BOTH-000377-2016 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Ift Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: BOTH-000377-2016 Date Issued: Thursday, July 14, 2016
This is to certify that work requested to be done as shown by Permit Number BOTH-000377-2016
has been completed.
Tax Map Number: 252.-1-36.6
Location: 268 LOCKHART MOUNTAIN RD
Owner: JAMIE JOHNSON
Applicant: CERRONE BUILDERS,INC.
This structure may be occupied as a: Demolition of 3000 s.£ SFD
Asbestos report attached By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, �Y
Variance,or other issues and conditions as a result of approvals by the
Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: BOTH-000377-2016
Tax Map No: 252.-1-36.6
Permission is hereby granted to: CERRONE BUILDERS, INC.
For property located at: 268 LOCKHART MOUNTAIN RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: JAMIE JOHNSON Demolition $0.00
Owner Address: 268 Lockhart Mountain RD Total Value $0.00
Lake George,NY 12845
Contractor or Builder's Name/Address Electrical Inspection Agency
CERRONE BUILDERS, INC.
1589 State Route 9
Fort Edward,NY 12828
Plans&Specifications
Demolition of 3000 s.f. SFD
Asbestos report attached
$ 30.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Thursday, June 15. 2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Townu sVury �p Mo y une 20, 2016
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
Town of Queensbury Building & Codes Office Use Only
Received
DEMOLITION PERMIT APPLICATION Permit#: ----
NO WORK MAY COMMENCE UNTIL PERMIT IS ISSUED
Permit Fee
Provide 2 plot plans drawn to scale,showing lot boundaries with dimensions and adjacent roads/streets. Show all existing structures
on property and Indicate which are to be demolished. Indicate the location of all utilities
Date ___ ___ __ Demolition Location 74 At
Tax Map ID _Z�z__ _-2�40 "
APPLICANT _/ ./_i�[,L�11.1 OWNER `Y1�
Address — — �—, �— ------ — Address — — — — —
_ '_L _LRC_ e4 a --
Phone ---��'-- -- ------------- Phone f_��------ ---------
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: 1���. 2 ---------Phone:
i. Person Responsible for Work
2. Where will demolition material be disposed? 1,4A/O—
3. All buildings to be demolished require an Asbestos Survey
4. Any building substantially damaged by fire must obtain an Asbestos Removal Permit from the Department of Labor
5. Asbestos Information: The Asbestos Removal Report must be filed with our offic before demolition begin
a) Is there any asbestos in the building to be demolished ___Yes _ __No
b) If Yes,our office needs the following Information ___Yes ____No
Name of firm removing the asbestos
License number of firm
Indicate where the asbestos material will be disposed
b. Structure Information
a) Indicate the structure(s)to be demolished Residence __— Garage ___Business
___Storage Bldg.___Other
b) Size of Structure
c) Number of Stories 'Z,,,.
d) Foundation Type dA/e.
e) Foundation
Q Structure(s)
7. Utilities information
a) Indicate utilities for this structure___Gas ___Electric Propane ___Public Water ___Public Sewer
___On-site well water pump jI « � ►
a) Have you notified the Town Water Department for public water and sewer disconnect? ____Yes _ __No
b) Have all utilities been disconnected? Yes ____No
8. Signature
Print Name: -C------------- Date ----------------
Signature: --- -- — ----- ------------------- Date ----------------
Town of Queensbury Building&Codes-Demolition Permit-December 2014
FI =COPY
HANSON
GEOLOGIC&ENVIRONMENTAL CONSULTANTS
V AN VLEET, LLC
December 16,2015 252.-1-36.6 BOTH-000377-2016
Johnson, Jamie
Mr.John Cifone 268 Lockhart Mtn. Rd.
