16 ENGLISH STREET - BUILDING JACKET 1
UPC10330
No. 153E
"cshcocc�
MASTINGS,.MN
BOSTON ENVIRONMENTAL
Assessment and Remediation, Inc.
17 Bentley Street
Salem, Massachusetts
978-741-8105
Mr. Thomas St. Pierre November 20, 2002
City of Salem Acting Building Commissioner
and Acting Zoning Official
120 Washington Street
Salem, MA 01970
Re: 16 English Street
Salem, MA
RTN 3-20038
Dear Mr. St. Pierre:
A historic release of oil and/or hazardous material has occurred at the above-referenced
property. Boston Environmental Assessment & Remediation, Inc. (Boston
Environmental) has been contracted to respond to this release in accordance with 310
CMR 40.0000, the Massachusetts Contingency Plan (MCP).
Boston Environmental has completed an Immediate Response Action(IRA) for this
release in accordance with the MCP. Boston Environmental hereby provides notice of the
availability of the IRA Completion and Response Action Outcome Report. The Report is
available for review at the Northeast Regional Office of the Massachusetts Department of
Environmental Protection at 205A Lowell Street in Wilmington, MA 01887.
In addition, in accordance with 310 CMR 40.1403(7), Boston Environmental hereby
submits to you a copy an Activity and Use Limitation recorded at the Essex South District
Registry of Deeds on October 22, 2002.
If you have any questions please feel free to contact us.
Sincerely,
For Boston Environmental
Assessment and Remediation, Inc.
2�
Jeffrey S. Kelly,
On behalf of Mr. Ronald Sweeney
Cc: Massachusetts Department of Environmental Protection
& PLAN
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NOTICE Ola ACI7VITY AND`USE LIM1T'ATI0N
M.G.L. c. 21E, § 6 and 310 CMR 40.0000
U Disposal Site Name: Tti English Street Salem,MA I Ilei II II�IIIIIII IIII III II III�I
DEP Release Tracking No.: 3-2oo3s 2002102200411 Bk;19448 Pg:1
I i 10/22/2002 11:09:00 OTHER Pe 1/15
This'Notice of Activity and Use Limitation("Notice")is made as of this 2e day of October,
2002, by Ronald i . Sweeney and Susan G. Sweeney of 16 English Street Salem, Massachusetts,together
with their successors and assigns(collectively"Owner').
'v7ITNES SETH:
WHEREAS, Ronald I Sweeney and Susan G. Sweeney are the owners in fee simple of that
certain parcel of land located in Salem, Essex County, Massachusetts with the buildings and
improvements thereon, pursuant to a deed recorded with the Essex South District Registry of Deeds in
Book 16287,Pale 475;
WHEREAS, said parcel(s) of land, which is more particularly bounded and described in
Exhibit A, attached hereto and made a part hereof("Property") is subject to this Notice of Activity and
Use Limitation The Property is shown on a plan recorded in the Essex South District Registry of Deeds
in Plan Book Plan ; Io�aaloa -'y!7—
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WHEREAS, a portion of the Property("Portion of the Property")is subject to this Notice of
Activity and Use iLimitation. The Portion of the Property is more particularly bounded and described in
Exhibit A-1, attached hereto and made a part hereof The Portion of the Property is shown on a plan
recorded with thel Essex South District Registry of Deeds in Plan Book .Plan
WHEREAS, the Portion of the Property comprises part of a disposal site as the result of a
release of oil and/or hazardous material. Exhibit B is a sketch plan showing the relationship of the
Portion of the Property subject to this Notice of Activity and Use Limitation to the boundaries of said
disposal site existing within the limits of the Property and to the extent such boundaries have been
established. Exhibit.B is attached hereto and made a part hereof;and
WBEREAS, one or more response actions have been selected for the Portion ofthe Disposal
Site in accordance with M.G.L. c. 21E ("Chapter 210) and the Massachusetts Contingency Plan, 310
CMR 40.0000 ("MCP"). Said response actions are based upon(a)the restriction of human access to and
contact with oil and/or hazardous material in soil and/or(b)the restriction of certain activities occurring
in, on,through, oLver or under the Portion of the Property. The basis for such restrictions is set forth in
an Activity and Use Limitation Opinion ("AUL Opinion"), dated October 18, 2002, (which is attached
hereto as Exhibit C and made a part hereof);
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NOW, TFFR.RRFORE, notice is hereby given that the activity and use limitations set forth in
said AUL Opinion are as follows:
1. Activities and Uses Consistent with the AUL Opinion. The AUL Opinion provides that a
condition of No Significant Risk to health, safety, public welfare or the environment exists
for any foreseeable-period of time{pursuant to 310 CMR 40.0000) so long as any of the
folloI . g activities and uses occur on the Portion of the Property:
(i) All typical residential activities and uses that do not compromise the structural .
