Demolition/renovation Notification Form (Page 2 of 2) in pdf

Demolition/renovation Notification Form Page 2

INSTRUCTIONS

Waiver #: Indicate Emergency Renovation/Demolition Project number assigned by DES (271-1370).

Check whether this is a new notification or revision of a previous notification.

Fee Enclosed: Indicate the amount enclosed according to the following fee schedule. Make checks

payable to Treasurer, State of New Hampshire:

$300.00 – For Class “N” Major projects involving at least 260 linear feet (lf), 160 square feet (sf),

or 35 cubic feet (cf)

$50.00 –

For Class “S” Major projects involving greater than 10 linear feet (lf), 25 square feet (sf),

or 3 cubic feet (cf) but less than 260 lf, 160 sf, or 35 cf

$25.00 –

Each Revision

$0.00 –

Projects up to 10 lf, 25 sf, or 3 cf

Owner of property information.

Abatement contractor information (or Demolition contractor information in the case of a demolition

project with no asbestos present).

Building name and address (for example, Jones Residence or Widgets Inc., factory).

Check the type of project. For Emergency Demo/Reno, obtain waiver # from DES and indicate on

line provided at top of form.

Building description. If exact information not available, provide an estimate.

ACM –– List known quantity of Asbestos Containing Material present in building and quantity to

be abated.

Start and End dates of abatement work or demolition, including hours of operation and days of

week.

Location in building of ACM to be abated, example: boiler room or 3

floor hallway.

Licensed Asbestos Abatement Supervisor.

10. & 11. Transporter name and address, and final disposal site for ACM waste.

12.

Brief description of work practices to be employed to comply with applicable rules and regulations,

example: full containment, negative pressure, wet methods.

13.

Name of inspector for demolition and large renovations where ACM isn’t assumed to be present.

14.

Brief description of unusual work practices, example: “dry removal around electrical gear” or

“modified containment with full decon of contaminated basement.” Attach written waiver where

required.

15.

Government Agency, including responsible person, if an ordered demolition.

16.

Certification. Provide signature of responsible person and date.

Demolition/renovation Notification Form Page 2