13 2)(a)1.and 3., and 453 CMR 6.14(1)(a),as applicable. All work must be done in compliance with the applicable :gulations at 310 CMR 7.15. Ig None of the above conditions apply,generate a new form. Revised: 11/13/2013 Wage 1 of 1 Massachusetts Department of Environmental Protection 100371925 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision f— Cancellation A. Asbestos Abatement Description 1.Facility Location: FORMER MOOSE LODGE 196 COOKE AVENUE Instructions 1.All a.Name of Facility b.Street Address sections of this form NORTHAMPTON MA 01060 4135871262 must be completed in order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification NATHAN CHUNG GRANTS ADMINISTRATOR requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: MOOSE LODGE Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? r a.Yes P b.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? r a.Yes r b.No MassDEP Use Only 4. Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# 6.Asbestos Contractor: ASSOCIATED BUILDING WRECKERS INC 352 ALBANY STREET a.Name b.Address SPRINGFIELD MA 01105 4137323179 c.City/Town d.State e.Zip Code f.Telephone AC000898 h.Contract Type: P 1.Written r 2.Verbal g.DLS License# JAMES BEAUDRY AS074322 7. a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# ANDY ROLINGER AM000114 8. a.Name of Project Monitor b.DLS Certification# 9 O'REILLY TALBOT&OKUN ASSOCIATES INC AA000089 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 9/12/2022 9/26/2022 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7:OOAM-3:30PM N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11. What type of project is this? r a.Demolition E b.Renovation f c.Repair f d. Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection 100371925 !Lel BWP AQ 04 (ANF-001) Asbestos P Project# Asbestos Notification Form r- Project Revision r Project Cancellation A.Asbestos Abatement Description: (cont.) 12. Abatement procedures(check all that apply): — a.Glove Bag r b.Encapsulation r c.Enclosure F d.Disposal Only r e.Cleanup f Full Containment r g.Other-Please Specify: 13.Job is being conducted: Pi a. Indoors P b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 50 3100 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j. Insulating Cement 50 ASPHALTIC ROOF,LINOFLOOR 3100 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: REMOTE AND CONTIGUOUS 3 STAGE DECON UNIT WITH TEMPERED WATER AND FILTRATION 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CM' 6.14(2) (g): THOROUGHLY WETTED,DOUBLE BAGGED,LABELED AND DISPOSED OF PROPERLY 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the e ergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18. Do prevailing wage rates as per M.G.L.c. 149, § 26,27 or 27A—F apply to this 17 a.Yes r b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection 100371925 L BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r- Project Revision I— Project Cancellation B. Facility Description I. Current or prior use of facility: FORMER MOOSE LODGE 2. Is the facility owner-occupied residential with 4 units or less? 1- a.Yes i✓ b. No 3 CITY OF NORTHAMPTON 210 MAIN STREET a.Facility Owner Name b.Address NORTHAMPTON MA 01060 4135871262 c.City/Town d.State e.Zip Code f.Telephone 4 NATHAN CHUNG 210 MAIN STREET a.Name of Facility Owner's On-Site Manager b.Address NORTHAMPTON MA 01060 4135871262 c.City/Town d.State e.Zip Code f.Telephone 5 ASSOCIATED BUILDING WRECKERS INC 352 ALBANY STREET a.Name of General Contractor b.Address SPRINGFIELD MA 01105 4137323179 c.City/Town d.State e.Zip Code f.Telephone GREAT DIVIDE INSURANCE CO. g.Contractor's Worker's Compensation Insurer WCA1545165-21 2/1/2023 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 3800 2 a.Square Feet b.