integrity of the basement floor and/or-disturb petroleum-contaminated soil located
beneath the basement floor;
(ii) Excavation associated with emergency or short term(three months or less)
underground utility and/or construction work,provided it is conducted in
accordance with-a Sort Management-Plan and a Health and Sa€ety Plan-in
accordance with Obligations(i)and(ii) of this Notice; and involves the repair
andlor replacement of the basement floor with a comparable barrier immediately
following the completion of the project;
(iii)'; Activities and uses which are not identified by this Notice as being inconsistent with
maintaining a condition of No Significant Risk;
(iv) Such other activities and uses which in the Opinion of an LSP, shall present no
greater risk of harm to health, safety,public welfare, or the environment than the
activities and uses set forth in this paragraph; and
(vi): Such other activities and uses not identified in Paragraph 2 as being Activities and
Uses Inconsistent with the AUL.
2, Activities and Uses Inconsistent with the AUL Opinion. Activities and uses which are
inconsistent with the objectives of this Notice of Activity and Use Limitation, and which, if
implemented at the-Portion of the Property, may result in a significant risk of harm to heahh,
safety,public welfare or the environment or in a substantial hazard, are as follows:
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(i) Activities and/or uses which are likely to involve the removal and/or disturbance of
the basement floor in the AUL Area and/or the disturbance of the petroleum-
contaminated
etroleumcontaminated soil located beneath the basement floor without prior development of
a Soil Management Plan and a health and Safety Plan in accordance with
Obligations(i) and(ii)of this Notice;
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(ii)l relocation of the petroleum-contaminated soil from beneath the basement floor in
the AUL Area unless an LSP renders an Opinion which states that such relocation is
I consistent with maintaining a condition of No Significant Risk; and
(iii) Activities and/or uses which may cause physical or chemical deterioration,
breakage, or structural damage to the basement floor in the AUL Area.
3. Obligations and Conditions Set Forth in the AUL Opinion. If applicable, obligations
and/or conditions to be undertaken and/or maintained at the Portion of the Property to
maintain a condition of No Significant Risk as set forth in the AUL Opinion shall include the
following:
(i) A Soil Management Plan must be prepared by an LSP and implemented prior to
the commencement of any activity that is likely to disturb the petroleum-
contaminated soil located immediately beneath the basement floor. The Soil
Management Plan must be prepared in accordance the guidelines discussed in the
Activity and Use Limitation opinion attached hereto as Exhibit C;
tu:) A Health and Safety Plan must be prepared and implemented in accordance with
the guidelines discussed in the Activity-and Use Limitation Opinion attached hereto
as Exhibit C prior to the commencement of any activity which involves the
removal and/or disturbance of the basement floor and/or is likely to disturb the
underlying petroleum-contaminated soul within the AUL Area;
(iii) The basement floor within the AUL Area must he repaired and/or replaced with a
comparable barrier to prevent future exposures to-underbing petroleum-
contammated soilimmediateiy following the completion of any activity that
involves its removal and/or disturbance;and
(iy) The basement floor must be maintained within the designated AUL area to ensure
I that the petroieumrcoutaminated soil located beneath the basement floor remains
inaccessible.
4, proposed Changes in Activities and Uses. Any proposed changes in activities and uses at
the 'ortion of the Property which may result in higher levels of exposure to oil and/or
haz rdous material than currently -exist shall be evaluated by an LSP who shall render an
Opi Aaron, in accordance with 310-CMR 40.1080 et seq., as to-whether the proposed changes
will present a significant risk of harm to heahk safety, public welfare or the environment.
