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DEMO-0509-2022 Office Use Only FEW J DEMOLITION APPLICATION Permit#: �&—'�O - ®� ' �2 Permit Fee:$ Town of Quccnsbury Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensburV.net Flood Zone? Y Reviewed B Demolition Location: l 03 Lem 6r. Tax Map ID#: **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** DEMOLITION INFORMATION: 1. Where will demolition material be disposed? L A AJ 2. Type of structure to be demolished: a. Residence_ d. Storage Building p i b. Garage e. Other: AM,- 4 •,-,,, 4 c � c. Business ZO 3. What type of utilities are connected to the structure: ni m C" a. Gas f. Well-Water Pump Onz c b. Fuel Oil g. Public Sewer 0 W N c. Propane h. Other M if d. Electric d L None < e. Public Water oe 4. Have ALL utilities (water, electric, etc.) been disconnected? Yes No ADDITIONAL INFORMATION: 1. Two inspections are required: an inspection to determine that utilities are disconnected, and a final inspection after the structure is removed and the site is cleaned up and graded. 2. Twenty-four (24) hour notification is required for inspections. 3. Workers' Comp insurance information is required to be submitted with this application. Declaration: I acknowledge that no structure(s)will be removed from the parcel until the demolition application has been reviewed and approved by the Town of Queensbury Building&Code Enforcement and Zoning Departments and a permit has been issued. I have read and agree to the above: PRINT NAME: — �J SIGNATURE: �— DATE: G Demolition Application Revised June 2022 A� CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Mailing Address, C/S/Z: 10 Cell Phone:(�i P;17g G- 4S'A,r Land Line: N'lA-- Email: ti,-tL c . • Primary Owner(s): Name(s): '�� Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Check if all work will be performed by property owner only • Contractor: (List all additional contractors on the back of this form) Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: Land Line: Email: **Workers' Comp documentation must be submitted with this application** Contact Person for any questions regarding this project: N � ► Cell Phone: �;79 -71(, (ova- 1 Land Line: Email: &A41 te a vkkL , Cum _ Demolition Application Revised June 2022 FE COPv Pre Demolition Asbestos Survey At -� Single family home C n 15 Leo Street z o a Queensbury, NY 12804 rn Q, Oz o mU N t CI)�C , I; i Prepared for: Mr. Nicholas Daigle Daigle Construction � � _�"� S��PPT 11 Sugar Pine Road BUIL )ii��G & C0 Queensbury, NY 12804 f�e�riti Wed hy° Date �� ` Prepared by: DVD Environmental Inc. PO Box 2152 OWN OF QUEENSBURY Cliffside Park, NY 07010 UILDING DEPARTMENT 212 260 9818 Based or ur limited examination,compliance with our mments shall not be construed,as indicatin, the plans and specifications are in July 11, 2022 full com lance with the Building Codes of New Yor State. 308.8-2-18 DEMO-0509-2022 Daigle, Nick 15 Leo St Demolition of manufactured home Asbestos survey DVD Environmental Inc. 1/22 TABLE OF CONTENTS Section Page No. 1.0 Project Fact Sheet 2 2.0 Executive Summary—Homogeneous materials, Listing by Floor 3 3.0 Introduction 4 4.0 Building Description and Space Use 4 5.0 Survey Procedures and Guidelines 4 6.0 Analytical Methods 5 7.0 Reporting 5 8.0 Discussion—Regulatory Review 6 9.0 Certification 10.0 Sample results ; Asbestos survey DVD Environmental Inc. 1/22 1.0 PROJECT FACT SHEET Project Title: Pre Demolition Asbestos Inspection Report Project Location: 15 Leo Street, Queensbury,NY 12804 Building: 15 Leo Street Prepared For: Mr.Nicholas Daigle Owner: Mr.Nicholas Daigle 11 Sugar Pine Road Queensbury,NY 12804 Contacts: Mr.Nicholas Daigle 518 796 6521 Consultant: DVD Environmental, Inc. PO BOX 2152 Cliffside Park,New Jersey 07010 212-260-9818 Inspector(s): Tim