#of Floors Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal containing waste 1.Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place f— a. Directly to Landfill or f•70' b.To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer ASSOCIATED BUILDING WRECKERS,INC. 352 ALBANY STREET station that is c.Name of Transporter d.Address permitted by MassDEP and SPRINGFIELD MA 01105 4137323179 operated in e.City/Town f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 CMR 19.000 2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: RED TECHNOLOGIES LLC 173 PICKERING STREET a.Name of Transporter b.Address PORTLAND CT 06480 8603421022 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100371925 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form Project Revision r Project Cancellation C. Asbestos Transportation& Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TRANSFER&LOGISTICS 173 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND Cr 06480 8603421022 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA ENTERPRISES a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification ANDREW MIRKIN ANDREW MIRKIN "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 8/29/2022 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 4137323179 ASSOCIATED BUILDING WRECKERS,I on my inquiry of those 5.Telephone 6.Representing individuals immediately 352 ALBANY STREET SPRINGFIELD responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 01105 information is true,accurate,and complete. I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 -"'" ASSOBUI-01 DKELLEY ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �.r 8/8/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC TE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Denise Kelley,CISR AssuredPartners New England,Inc. PHONE FAX One Monarch Place, 12th Flr (A/c,No,Ext):(413)327-7517 (AIC,Np):(413)327-7517 Springfield, MA 01144 Ao RESS:Denise.Kelley@AssuredPartners.com INSURER(S)AFFORDING COVERAGE NAIC M INSURER A:Nautilus Insurance Company _ 17370 INSURED INSURER B:Great Divide Ins.Co. 25224 Associated Building Wreckers,Inc. INSURER C: 352 Albany Street INSURER D: Springfield,MA 01105 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEG TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR W INSD VD (MM/DDIYYYY1 (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCURECP2031158-12 2/1/2022 2/1/2023 DAMAGETORENTED 100,000 . X x PREMISES(Ea occurrencel, $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X S& LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) _. ANY AUTO BODILY INJURY(Per person) $_ _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ - �N-OW E PROPERTY DAMAGE — HIREDS ONLY AUTOS ONLYY (Per acciden $_ $ A — UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAR CLAIMS-MADE X X FFX2036791-10 2/1/2022 2/1/2023 AGGREGATE $ 5,000,000 DED RETENTION$ $ B WORKERS COMPENSATION X STATUTE OT H- AND EMPLOYERS'LIABILITY WCA1545165-21 2/1/2022 2/1/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N NIA 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below _ E L.DISEASE-POLICY LIMIT $ A Pollution Liability x x ECP2031158-12 2/1/2022 2/1/2023 See Description Box DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Pollution Liability Limit: Limit Per Occurrence;$1,000,000: Limit Aggregate;$3,000,000 Please be advised the below listed certificate holder is listed as Additional Insured on a Primary and Non-Contributory basis in regards to the General (Liability,Pollution Liability,Umbrella(Excess)Liability,and Workers Compensation