AnyI and all requirements-set forth in the Opinionto meet the objective of this Notice shall be
satisfied before any such activity or use is commenced
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5. Violation of a Response Action Outcome. The activities, uses and/or exposures upon
which this Notice is based shall not change at any time to cause a significant risk of harm to
health, safety, public welfare, or the environment or to create substantial hazards due to
exposure to oil and/or hazardous material without the prior evaluation by an LSP in
accordance with 310 CMR 40.1080 et seq., and without additional response actions, if
necessary, to achieve or maintain a condition of No Significant Risk or to eliminate
substantial hazards.
If the activities, uses, and/or exposures upon which this Notice is based change without the
prior evaluation and additional response actions determined to be necessary by an LSP in
accordance with 310 CMR 40.1080 et seq., the owner or operator of the Portion of the
Property subject to this Notice at the time that the activities, uses and/or exposures change,
shall comply with the requirements set forth in 310 CMR 40.0020.
6. incorporation Into Deeds Mortgages, Leases, and Instruments of Transfer. This Notice
shall be incorporated either in full or by reference into all future deeds, easements,
mortgages, leases, licenses, occupancy agreements or any other instrument of transfer,
whereby an interest in and/or a right to use the Property or a portion thereof is conveyed.
Owner hereby authorizes and consents to the filing and recordation of this Notice, said
Notice to become effective when executed under seal by the undersigned LSP, and recorded
and/I or registered with the appropriate Registry of Deeds.
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WITNESS the execution hereof under seal this day of October 2002.
Ronald . Sweeney
COMMONWEALTH OF MASSACHUSETTS
Essex, ss OctoberO 2002
Then,personally appeared the above-named Ronald J. Sweeney
and acknowledge,'d the foregoing instrument to be his free act and deed before me,
Notary Public:
My Commission Expires:
Paul D. Ru00C0
NOTARY PUBLIC
My=ntu ca6#es,Jy24,2b
WITNESS the execution hereof under seal this a� day of October 2002.
Susan G. Sween
COMMONWEALTH OF MASSACHUSETTS
Essex, ss October,� 2002
Then personally appeared the above-named Susan G. Sweeney
and acknowledged the foregoing instrument to be her free act and deed before me,
NotaryPublic:
My Commission Expires:
Paul D. P00066
NOTARY PUBLIC
j PRye�irasJdY?A.2003�
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The undersigned LSP hereby certifies that he executed the aforesaid Activity and Use
Limitation Opinion attached hereto as Exhibit C and made a part hereof and that in his Opi ' s Notice
of Activity and Use Limitation is consistent with the terms set forth in said Activity Use L iitation
Opinion.
Date: r *a
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dore r. LSP
em a
tNDF MASSgC
I H
go= Gs�
o I(AEGAERJR. m
N0.1127 c
�i cFy 9FGISTFP�O�y�o
COMMONWEALTH OF MASSACHUSETTS DSI TE PPk"
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Bristol, ss October2002
Then personally appeared the above named Theodore J. Kaegael, Jr. LSP and aclmowledged .
the foregoing instri ment to be his free act and deed before me,
- 1110 -QOMO � q(�Mi'�PiA 1.II�,Il
Notary Public:
My Commission Expires:
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Upon recording, return to:
Boston Environmental
17 Bentley Street 1
Salem,MA 01970
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Exhibit A
Activity and Use Limitation
j 16 English Street Salem,Massachusetts
Description of Parcel of Land Subject to Activity and Use Limitation
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The land together with the buildings thereon, situated in Salem, County of Essex,
Commonwealth of Massachusetts, bounded and described as follows:
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Beginning at the northeasterly comer at an iron rod set on the southerly side of English
Street,thence conning,
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S 100 56' 46"IW by land of Jeremy Bumagin and Rebecca Kenneally a distance of
sixty seven and no hundredths(67.00)feet to an iron rod set at land
of Richard E. Savickey;thence turning and running,
N 76°59' 45 j W by land of said Savickey and land of Lieselotte Gallagher and halo
Gallagher a distance of twenty nine and three hundredths(29.03)
feet to land of Scott Ian Patrowicz and Lucy Juneau Patrowidz;
thence tummg and running,
N 10°20' 24"E by land of said Patrowicz a distance of sixty four and two
hundredths(64.02)feet to a point;thence tummg and running,
S 820 47' 38"'E by English Street a distance of twenty nine and seventy five
hundredths(29.75)feet to the point of beginning.