Cifone Construction Co.,Inc. Demo of 3000 s.f. SFD
P.O.Box 684
Glens Falls,New York 12801
RE: Pro-Demolition Asbestos Survey �-
268 Lockhart Mountain Road
Town of Queensbury,New York
II IN 2 0 2016
Dear Mr.Cifone:
Hanson Van Vleet, LLC conducted an asbestos containing material (ACM) survey of the
residential structure at 268 Lockhart Mountain Road,Town of Queensbury,Warren County,New
York. The property is on the east side of Lockhart Mountain Road,approximately 1.2 miles from
the intersection with Bay Road. The property is identified as tax parcel 252.-1-36.6. HW is
authorized by the New York State Department of Labor under license # 05-0220 to perform
asbestos inspections,sample collection and surveys. Samples of each type of suspected asbestos
containing material(SACM)were collected. All samples were collected by a NYSDOL licensed
Class D Inspector,in accordance with 12 NYCRR Part 56,(referred to as Industrial Code Rule 56)
and 29 CFR Part 1910. The sampling was conducted on December 10, 2015. A copy of the
NYSDOL Asbestos license is attached to this letter.
Methods
Prior to initiating sampling, an on-site walk through inspection of the structure was performed in
accordance with Subpart 56-5(e) of 12 NYCRR Part 56. Building plans were not available for
review. Based on the site inspection,sampling of materials was performed to evaluate for suspect
asbestos containing materials(SACH). Bulk samples were collected following standard sampling
procedures. The samples were placed in double sealed sample bags and delivered by Federal
Express to EMSL Analytical for analysis under formal chain of custody procedures. Friable type
materials were analyzed by Polarized Light Microscopy (PLM) via the NY State ELAP 198.1
method. Non-orgenically bound(NOB)materials were analyzed by PLM via NYS method 198.6
NOB. If the NYS method 198.6 NOB was inconclusive,the NOB materials were then analyzed
by transient electron microscopy(CEM)via NYS method 198.4 NOB.
902 Route 148 (518)371-7940
CNon Perk, New York 12055 Fax(518)371-5885
p,o.Demolition ACM Survey
268 t.addwrt Mounto-s Road
Queensbury,New York -
Page 2 of 3
1_a9Deefign Basalts
The inspection revealed a, two story residential structure, of wood framed construction on a
concrete slab,concrete block basement and concrete piers. The basement was not finished.
The exterior of the structure consisted of wood clapboard siding, wood trim, vinyl non-glazed
windows and vinyl soffits. The roof consisted of asphalt shingles over a snow shield type tar paper
underlayment.
The interior had been previously partially gutted by others. The interior walls were of drywall and
joint compound construction. Prior flooring coverings had been previously removed. Leveling
compound was evident on the plywood sub-floor in some areas.
Suspect ACM materials identified on the exterior of the house included: asphalt shingles and tar
paper underlayment materials. Suspect ACM materials identified in the interior of the house
included: drywall,joint compound and floor leveler. Bulk samples were collected of: 1) floor
leveling compound;2)joint compound;3)drywall;4) asphalt shingles and 5)roof underlayment.
Asbestos Containing Material SamDtiaE Results
Fifteen samples of five types of suspected ACM were collected for analysis for possible asbestos
content.A minimum of three samples of each type of suspected ACM was collected. The samples
and results are summarized in Table I below. The Analytical results and chain of custody are
attached to this letter.
Table 1
Asbestos Sampling Locations and Analytical Results
268 Lockhart Mountain Road,Queensbury,NY
SOURVIC No of Material Location Result
S-IA Drywall Family Room ND
S-1B Drywall Kitchen ND
S-IC Drywall Stairwell ND
S-2A Floor Leveling Compound Living Room ND
S-2B Floor Leveling Compound Entry ND
S 2C Floor Level' Living Room ND
S-3A Joint Courpound Kitchen ND
FS-3B Joint and Basement Stairwell ND
Joint Second Floor ND
S ' e Roof ND
S ' e Roof ND
S ' e Roof ND
Underlayment I Roof ND
S-SB Uledayment Roof ND
SSC t Roof ND
Pre-Demolition ACM Survey
20 Lod&,wt Mowtain Rood
Qw msbury,New York
Page 3 of 3
Conclusion
No asbestos containing materials were identified in the structure. The Analytical results and chain
of custody are attached to this letter.