policies listed above when being required by written contract.Waiver of (Subrogation in favor of certificate holder for all above listed policies. Umbrella(Excess)Policy is written on a follow form basis over the above listed General Liability,Pollution Liability,Employers Liability(Workers Compensation),and the Auto Liability with Commerce Insurance,Policy#19MMZP4610. Demolition of structures at 196 Cooke Ave,Northampton,MA and asbestos and other hazardous material remediation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE .1 ife.41.1:I i ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A DATE(MM DDYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/8/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Dowd Agencies, LLC PHONE _ - FAX 14 Bobala Road (A/C.No.Eat).413-538-7444 (A/C,No): E-MAIL Holyoke MA 01040 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Commerce Insurance Company 34754 INSURED INSURER B: Associated Building Wreckers, Inc. 352 Albany Street INSURER C: Springfield MA 01105 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:484090964 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDINSD TYPE OF INSURANCE WVD SUER POLICY EFF POLICY EXP LTR POLICY NUMBER (MM/DD/YYYY) IMM DD/YYYY) LIMITS , INSD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ _ _ CLAIMS-MADE L OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ _ OTHER: $ A AUTOMOBILE LIABILITY ZP4610 4/22/2022 4/22/2023 COMaccident)BINED SINGLE LIMIT $1,000,000 {Ea X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached it more space is required) Demolition of structures at 196 Cooke Ave, Northampton, MA and asbestos and other hazardous material remediation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton 210 Main Street AUTHORIZED REPRESENTATIVE Northampton MA 01060 944) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Environmental Protection 100372115 BWP AQ 0 ^, _, Notification Prior6 to Construction or Demolition Asbestos Project # r Project Revision 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)? P a.Yes r b.No 2.Blanket Permit Project Approval,if applicable: Approval ID# 3. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# Instructions: B. Facility Description 1.All sections of this form must be 1. Facility Information: completed in order to FORMER MOOSE LODGE 196 COOKE AVENUE comply with the Department of a.Name of facility b.Street Address Environmental NORTHAMPTON MA 010600000 4135871262 Protection c.City/Town d.State e.Zip Code f.Telephone notification requirements of 310 NATHAN CHUNG GRANTS ADMINISTRATOR CMR 7.09. g.Facility Contact Person h.Facility Contact Person Title 4135871262 NCHUNG@NORTHAMPTONMA.GOV i.Facility Contact Person Telephone j.Facility Contact Person Email MassDEP Use Only k.Facility Size: Date Received 1594 2 1.Square Feet 2.Number of Floors 17 I.Was the facility built prior to 1980? 1.Yes 2.No m.Describe the current or prior use of the facility: MOOSE LODGE n. Is the facility a residential facility? r 1.Yes r 2.No o. If yes,how many units? 2. Facility Owner: 1- Same address as Facility CITY OF NORTHAMPTON 210 MAIN STREET a.Facility Owner Name b.Address NORTHAMPTON MA 010600000 4135871262 c.City/Town d.State e.Zip Code f.Telephone 3. Facility On-Site Manager/Owner Representative: P Same contact person as facility 1- Same address as facility P Same address as owner NATHAN CHUNG 210 MAIN STREET a.On-Site Manager/Owner Representative b.Address Northampton MA 01060 4135871262 c.City/Town d.State e.Zip Code f.Telephone Revised:03/17/2014 Page 1 of 3 Massachusetts Department of Environmental Protection 100372115 BWP AQ 06 Asbestos Project # ` Notification