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Exhibit A-1
Activity and Use Limitation
16 English Street Salem,Massachusetts
Description of the Portion of the Property Subject to the Activity and Use
Limitation
A portion of land situated on the southerly side of English Street in Salem, County of
Essex, Commonwealth of Massachusetts,which portion is subject to an activity and use
limitation is bounded and descnW as follows:
Beginning at the northeasterly comer of the dwelling located on said property,thence
running,
S 08053' 1T'W by the easterly line of the dwelling a distance of thirty and forty six
hundredths(30.46)feet to a comer of the dwelling;thence tuming
and mmniug,
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N 81°40' 56"W by the dwelling a distance of four and no hundredths(4.00)feet to
a comer of the dwelling;thence tummg and running,
S 09°37' 09'1 W by the dwelling a distance of thirteen and sixty hundredths(13.60)
1 feet to a comer of the dwelling;thence turning and running,
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N 79°51' 19'[W by the dwelling a distance of fourteen and fifty four hundredths
I. (14.54)feet to a comer of the dwelling;thence turning and
running,
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N09'19' 43"I E by the dwelling a distance of forty three and eighty three
hundredths(43.83)feet to a comer of the dwelling;thence turning
and running,
S 800 58' 26",E by the dwelling a distance of eighteen and thirty seven hundredths
j (18.37)feet to the point of beginning.
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Exhibit B
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N76'5
'
9'45"W
LqT AREA` -
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� "O);. ;.0'3.40_•',".. _
r .0
,-N N
m
11.6
7Y' -
_.7.56"
29.75
58247'38"E
ENGLISH - STREET
i SKETCH PLAN SHOWING RELATIONSHIP
BETWEEN THE AUL AREA AND
RAO
THE DISPOSAL SITE
DISPOSAL SITE
16 ENGLISH STREET
SALEM,
jRESTRICTED AREA SCALE 1"
= 10' OCTOBER 10, 2002
NORTH SHORE .SURVEY CORPORATION
47 LINDEN ST., 'SALEM, MA #1988
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Exhibit C
Activity and Use Limitation
16 English Street Salem,Massachusetts
Activity and Use Limitation Opinion
In accordance with the requirements of 310 CMR 40.1074,this Activity and Use Limitation
Opinion has be prepared to support a Notice of Activity and Use Limitation for the property
located at 16 English Street, Salem, Massachusetts. At the time of the recording of this AUL,the.
subject property and the surrounding vicinity are zoned for residential use.As illustrated in
Exhibit B attached hereto,the subject property is occupied by a one-story single-family dwelling.
The area betweei I L 16 English Street and the abutting property(to the southeast)at 18 English
Street is paved with asphalt. A small grassy lawn is located behind(to the southwest) of the
subject property puilding.
Site History
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On October 13, 2000,the Massachusetts Department of Environmental Protection was notified
that a volume of Number 2 fuel oil estimated to be 200 gallons was released from the feed lime of
an aboveground Storage tank located in the basement of the subject property. The fee line was
situated below the concrete basement floor. Soil and groundwater located under the basement
floor and locatedl in the area between 16 and 18 English Street was contaminated with oil.
Subsequent response actions included pumping oil from groundwater wells, excavation of
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contaminated soil from the subject building basement, and application of concentrated hydrogen
peroxide to the area under the basement floor and to the area between 16 and 18 English Street to
reduce residual pletrolerun concentrations in soil and groundwater.
Reason for Activity and Use Limitation
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A Method 1 Risk Characterization was prepared to support a Response Action Outcome for the
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site. Concentrafrpns of petroleum constituents in groundwater at the site meet the applicable
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Method 1 GW-2 I and GW-3 cleanup Standards and as such do not pose an excess risk of harm to
human health, safety,public welfare, and the environment undercurrent and foreseeable future
conditions.
Concentrations of residual petroleum constituents in soil outside the footprint of the site building
meet the most conservative Method 1 S-1 cleanup standards and as such do not pose an excess
risk of harm to human health, safety,public welfare, and the environment under both current and
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foreseeable future conditions.