Donohoe 1 & NEw r° cs' '0 . ° �f- y0 O —t a TOS\ '. Tim Donohoe NYS Certified Asbestos Inspector EPA Certified Asbestos Inspector NYCDEP Investigator -2- Asbestos survey DVD Environmental Inc. 1/22 2.0 EXECUTIVE SUMMARY DVD, INC. was contracted to provide environmental support to Mr. Nicholas Daigle for the building at 15 Leo Street in Queensbury,NY. This contract required the performance of a building inspection for asbestos-containing building materials. This data will be used for reporting only. DVD's EPA certified inspector performed the asbestos inspection on July 6, 2022. The entire building was surveyed. This asbestos inspection survey report includes a listing of all materials suspected to contain asbestos, analytical methods, limitations and results, and an area by area inventory of ACM. An investigation of accessible spaces was performed at the property to identify all suspect ACBM. Section 2.0 Listing of Suspect Asbestos Containing Materials HOMOGENEOUS MATERIALS & ACBM CONFIRMATION LIST H# HG Material Description F/NF Analysis ACBM ACM Type 1 Roof shingles NF TEM N 2 Cellulose ceiling board NF TEM N 3 Sheetrock F PLM N 4 Joint compound NF TEM N 5 1x1 Brown floor tile NF TEM N 6 1x1 faux wood floor tile NF TEM N 7 1x1 Blue floor tile NF TEM N 3.0 INTRODUCTION An inspection for asbestos containing materials was performed at the 15 Leo Street ' Building in Queensbury, NY. The scope of the inspection was to locate, sample, quantify, and report asbestos containing materials in all areas within the structure. 4.0 BUILDING DESCRIPTION AND SPACE USE The property consists of a 1200 square foot house. The HVAC system consists of a central gas heater and ducted hot air with a hot water tank. The building was constructed in 1970 and has undergone minimal renovation. The building is a currently unoccupied single family house which is deteriorating and collapsing in places. 5.0 SURVEY PROCEDURE AND GUIDELINES The survey was performed according to the Environmental Protection Agency recommended procedures found in EPA 560/5-85-024. These procedures call for the visual inspection of the building for suspect asbestos containing material and analysis of representative samples of such materials. In addition to the required visual inspection, fiberglass insulated systems were penetrated to determine the substrate in several locations. ' -3 - Asbestos survey DVD Environmental Inc. 1/22 The survey and sampling was performed by Timothy Donohoe, All procedures meet the above requirements. All accessible areas were inspected for three basic types of asbestos used in building materials: 1. Surfacing Material that is sprayed-on, troweled on or otherwise applied to surfaces, such as acoustical plaster on ceilings, fireproofing materials on structural members, or other materials for acoustical, fireproofing or decorative purposes. 2. Thermal System Insulation applied to pipes, fittings, boilers, breaching, tanks, ducts, or other structural components to prevent heat loss or gain, water condensation, or for other purposes. 3. Miscellaneous ACBM means building materials on structural components, structural members or fixtures, such as floor and ceiling tile, transite wall panels, transite pipe, roofing shingles, roof flashing and many other materials that are exclusive of surfacing or thermal system insulation. SOURCES OF INFORMATION- Survey Information was collected by means of visual inspection, interviews, sample collection, and sample analysis. 