Prior to Construction or Demolition 1— Project Revision ti i— Project Cancellation C. General Project Description 1. This project is: r New Construction P Demolition r Renovation 2. Project Dates: 9/26/2022 3/26/2023 a.Project Start Date(MM/DD/YYYY) b.Project End Date(MM/DD/YYYY) 3. General Contractor: ASSOCIATED BUILDING WRECKERS,INC. 352 ALBANY STREET a.Name b.Address SPRINGFIELD MA 011050000 4137323179 c.City/Town d.State e.Zip Code f.Telephone WILLIAM BABCOCK 4137323179 g.General Contractor's On-site Manager/Foreman h.Telephone 4. Construction or demolition contractor: W Same as General Contractor ASSOCIATED BUILDING WRECKERS,INC. 352 ALBANY STREET a.Contractor Name b.Address SPRINGFIELD MA 011050000 4137323179 c.City/Town d.State e.Zip Code f.Telephone WILLIAM BABCOCK 4137323179 g.Construction and Demolition On-site Manager h.Telephone 5. Licensed Construction Supervisor: ANDREW MIRKIN CS-062382 a.Supervisor Name b.Construction Supervisor License(CSL)Number 17 6. Is the entire facility to be demolished? a.Yes ti b.No 7. Describe the area(s)to be demolished: THE ENTIRE STRUCTURE INCLUDING SLAB AND FOUNDIONS 8. Describe the building(s)or addition(s)to be constructed: 9 a. Were the structure(s) surveyed for the presence of Asbestos-Containing 1%-• 1.Yes r 2.No Material(ACM)? b. Who conducted the survey? ANDREW ROLINGER A1000025 1.Name of Asbestos Inspector 2.DLS Certification# Massachusetts Department of Environmental Protection 100372115 �� BWP AQ 06 Asbestos Project # '�'� Notification Prior to Construction or Demolition �� )— Project Revision I— Project Cancellation C. General Project Description (continued) 10 a. Was asbestos containing material (ACM)found? I 1.Yes r 2.No General b. If ACM was found during the survey,please provide the Asbestos 100371925 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 r a. Seeding b. Wetting r c.Coveringr d. Paving r e. Shrouding responsible parties must comply with 310 r f.Other-Specify: CMR 7.00,7.09,7.15, and Chapter 21E of the General Laws of 12. Is this an Emergency Demolition Operation? r a.Yes r b.No the Commonwealth. This would include, but would not be c.Name of MassDEP Official who evaluated the emergency limited to,filing an asbestos removal notification with the d.Title Department and/or a notice of release/threat of e. Date of Authorization(MM/DD/YYYY) f.MassDEP Waiver Number release of a hazardous D. Certification substance to the Department,if "I certify that I have personally ANDREW MIRKIN applicable. examined the foregoing and am 1.Print Name familiar with the information ANDREW MIRKIN contained in this document and 2.Authorized Signature all attachments and that, based PRESIDENT on my inquiry of those individuals immediately 3.Position/Title responsible for obtaining the ASSOCIATED BUILDING WRECKERS,INC. information, I believe that the 4.Representing information is true, accurate, and 9/1/2022 complete. I am aware that there 5.Date(MM/DD/YYYY) are significant penalties for submitting false information, including possible fines and 6.P.E.# 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 of 3 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: DEMOCOORD Transaction ID: 1424900 Document: AQ 06 - Construction/Demolition Notification Size of File: 223.10K Status of Transaction: In Process Date and Time Created: 9/1/2022:7:45:21 AM 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. Massachusetts Department of Environmental Protection mil. ` � BWP AQ 06 Pre-Form i Notification Prior to Construction or Demolition t ✓ 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: 1 ✓ This job is being conducted under a Non Traditional