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Concentrations off residual petroleum constituents in soil inside the footprint of the site budding
meet the applicable Method 1 S-3 and more conservative S-2 cleanup standards. As such,
residual petroleum constituents in soil within the footprint of the site building do not pose an
excess risk of halm to human health, safety,public welfare, and the environment under current
conditions. However, since some of the petroleum concentrations measured in soil located
beneath the basement floor exceed the more restrictive Method 1, S-1 cleanup standards, a level
of No Significant Risk is not supported for unrestricted fiAwe activities and uses of this portion of
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the property. In f rder to achieve a level of No Significant Risk for future foreseeable site
activities and uses, an Activity and Use Limitation is necessary to ensure that the soil located
beneath the basement floor remains inaccessible and the exposure pathways remain incomplete.
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Activities which may result in the disturbance of the basement floor and the underlying soil must
be restricted in otder to prevent exposures which may pose a Significant Risk to sensitive
receptors.
Permitted Activities and Uses
(i) All typical residential activities and uses that do not compromise the structural 'integrity of
the basement floor and/or disturb petroleum-contaminated soil located beneath the
basements floor;
(ii) Excavation associated with emergency or short term(three months or less)underground
utility and/or construction work,provided it is conducted in accordance with a Soil
Manage�ent Plan and a Health and Safety Plan in accordance with Obligations(i) and(ii)
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of this Opinion; and involves the repair and/or replacement of the basement floor with a .
comparable barrier immediately following the completion of the project;
(iii) Activities and uses which are not identified by this Opinion as being inconsistent with
maintainiag a condition of No Significant Risk;
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(iv) Such other activities and uses which,in the Opinion of an LSP, shall present no greater
risk of halm to health, safety, public welfare, or the environment than the activities and
uses set forth in this paragraph; and
(vi) Such other activities and uses not identified in the following paragraph as being Activities
and Uses inconsistent with the AUL.
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Restricted Activities and Uses
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(i) Activities;and/or uses which are likely to involve the removal and/or disturbance of the
basementfloor in the AUL Area and/or the disturbance of the petroleum-contaminated
soil located beneath the basement floor without prior development of a Soil Management
Plan and a Health and Safety Plan in accordance with Obligations(i)and(ii)of this
opinion;
(ii) Relocation of the petroleum contaminated soil from beneath the basement floor in the
AUL Area unless an LSP renders an Opinion which states that such relocation is
consistent with maintaining a condition of No Significant Risk;and
(iii) Activities'and/or uses which may cause physical or chemical deterioration,breakage, or
structural damage to the basement floor in the AUL Area.
Obligations and Conditions
i A Soil Mana ement Plan must be prepared b an LSP and implemented prior to the
O g P P. Y �P
commencement of any activity that is likely to disturb the petroleum-contaminated soft
located beneath the basement floor. The Soil Management Plan should describe
appropriate soil excavation,handling, storage,transport, and disposal procedures and
include a aescription of the engineering controls and air monitoring procedures necessary
to ensure'that workers and receptors in the vicinity are not affected by fugitive dust or
particulates. On-site workers must be informed of the requirements of the Soil
Management Plan, and the plan must be available on-site throughout the course of the
project;
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(ii) A Health)and Safety Plan must be prepared by a Certified Industrial Hygienist or other
qualified;dividual sufficiently trained in worker health and safety requirements and
implemented prior to the commencement of any activity which involves the removal
and/or disturbance of the basement floor and/or is likely to disturb the underlying
petroleum-contaminated sod;rendering it more accessible: The plan should clearly
describe the location of the petroleum-contaminated soil and specifically identify the types
of personal protective equipment; monitoring devices; and engineering controls necessary
to ensure that workers are not exposed to petroleum through dermal contact;ingestion;
and/or the inhalation of particulate dusts: Workers who may come in contact with
petroleum contaminated soil within the designated AUL area must be informed of the
location bf the contamination and all requirements of the Health and Safety Plan. The plan
must be#ailable on-site throughout the course of the project;
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(iii) The basement floor within the AUL Area must be repaired and/or replaced with a
comparable barrier to prevent future exposures to underlying petroleum-contaminated soil
immediately following the completion of any activity that involves its removal and/or
disturbance;and
(iv) The basement floor must be maintained within.the designated AUL area to ensure that the
petroleum-contaminated soil located beneath the basement floor remains inaccessible.