6.0 ANALYTICAL METHODS POLARIZED LIGHT MICROSCOPY (PLM) is the EPA recommended method (EPA method 40 CFR 763, subpart F, App A) for determining the presence of asbestos in building materials. These materials include, but are not limited to, pipe and boiler insulation, acoustical coatings, spray-on fireproofing,plasters, ceiling tiles, and floor tiles. The PLM 't procedures involves taking a small amount of the suspect material, isolating the fibers present, and identifying them based on the crystalline properties observed. All asbestos types are crystalline materials and as a result can be identified by specific optical properties observed in the polarized light microscope. In addition, non-asbestos fibrous materials can also be identified including: glass, mineral wool, cellulose, gypsum, and synthetic fibers. Results of the analysis are reported as a percentage of the total sample. The PLM method is sensitive to concentrations of asbestos down to 1%. Each sample was first examined under the stereo microscope. The analyst looked for layering, colors, friability, fibrosity and general appearance. Approximately 0.5mg of each unique layer of each sample was immersed in refractive index oil and was observed in the microscope at 40-400X. The sample's components were then identified by six different optical criteria to determine fiber type and visual percentages. The optical criteria determined include: morphology, pleochroism, birefringence, extinction, sign of elongation, and refractive index parallel and perpendicular to elongation. Non-friable, organically bound (NOB) material (floor tiles, roofing, mastic flashing) determined to be negative for asbestos by PLM analysis are considered positive by the NYS Environmental Laboratory Approval Program until proven negative by transmission electron microscopy (TEM) - (NYS ELAP Protocols 198.1/198.4). Therefore, TEM analysis was performed on all NOB materials where no asbestos was detected using PLM. -4- Asbestos survey DVD Environmental Inc. 1/22 7.0 REPORTING HOMOGENEOUS MATERIALS & ACBM CONFIRMATION LIST- is a summary list of each building material that was tested. Note that each material was assigned a homogeneous material number (HA No.) in the first column of the list. The second column is the material description, the third column indicates if the material is friable (F) or non-friable (NF), the fourth column is a code assigned to each homogenous material for purposes of classification and recording on sample log sheets (Chain of Custody form). The fifth and sixth column is used in categorizing each for the existence of asbestos (Y-Yes, N-No). Positive materials contain greater than one percent (>1%) asbestos as per OSHA 29 CFR Part 1926.1101.b, (Subpart Z). Any material not sampled is considered Presumed Asbestos Containing Material-PACM is material has not been tested by a certified laboratory to confirm asbestos content. Material must be treated as ACM until laboratory results confirm otherwise. The last column is for footnotes specific and unique to the each building. 8.0 DISCUSSION This report is designed as a database of all ACBM discovered during the asbestos survey. Accordingly, the USEPA, NYSDOL requires the building owner to provide an asbestos inspection prior to building demolition or demolition and notification prior to abatement. This process requires a detailed review of plans and specifications in order to determine the extent of construction influence that might extend to areas that contain ACBM. OSHA Asbestos standard 29CFR1910.1001 applies to all occupational exposures to asbestos in all industries covered by the Occupational Safety and Health Act, except construction work and ship repairing, shipbuilding and shipbreaking employment and related employments. All materials found are non-asbestos, demolition can be performed without disturbing asbestos containing materials. � a 5- Asbestos survey DVD Environmental Inc. 1/22 9.0 License 1 v 8w -6- -r New-York State-Department=of.Cabor- - -- ; Division of Safety and Health I \_ r--'r License and Certificate Uhitt ti State Campus,Building 12 t Albany,-NY_12240- ASBESTOS HANDLING LICENSE DVD Environmental, Inc. ,_��;_. , y �,,�_`FILE NUMBER: 06=0631'� • LICENSE NUMBER: 28545- • 71 .0.0, B63`2152 LICENSE CLASS: RESTRICTED'- T �} I DATE OF ISSUE: 08/23/2021 .' ,Cliffsid_e.Park, NJ 0701-0 ,..r'' . ., EXPIRATION DATE: 08/31/2022 s; • _ ' - - :, r _ ;.