Abatement Work Practice Permit. MassDEP assigned Non Traditional Work Practice Authorization ID: 1 17 None of the above conditions apply,generate a new form. 9/1/22, 7:41 AM eDEP-MassDEP's OnlineFiling System MassDEP Home I Contact I Privacy Policy ,51212 MassDEP's Online Filing System ` Username:DEM000ORD Nickname:DEMO1 Loa OFF My eDEP! Forms i My Profile ( Help I Notifications Receipt Forms Signature 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: 1424900 Date and Time Submitted: 9/1/2022 7:41:43 AM Other Email : DEP Transaction ID: 1424900 Date and Time Submitted: 9/1/2022 7:41:43 AM Other Email : Form Name: AQ 06 - Construction/Demolition Notification Form Name: AQ 06 - Construction/Demolition Notification Payment Information DEP code Date Amount ($) Payment Detail My eDEP MassDEP Home I Contact I Privacy Policy MassDEP's Online Filing System ver.15.22.2.0© 07/15/2022 MassDEP https://edep.dep.mass.gov/eDEP/Pages/PrintReceipt.aspx 1/1 t y I e r COMMERCIAL PROPERTY RECORD CARD 2023 NORTHAMPTON citdivis on I Situs: 196 COOKE AVE Map ID: 18-022-001 Class:Vacant,Conservation Card: 1 of 1 Printed:September 1,2022 r CITY OF NORTHAMPTON Living Units PLANNING DEPARTMENT Neighborhood 15 210 MAIN ST Alternate Id — NORTHAMPTON MA 01060 Vol/Pg 20/70 . v _ .. District , r ,rl Zoning :4- ' Class COMMERCIAL ; 4 s., • Assessment ligbrmation `*,-— .., ... > Type Size Influence Factors Influence% Value Assessed Appraised Cost Income Market Prime Site AC 1.0000 121,750 Land 139,400 139,400 139,400 0 0 Undeveloped AC 2.0700 Topography -30 17,680 Building 102,900 102,900 102,900 0 0 Total 242,300 242,300 242,300 0 0 Manual Override Reason Base Date of Value Value Flag COST APPROACH Effective Date of Value Total Acres:3.07 Gross Building: Spot: Location: Date ID Entry Code Source Date Issued Number Price Purpose %Complete 04/09/21 JA Not At Home Other 01/29/03 FS Entry&Sign Other Transfer Date Price Type Validity Deed Reference Deed Type Grantee 05/05/22 100,000 Land+Bldg To/From Government LC24/3 Warranty Deed CITY OF NORTHAMPTON 12/19/07 165,000 Bldg Only To/From Exempt Org 20/70 CITY OF NORTHAMPTON Inspection Witnessed By t y l e r COMMERCIAL PROPERTY RECORD CARD 2023 NORTHAMPTON cli division Situs: 196 COOKE AVE Parcel Id:18-022-001 Class:Vacant,Conservation Card:1 of 1 Printed:September 1,2022 11. Building Inf Year Built/Eff Year 1900 / Line Type +l- Mead Meas2 #Stops (dent Units Line Type +l- Meas1 Meas2 #Stops [dent Units Building# 1 1 Wood Deck 32 1 1 Structure Type Social/Fraternal Ha0 1 Utility Bldg-Frame 36 1 1 Identical Units 1 Total Units Grade D #Covered Parking #Uncovered Parking DBA MOOSE LODGE L 614 . tor"or/Exterior info n ' Line Level From-To Int Fin Area Perim Use Type Wall Height Ext Walls Construction Partitions Heating Cooling Plumbing Physical Functional 1 B1 B1 100 1,676 178 Social/Fratemal H: 8 None Wood Frame/Joist/B Normal Hot Air Central Normal 1 1 2 01 01 100 1,772 194 Social/Fraternal H: 10 Frame Wood Frame/Joist/B Normal Hot Air Central Normal 2 2 -- Outbuilding Data . Line Area Use Type %Good %Complete Use Value/RCNLD Line Type Yr Bit Meas1 Meas2 Qty Area Grade Ph y Fun Value 1 1,676 Social/Fraternal Hall 32 35,260 2 1,772 Social/Fraternal Hall 47 67,680 t y I e r COMMERCIAL PROPERTY RECORD CARD 2023 NORTHAMPTON Situs : 196 COOKE AVE j Parcel Id: 18-022-001 Class:Vacant,Conservation Card: 1 of 1 Printed:September 1,2022 34 ID Coe1e Description Area A VE1 tslE 1428 B VBt 103 248 __CV51 13 C '✓C8 SHED 36 E Nh'1 WOK 32 F 064 SOCIAL+FRATERNAL MALL 1676• G 064 SOCIALIFRATERNAL HALL 1772• H WDt WOOD DECK 32• I RS1 UTILITY BLDG-FRAME 36" 42 42 1D 4 3 20 E 13 12 4 c d` 12 Addtional Property