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' Oct 14 02 10:25.a Jeff Kelly 1-878-745-8204 P. 1
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MaSSachusettS Department of Environmental Protection BWSC-114
Sureau of Waste Site Cleanup
l Release Tracking Number
ACTIVITY & USE LIMITATION (AUL) OPINION FORM ❑
pursuant to 310 CMR 40.1070-40.1084(Subpart J) 3 - 2Q038
COMPLETE THIS FORM AND ATTACH AS AN EXHIBIT TO THE AUL DOCUMENT TO BE RECORDED AND/OR
REGISTERED NTH THE REGISTRY OF DEEDS AND/OR LAND REGISTRATION OFFICE.
A. LOCATION OF DISPOSAL SITE AND PROPERTY SUBJECT TO
Disposal Ste Name:
Street: 1 6 F.aa1 i sh Sitreet Location Ad:
Ctylroran: Salem ZIP Code: 01970-0001)
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Address of property subject to AUL,It different than Street: SeLme
Ctyrrown: ZIP Code:
B. THIS FORM IS BEING USED TO: (check
® Protide the LSP opinsillto a Notice of Activity and Use Limitation,purslsm to 310 CMR 40.1074(complete all sections of this corm).
Provide the LSP Opinion
rofor an Amended Notice of Aetivityand Use Limitation,pursuant to 310 CMR 40.1081(4)
(complete all sections of this form).
Protide the LSP Opinion for a Termination of a Notice of Activity and Use Limitation,pursuant to 310 CMR 40.1083(3)
(complete all sections o'f this form).
Provide the LSP Opinion for a Grant of Environmental Restriction,pursuant to 310 CMR 40.1071,(complete all sections of this form).
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E] ProMde the LSP Opinion for an Amendment of Environmental Restriction,pursuant to 310 CMR 40.1081(3)
(complete all sections of this torn).
Provide the LSP Opinion for a Release of Environmonted Restriction,pursuant to 310 CMR 40.1 D83(2)(complete all sections of this form).
C. LSPOPINION:
I attest under the pains and 1penalties;of perjury that I have personally examined and am familiar with this submittal,Including any and all
documents accompanying this submittal. In my professional opinion and judgment based upon application of m the standard of care In 309
CMR 4.02(1),(D the applicable provislons of 309 CMR 4.02(2)and(3),and(kip the prWelo ns of 309 CMR 4.030,to the best of my
> If Section 8Indicates that a Nbfbe of AeOvlty and EA.Llmltatlon is befng reglsfened andcrrxarrbd,the Activity and Use Limitation that Is
the subject of this submittal(p is being provided In accordance with the applicable provislons of M.G.L.c.21 E and 310 CMR 40.0000 and 04
compiles with 310 CMR 40.1074(1)(6);
> F Section B indicates mat an Amended Notice ofAcONltyand Use Um/tWon Is behlgregktered androrrecorcbd,the ACU ty and Use
Limitation that Is the subject orthis submtial(n Is being provided In accordance with the applicable provisions of M.G.L.c.21 E and 310 CMR
40.0000 and(8)complies with 310 CMR 40.1090(1)and 40.1081(1);
> C Section S Indicates that a Iramina8on of a Wee of Activ)tyand Use Umttallon Is being registered androrrecorded,the Activity and Use
Limitation thud Is the subject of this submittal(p is being prodded In accordance with the applicable provisions of M.G.L.c.21 E and 310 CMR
40.0000 and i complies w!lh 310 CMR 40.1083(3)(a);
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> If Section 8 IrAtatas that a Grant ofEnvtronmental Res6fodon Is being registered anoW necerded,the Atthdy and Use Limitation that is
the subject of this submttall m Is being provided in accordance with the applicable proNebns of M.G.L.e.21 E and 310 CMR 40.0000 and lip -
complies with 310 CMR 40.1071(1)(b);
> ff Section B lndlcatw that an Amendment to a Grant of Environmental Restriction Is being registered aneWrecaded,the Activty and Use
Limitation that Is the subject of this submittal(p is being provided In accordance with the applicable previsions of M.G.L.c.21 E and 310 CMR
40.0000 and(Ip complies with 310 CMR 40.1080(1)and 40.1081(1);
> IF Section 8 irMkates the!a Release of Grad ofEnv)moamentar Reablcffom Is beingregfsta ed and0wrecerded,the ActhAty and Use
Lim cation that Is the subject of this submittal(p Is being provided in accordance with the applicable prWsbns of M.G.L.c.21 E and 310 CMR
40.0000 and Op complies with 310 CMR 40.1083(3)(a).