If you have any questions regarding this survey,Please contact us at(518) 371-7940.
Very truly yours,
Hanson Van Vlect,LLC
/4 r�
Kirby Van Vleet
NYSDOL Class D Inspector Certificate# 92-04899
CC: NYSDOL
EML
EMSL Analytical, Inc. Custon dD: HANS2421
CustomerlD: f1A11S22
200 Pout 130 More,Cteanabwar,NJ D8077 CustorrsrPO: 82588
P=MIFes (900)2204M I(SW 7WZ974
ha AmmNEMSLcom cinn"WWAEMS1. ProjedlD:
AWr: lamy Van Meet Phone: (518)371-7840
Fax
ole C
Hanson Van Meet, LLC Received: 12111/15(518)3716865
902 Route 146 AnaNsi Dare: 12115120155 AM
Clifton Park, NY 12065 to olelied: 12/1012015
cftm
Test Report:Asbestos Analysis of Bulk Material
Non Asbeefts
Teat color Fibrous Non-Flbmus Asbestos
Sample ID &IA Dwodptkm Fam2y Room-Drywe9
041536421-OM Hanwgwmft HwwgmmM
PIJ9 NYS 198.1 FrbdA9 12/152015 Whke 15.00%Cek dose 85.00%Non-lmrous(other) None Detected
PLY NYS 196A VCM Not Arralymd
PLM NYS 198.8 NOB Not ArralYmd
TEM NYS 199.4 NOB Not AnaVmd
Sample ID S-1 B D"Cliption FOtchen-DSD
041636421-0002 HormaganNly HOmogereous
PLM NYS 198.1 FrWft 1211&2015 vvw 15.00%Ce9Wose 85.00%Non4two s(other) Nana Detected
PLM NYS 196.6 VCM Not AneVzod
PLM NYS 198.6 NOB NotAtitned
Not AnalYmd
TEM NYS 198.4 NOB
Sample lD S•1C DowApdoe -DrywNi
011536121-0009 mornopeneft Homogeneous
PLM NYS 199.1 We 1211512015 81VmV ray 15.00%CeKwm 85.0096 Non4 brow(VON* Norte Detected
PLM NfS 19LS VCM Notes
PLM NYS 12LO NOB Not Analyzed
Not Aneh/md
TEM NYS MA NOB
Segnoe ID S-2A DsecrIPCon LMN Room-Floor Leveler
041596421-0004 HornaBsneNy Honvogeneous
PLY NYS 19&1 Frt4lhle 12/15!2015 Gray 100.00%Nw4h-aa(other) None Detected
PLY NYS 196.6 VCY Not AnaPped
Not
PLM NYS 19&8 NOB
Not Anehmd
TEN NYS 198.4 NOB
Sampo ID S-2B DewApow Entry-Floor Leveler
641596421-0006 FWawgeneny HOmOgPJImm
PLM NYS 198.1 FdW* 121152015 Gray 100.00%Non4brors(otheq None Detected
Not Aradymd
PLN NYS 198.6 VCM
Not Aluymd
PLY NYS 188.6 NOB
Not Arlaymd
TEM NYS 198A NOB
Wtiel Report Flan 12//84015 0OA7:30
Page 1
Teat Repel 196VCM-130.0 Ptbded:12/162A1512:47:30 AM
EMSLAnay►tical, Inc. EMSL Order. 041536621
CustmnerID: HANS22
200 R 1 130 NoNy Cimumanoq NJ 0!077
PMaaff c f8 MMc- 6761(656)7WW4 CuslomerPO: 82586
Mto�lwew.ENSl.can ^rn^'�. Pro1eclID:
Test Report:Asbestos Analysis of Bulk Material
Non Asbestos
Test cola Fibrous Non+Ibrous Asbestos
Samba W S,2C Deaalption Living Room-Floor Leveler
041530421-0" Homogeneity Homogeneous
PLA NYS 198.1 Fri" 12/1512015 Gray 100.00%Non fibrous(other) None Reacted
PLA NYS 1s&6 VCM Not Analyzed
PLM NYS 166.6 NOB NotAnalyaed
TEM NYS 198.4 NOB Not Analyzed
Sample ID S3A Deecriptlon tatct rt-Jolnt CO1"pousd