Photos t y l e r COMMERCIAL PROPERTY RECORD CARD 2023 NORTHAMPTON elt division Situs:196 COOKE AVE Parcel Id: 18-022-001 Class:Vacant,Conservation Card:1 of 1 1 Printed:September 1,2022 RIP - INSINP— Income Detail(Includes all Buildings on Parcel) Use Mod Inc Model Units Net Area Income Econ Potential Vac Vac Additional Effective Expense Expense pense •' er • F. Grp Type Mod Description Rate Adjust Gross Model Adj Income Gross Model% Adj% Adj Expenses Expenses Operating Income Income Income 16 S Restaurant 0 2,945 55 0 ,,ciiiii maiiiiApartm�it Detail 1 of 1MIME Building Cost Building 1 Line Use Type Per Bldg Beds Baths Units Rent Income Total Gross Building Area 3,448 Replace, Cost New Less Depr 102,940 Percent Complete 100 Number of Identical Units 1 Economic Condition Factor Final Building Value 102,940 Value per SF 29.85 N uildfa5 1 of 1 Income Summary(Includes all Building on Parcel) PREVIOUSLY FOR SALE-CY2016 Total Net Income LISTING PRICE UNAVAILABLE Capitalization Rate 0.000000 Sub total Residual Land Value Final Income Value Total Gross Rent Area 3,448 Total Gross Building Area 3,448 Planning & Sustainability . City of Northampton planning I resiliency I conservation I place-making I sustainable transportation I zoning I GIS I historic I CB architecture I agricultwre and food 413-587-1262 NORTHAMPTON HISTORICAL COMMISSION DEMOLITION REVIEW ACTION Property: 196 Cooke Ave / Moose Lodge Map 18 Parcel 22 Year Built 1900(?) Address: 196 Cooke Ave Received in Building Department: May 13, 2022 Referred from Building Department: May 18, 2021 Action Taken Action Taken By: Entire Commission _X_ Sub-Committee of the Commission Commission Designee/ Staff Date Action Taken: May 25, 2022 Significance Determination NA Public Meeting held NA Public Hearing Held Determination Made: X Property has been determined not to be Significant according to Ordinance definition. No further action will be taken. Demolition Permit may be issued. Property has been determined to be Significant according to the Ordinance definition and a Public Hearing has been/will be scheduled. Demolition Permit may not be issued at this time. Public Hearing has been held, Property was determined Significant but not Preferably Preserved.iNo further action will be taken/ Demolition Permit may be issued. Photo documentation may be required. ii ,.sMR CITY of NORTHAMPTON 9 `�'T�'ti .'' •-;)� PUBLIC HEAL TH DEPARTMENT r r� ��� Public Health Director-Merridith O'Learv.RS .�`k� i Municipal Building-212 Main Street-Northampton,MA 01060 • y Phone(413)587-1214-Fax(413)587-1221 ��Ll�v,.,��,h =s" � ii7 http://www.nnrthamptatma.gnv/245/Health Prevent.Promote.Protect. WITNESS OF EXTERMINATION Date 1,0(c�-5/ Time g ;aR AM Property Owner: City of Northampton Property Address: 196 Cooke Ave, Northampton, MA 01060 Exterminator: J O-.GOb Mee L t C- A - 5 bo-)5 6 Company: Braman Termite& Pest Elimination Company Address: 147 Herbert P Almgren Drive,Agawam, MA 01001 A Rodenticide/Chemicals Applied CO N ro-c A li -We o- er @`o x E t",/�A * +.3-9 55-79 Reason for Extermination: Demolition of former Moose Lodge structure Comments: Demolition will be performed by Associated Building Wreckers, Inc. of Springfield-call them at (413)732-3179 with any questions. I hereby certify, under the pains and penalties of perjury,that Ito the best of my knowledge and belief, have applied the above noted pesticide in accordance with Chapter 1328 of the General Laws and any other applicable law or regulation. If app icable ■ •• r o I Board o'`.ealth Representative Signature of Exterminator de IL Braman Termite&Pest Elimination Service Inspection Report BRAMAh P.O. Box 368 