I am aware that significart penaltles may result,Including,but net limited to, possible fines and imprisonment,If I submit Information which I
know to be false,Inaccurate or materially Incomplete.
Check here If the Resp prise Action(s)on which this opinion is based,H any,are(were)subject to any order(s),permt(s)andfor approvals)
Issued by DEP or EPA) lithe box Is checked,you MUST attach a statement Identifying ing the applicable prw,tslons thereof.
SECTION C IS CONTINUED ON THE NEXT PAGE.
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Oct 1402 1a:?Sa Jeff Kelly 1-978-745-8204 p.2
Ma"Iachusetts Department of Environmental Protection BWSC-114
Bureau of Waste Site Cleanup
Release Truldng Number
ACTIAj nTY & USE LIMITATION (AUL) OPINION FORM ❑
Pursuant to 310 CMR 40A070-40.1084(Subpart J) 3 20038
C. LSP OPINION:
LSPName: Thonelnra 1T. KAaoNnA1 , Jr. LSP*. 1127 Stamp: ,y
.q jOF Bias
Telephone S06-575-PA00 EA.: A��P S,yCW
FAX
l ,e' GJ LS aD�'7DfJ c THEOEJ. - P
KAEGAELJR.
LSPSignalur f NO.1127 -,
Q
Date: ISTEP��5��2
YOU MUST COMPLETE ALL RELEVANT SECTIONS OF THIS
FORM OR DEP MAY FIND THE DOCUMENT TO BE INCOMPLETE.
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The Commonwealth of Massachusetts
y Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR,7m edition. MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate.O I emo�ish a Revised January
.�..::: . _ 1, 2008
One-or Two-Family Dwelling , : 1. , _:�
This Se Fer-9 ' 1 Use Only "
71
Building Permit Number,, 'Date App ied:"
Signature•
' 'Build' g Co sinner/ Buil '- ". Date
�STCTION 1:SITE INFORMATION
1.1 Property�Address: 1.2 Assessgg1,X"gpnJ;#rr�
E4_ (yrpbers
1.1 a Is this an'accVpted street?yes no Map Number >{ Parcel Number
1.3 Zoning Information: 1.4 PropertyDemsious:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system. ❑
Check if yesO
„ SECTION 2: PROPERTY OWNERSHIP,'.
2.1 err of R ord: C�
f�lM� &alp 4 elf
Name(Print) Address for Si/vice:
.Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item . Official Use Only
Labor and Materials
1.Building 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑TotalProject Cosr (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash`Amount:
6.Total Project Cost: $��, ❑paid in Full 0 Outstanding Balance Due:
r r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ,7 .7 7
License Number Expvation Date
Name of CSL-Holder Ile W.palm
List CSL Type(see below)
3 Hiltm Siree�_
Address Salem MA 01970 Type
e, Unrestricted u to35 Descriptiono L
R Restricted 1&2 FamilyDwelling
Sign a '• M Rest Only
� RC Residential RoofingCovering
Telep m WS Residential Window and Siding
�y ,� 3 SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) - ,/,z�o
eq
won LLC
HIC Company Name or HIC R ' Registration Number
Add
6 I'll Jefferlibn Avenue 31jZ 11-b
Sglem lye 01970
Expiration Date
Signs re Telephone
SECTION 6:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be comocted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, f rl SW-eZtve4 as Owner of the subject property hereby
authorize (i i 7, b a to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owiier V Date
• -. SECTION 7b:OWNEW OR AUTHORIZED AGENT,DECLARATION
I, �✓iG 1 Q llyl as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print e
S7Ly
Signature of Owner or Authorized Agent - Date
(Signed under the pains and penalties of
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110:R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"