04/5904214007 bleary gpnelly Homogeneous
PLA NYS 198.1 Friable 12H512015 While 100.00%Non-fibrous(olfw) None Defected
PLA NYS 198.6 VCM Not Analyzed
PLJ6 NYS 196.6 NOB NotAlrayzed
TEM NYS 196.4 NOS Not Analyzed
Sample ID S-3B Daecdpdon Basement SWn%en-Jokd Compound
041596m4we HOmOgMlely Homogeneous
PLM NYS 198.1 Frabie 12115M15 WNID 100.00%NonAlbrous(Oahu) None Deaeatod
PLM NYS 198.6 VCM Not ArwVzed
PLJA NYS 198.8 NOB Not Analyzed
TE3AWt3198A NOB I&AAnayaed
Sample ID S4C - DescrIlWo r Second Floor Lan6ng-J01r6 Compound
041595421-0000 Homogenaly Homogereare
PLN NY8180.1 F2abta 17/15/2015 WMa 100.0016 Non-fibrous(00*0 Nor*Da4tbd
PLM NYS 1985 VCM Not Aneyaed
PLM NYS 1986 NOB NotAr1dIied
Not Andy=d
TEM NYS 190.4 NOB
Sample ID S4A Dandpdon Roof-SW*
0415SUV- O HwwWwMIy Homogeneous
Not Analyzed
PLM NYS 1981 Flable
Not Anayzad
PLUM"190.6 VCM
PLM NYS 190.6 We 12/1512tJ15 Blade 8.3% Class �Nor*��
TEM NYS 196A NOB 12(1612015 Bade None Dahelad
SampleW S4B DeecAptan Roof-S'hega
041595421-0D71 tlemegetreNy Homogeneous
NotAnalyzed
PLM NYS 198.1 Fdable
Na Arrayzed
PLM NYS Me VCM
PLJA NYS 198.6 NOB 12/1515 BaMore Black &0% Glass Irreorr Mor ee Nor��eDaleaad
170
TEM NYS 1964 NOB 12/1612015 Bade
InNW Raport From 1711&2015 00A730 .
Page 2
Test Report/88YC0&7,3&0 Pdnbxi:12ROM 512:47:30 AM
EMSL Analytical, Inc. Cusco xarHANS 421
CustanerlD: HANS22
966 RmuY 170 Nerlh.Chwrebnan,W 09077 CkstomerPO: 82598
PtrodlFoc (90a)22D-367 jP"76&6674
hdW.&ww EMS1. c7nmsb1&bnEMSL cam ProjectlD:
Test Report:Asbestos Analysis of Bulk Material
Non Asbestos
Test Color Fmrous Non+lbrors Asbestos
Samoa ID S4C Descriptlon Roof-Shkgle
01&W4 -4D12 Homogenelty HoMogerleous
PLM NYS 196.1 Friable Not Analyzed
PLM NYS 196.6 VCM Not Analyzed
PLY NYS 196.6 NOB 12/1512015 Black 5.9% Glass bkondmWx None Debated
TEM NYS 198A NOB 121162015 Bleck None Dabeied
Sampo ID S5A Dseoripdm Roof-Roofing Felt
041630421-0013 Homogeneity Homogeneous
PLM NYS 1961 Frbble Not Arab-ad
PLM NYS 1966 VCM NatAnsy2ad
PLM NYS 1966 MOB 12/152015 Bleck hwoonclaillm Nor Detected
TEM NYS 199A NOB 121162015 Bleak Nor*Detected
Sample ID SSB Dncdpdon Roof-Roo"Felt
041538121.04 Homogendy Homogel saw
PLM NYS 1961 Fdowe "
PLM NYS 186.6 VCM NotAnslYmed
PLJI NYS 1666 NOB 12(152015 Black 9.4% Glass kwonclrsvx None Detected
TEM NYS 198.4 NOB ,12(182015 Black Nor*Debated
Samoa ID S5C Dwdpdon Roof-Roofing Felt
041539421-00/5 HCmapeMft Homogeneous
PLM MYS 1961 Feisble Not Analyzed
PLM NYS 1966 VCM NotArmbnd
PLJ9 NYS 19BJf MOB 12H52015 Black 5.5% Glees telcos wive:Ras
TEM MYS 1964 NOB 121`162015 Black leas Debated