� ;, 1, ., .'.�+�., :,;-,• "` � iL '� �' I ' ii ,�,�t+� I Ji i�}tl �:. — (�_•' —��'!rr P'�'j r; 'LI,I!,°� ' 1 ';l', 'r'' I'I" ,jA 7�— • � r-II 4i- II, '•�'' '�' � I Duly,Authorized,Representatives"�Timothy�Dono,oe: � �-_i ( '7' 1 I� ,j1`j -g� � �._i.+ •.''9 y_- l�';� '� _L3�� � I �'�� ' This'license has been issued in accordance+with+applicable:proisions Hof Article 30�of the Labor Law of New York.State and of the New York State Codes,RulesFand'Regulations-,(12 NYCRR Part'S6)-It-it to suspension or revocationffor a(1) serious violation of state,federal or local laws with.regard-to-:the conduct;of ari'.asbestos'project,or(2)demonstrated.lack-of responsibility in the conduct of any job.'involvin_g'.as6esYos or.'asbestos'matenal:% ,, ii -•', ` j��; t�'�r� '•���i.'i.`i,{o.^:�f` t•�4 This,license is-valid only,for`tlie contractor named above and this-license or a photocopy.must-be=prominently displayed'at,the asbestos project worksite.-This-license verifies that,all�persons-employed-by,the licen_'see on an=asbestos;project in New York State have been issued an Asbestos Certificate,,appropriate fo'i the type:of work-they perform,by the'New York_State' p' Department of Labor. 4 Amy Phillips,Director SH 432(8/12) For the Commissioner of Labor 0. OS cONTRUL PR si NYC DEP ASBEST ASBESf01 'CERTMCATE = -: - oo►vo�a�r-- - -- _ I TIMOTHY . 114VEDGATOR 116879 EXPIRES:0111812024- DOB:0111811966 M ©?" i TS MUST BE CARRIED ON ALL ASBESTOS P,ROJ�E`�esis STATEOFNEWYORK='DEPAKTOREABO "DONOHOE R- �QYT--S— C ASBESTOS CERTIFIC TE - N'F�t Tl OTkl rCEASS(FJEPIRES) `�� ATEC(01123) D INSP(01/23)i.. H PM'(01/23) I PD (D:1/23j -. CERTiY 89�09236 . UMUB-2�1451509"' MUST BE CARRIED ON ASBESTOS PROJECTS nnununm�unnm i Asbestos survey DVD Environmental Inc. 1/22 10.0 Sample Results 41, n e) p 0 7 3 DVD Environmental, Inc. PO Box 2152, Cliffside Park,NJ 07010 Phone: 212 260-9818 - E-mail Tdonohoe@dvdenvironmental.com Bulk Sample Chain of Custody/Data Sheet �Laboratory: Lab Address: ob#: roJect Information: Analysis Turnaround Time Comments: 1 LeD' S xz,,S 6 ype 6-8 hr 12 hr 24 hr 48 hr 72 hr 5 day L� I AP PLM Positive stop for all FLAP TEM homogeneous materials. ELAP PLMfrEM xx TEM/Water Inconclusive NOBS(only) Sampled By:Tim DonohoeTEM/Chatfield should go directly to TEM. Number: Mold Manager: LEAD OTHER Results to: tdonohoe dvdenvironmental.com IRetum Samples Yes X No Invoice to: DVD Environmental,Inc. Written Report to: DVD Environmental,Inc. Phone#: 212 260 9818 Comments: Read for V Positive of each material 10ther#: Sample Sample Location Material Type Damage Results Homog Quantity Date:� �L Time: p— 1) % PLM TEM Area u a e,r d / Z - - c� tOr R z A A J )--& I Al a 1 Relinquished By: Dat /Time Receiv d Date/Time: Invoice DVD Environmental, Inc. Invoice Number: PO Box 2152 Invoice Date ice Date: Cliffside Park, NJ 07010 Jul 12,2022 Voice: 212 260 9818 Page: Fax: 201 941 8739 1 Sold To:Daigle Construction Ship to: 11 Sugar Pine Road Daigle Construction Queensbury,NY 12804 11 Sugar Pine Road Queensbury,NY 12804 Customer ID Customer PO Payment Terms Daigle 15 Leo St 2% 10,Net 30 Days Sales Rep ID Shipping Method Ship Date Due Date Airborne 8/11/22 Quantity Item Description Unit Price Extension 1.00 Inspection Asbestos Inspection and Report 300.00 300.00 14.00 LM Bulk Sample analysis 15.00 210.00 10.00 LM-NOB TEM Bulk Sample Analysis 60.00 600.00 Subtotal 1,110.00 Payment/Credit Applied Check/Credit Memo No: TOTAL 19110.00