Detailed Service Report #2329656 Agawam, MA 01001-0368 Termite aZ Pest Elimination 800-338-6757 Material Application Details Material Applied Active Ingredient AI% Application Method EPA# AI Concentration Application Equipment Sq/Cu/L Ft Contrac Blox Bromadiolone 0.0050% Baiting 12455-79 N/A N/A N/A Target Pest: Rat Area/Device Name Finished Quantity Undiluted Quantity Technician Name Time Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->3 4.0000 Each 4.0000 Ounces Jacob Demeo 08:57 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->4 4.0000 Each 4.0000 Ounces Jacob Demeo 08:57 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->5 4.0000 Each 4.0000 Ounces Jacob Demeo 08:58 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->6 4.0000 Each 4.0000 Ounces Jacob Demeo 08:58 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->7 4.0000 Each 4.0000 Ounces Jacob Demeo 09:00 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->8 4.0000 Each 4.0000 Ounces Jacob Demeo 09:00 AM Weather: 0°,0 MPH First Strike Soft Bait Difethialone 0.0025% Baiting 7173-258 N/A N/A N/A Target Pest: Mouse,Rat Area/Device Name Finished Quantity Undiluted Quantity Technician Name Time 196 Cooke Ave Northampton->Interior-> 1 10.0000 Each 3.5000 Ounces Jacob Demeo 08:34 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->2 10.0000 Each 3.5000 Ounces Jacob Demeo 08:35 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->3 10.0000 Each 3.5000 Ounces Jacob Demeo 08:35 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->4 10.0000 Each 3.5000 Ounces Jacob Demeo 08:35 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->5 10.0000 Each 3.5000 Ounces Jacob Demeo 08:36 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->6 10.0000 Each 3.5000 Ounces Jacob Demeo 08:36 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->7 10.0000 Each 3.5000 Ounces Jacob Demeo 08:37 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Interior->8 10.0000 Each 3.5000 Ounces Jacob Demeo 08:37 AM Weather: 0°,0 MPH Printed: 10/25/2022 Page: 3/3 i Braman Termite&Pest Elimination Service Inspection Report P.O. Box 368 Detailed Service Report #2329656 Agawam, MA 01001-0368 p Termite et Test tEGmination 800-338-6757 Pest Summary Quantity With Without Total Device Exceptions Device Summary Activity Activity Inspected Replaced Removed Skipped Rodent Bait Box 0 8 8 0 8 0 -Totals 0 16 16 0 8 0 Additional pest findings may have been observed.Please see conditions and comments for more details. Area Inspections Area Inspected Pest Findings Time 196 Cooke Ave Northampton 8:37 AM 196 Cooke Ave Northampton->Exterior 8:37 AM 196 Cooke Ave Northampton->Interior 8:34 AM Device Inspection Details Area Device Name Device Type Activity Pest Findings Time 196 Cooke Ave Northampton->Exterior 1 Exterior Rodent Bait Station None 8:55 AM 2 Exterior Rodent Bait Station None 8:56 AM 3 Exterior Rodent Bait Station None B:57 AM 4 Exterior Rodent Bait Station None B:57 AM 5 Exterior Rodent Bait Station None 8:58 AM 6 Exterior Rodent Bait Station None 8:59 AM 7 Exterior Rodent Bait Station None 9:00 AM 8 Exterior Rodent Bait Station None 9:00 AM 196 Cooke Ave Northampton->Interior 1 Rodent Bait Box Removed 8:47 AM Removed 2 Rodent Bait Box Removed 8:47 AM Removed 3 Rodent Bait Box Removed 8:48 AM Removed 4 Rodent Bait Box Removed 8:48 AM Removed 5 Rodent Bait Box Removed 8:48 AM Removed 6 Rodent Bait Box Removed 8:48 AM Removed 7 Rodent Bait Box Removed 8:48 AM Removed 8 Rodent Bait Box Removed 8:48 AM Removed Total Devices: 16 Skipped: 0 No Activity: 16 Activity: 0 Material Application Details Material Applied Active Ingredient AI% Application Method EPA# Al