Ambers)
Kefshle Vaaryle2 Cmabal'
Saman w Rmdstom►Cry Benjamin ENs,Lffiaratory Marapar
or other approved signatory
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`-b leer Yolk Sob.TEM k anerdb er adperI tlbten be ued b delft lk e a N08 materids carr be mufdaed ortrealyd a oc m
normwbedeAude
AS ,-KysC#edslrwbrVembAlaaarr� Wee r*neteblestyIa NYS 196-1.
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EMSL ben rn reepaYtNftfor asr . commotion ae9ven oraraySml meetod flmft ns mlvpv"m and se a bet realaa are the respormu y d eke dent Srnplea rare
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Ir"Report From 12/162015 00:47:30
Test Report 198VCM-7.30.0 Pe~.1211628t512A7:30 AM THIS IS THE LAST PAGE OF THE REPORT. page 3
t UrderID: 041536421 , EMSL bt6.
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S-2C Living Room
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naaal AwAar Number(Lab use 0*) PHONE: 14MO-220-3675
7"74
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Shingle
SAA Roof
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page of 2— pages
Page 2 Of 2
New York State-:Department of Labor.
DMWon of safely and HepM
License And Ceffiicate Unit.
State Campos,WON 12
MxM,NY 12240 _
ASBESTOS HANDLING LICENSE .
Harsotl Ven Vieet, LLC FILE NUMBER: 05-0220
LICENSE NUMBER: 2&463
902 Route 146 LICENSE CLASS: RESTRICTED
DATE OF ISSUE: 03IM015
Ci t n.-Park,.NY 12065. EXPIRATION DATE: 03131(1016
Duyt A�,Representatime D Kirby Vanvleet'
Thu 1 V Las doen issued in acc:o,r.�d?ance with applicable provisions of Article 30 of the Labor Law of New Rork State and of,
flu Now Yodt Sta(p Codes.hulas gp�'RoguleTJdns(12 NYCRR Part 5� It m subject to sue ion or revocation for a 1)
secrous violation of state,federal or ,,W laws wrth regard to the conduct of an*bestw project or(2)demote look of
my�conduct of®y joti mvolving.as(iestos or asbestdos material
responsbihty
tYG i��� AI ^
This license urvalld only,for the contractor named above and this license or a photocopy must be prominently displayed at tbo
asbe�og pra(ed worksNa, Thrs licxne verifies that persons employed by.the licensee on anasbes<os project,in New Yoilr
State huge den inded ane *10S Certificate, 'p 116r for ilre type of work they Perform by the f Tew York State'
Departme4t of t allot.
:;: .. 1107
Eileen M.Franko, Director
SH 432(8112) For the Commissioner of Labor
.y
i
R.+
Y
'•� uy�.
ism
IF FOUND USTUM TO:
it 8718 SLU NYSDOL - L&C UNIT ;
H11IR GRY MM 161A SUILDDO 12
Bw 5 10" STATa OFFICR chwuS
ALSANY NY 12240
n
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