Concentration Application Equipment Sq/Cu/L Ft Contrac Blox Bromadiolone 0.0050% Baiting 12455-79 N/A N/A N/A Target Pest: Rat Area/Device Name Finished Quantity Undiluted Quantity Technician Name Time 196 Cooke Ave Northampton->Exterior-> 1 4.0000 Each 4.0000 Ounces Jacob Demeo 08:55 AM Weather: 0°,0 MPH 196 Cooke Ave Northampton->Exterior->2 4.0000 Each 4.0000 Ounces Jacob Demeo 08:56 AM Printed: 10/25/2022 Page: 2/3 • Braman Termite&Pest Elimination Service Inspection Report "VRAhlithilit P.O. Box 368 Detailed Service Report #2329656 Agawam, MA 01001-0368 p Termite eZ Test IECmination 800-338-6757 Client: 10001556 Service Location: 10001556 Associated Building Wreckers Associated Building Wreckers 352 Albany Street Massachusetts Springfield,MA 01105 Springfield,MA 01109 Phone: 413-732-3179 x0 Phone: 413-732-3179 x0 Customer Signature: Technician Signature: Licenses/Certifications MA-52156 Certified MA-Amtrak No one on site Jacob Demeo Time In: 10/25/2022 08:24 AM Terms: NET 30 Time Out: 10/25/2022 09:06 AM Order# Service Description Quantity Unit Cost Amount 2329656 Rodent Service 1.00 $325.00 $325.00 SubTotal: $325.00 Tax: $0.00 Total: $325.00 Amount Due: $325.00 Service Comments Order Instructions: Rodent Abatement to 196 Cooke Ave,Northampton,MA-Abandoned Building *Will have a key for inside access* PO#156 Tech Comment: Abatement for 196 Cooke Ave Northampton completed.Placed out 8 exterior rodent bait stations along exterior perimeter of the building.No access to the interior of the building due to the key provided not working.Please see inspection report for details.Thank you for choosing Braman as your pest control provider! Materials Summary EPA# Active Ingredient Finished Quantity Application Method Application Rate Material Applied Lot# AI Concentration Undiluted Quantity Application Equipment Sq/Cu/L Ft Contrac Blox 12455-79 Bromadiolone 32.000 Each Baiting N/A N/A 0.0050 32.000 Ounces N/A Target Pests:Rat Areas Applied:Exterior->Device 1,Exterior->Device 2,Exterior->Device 3,Exterior->Device 4,Exterior->Device 5,Exterior->Device 6,Exterior->Device 7, Exterior->Device 8 First Strike Soft Bait 7173-258 Difethialone 80.000 Each Baiting N/A N/A 0.0025 28.000 Ounces N/A Target Pests:Mouse,Rat Areas Applied:Interior->Device 1,Interior->Device 2,Interior->Device 3,Interior->Device 4,Interior->Device 5,Interior->Device 6,Interior->Device 7, Interior->Device 8 Pest SummaryWith Without Total Device Exceptions Quantity Device Summary Activity Activity Inspected Replaced Removed Skipped None Noted Exterior Rodent Bait Station 0 8 8 0 0 0 Printed: 10/25/2022 Page: 1/3 Associated Building Wreckers, Inc. 352 Albany Street,Springfield,Massachusetts 01105 Tel:(413)732-3179/(800)448-2822 Fax:(413)734-6224 www.buildinewreckers.com AA/EOE MUNICIPAL WORK INSPECTION SIGNOFF SHEET t_ (addr ss/location) MUNICIPAL WATER / SANITARY SERVICE DISCONNECTION HAS BEEN (circle one) INSPECTED AND APPROVED ON 10—Zo _Z ZZ (date) BY: ire"(41 J (4 '�(print name) SIGNATURE: PHONE#: 'I 7 - f S'} - (S 30 n r',.Fi:( (please indicate mobile or office) REMARKS,IF ANY: eirA kic-kli4y ifire0 c/V, 110 71'T Irom 51 W 1141.IL to ]V(L�iT gli Associated B 1:� ���, Wreciffes, Lac. 352 Albany Street,Springfield,Massachusetts 01105 Tel:(413)732-3179/(800)448-2822 Fax:(413)734-6224 www.buildinewreckers.com AA/EOE MUNICIPAL WORK INSPECTION SIGNOFF SHEET ck. Cod lie_ :1('t'1frr(y ' D b 0 !dress/location) MUNICIPAL WATER / SANITARY SERVICE DISCONNECTION HAS BEEN (circle one) INSPECTED AND APPROVED ON (date) BY: (print name) SIGNATURE: PHONE#: LJ 13-5%7• l o 49 g (please indicate mobile or office) REMARKS,IF ANY: ��acr e Snap e k Ci e C� aaVe-L692/.