NYC 9/11 Public Portal Document
ASBESTOS PROJECT NOTIFICATION STATE OF NEW YORK
Division of safety & Health DEPARTMENT OF LABOR
Asbestos Control Bureau
8uitdtng 12. Room 157
State Campus
Albany. NY 12240
A.. rYP OF OTrFICAT1ON ~. ,, ::•
Check only one rope ofnonjicarian below.
©✓ Initial....................... Complete all sections and submit 10 calendar days prior to starting date.
© Amended _•„.........„.. Submit amended notincation with all sections completed and amended item(st circled.
Cancelled .._............ Complete Section G and attach copy of initial notification or complete all sections.
® Emergency,••,_-...... You must first call the Program Manager's office of the Asbestos Control Bureau at 518-457-1255
for prior approval of emergency status then complete and return this form including:
Date (_/_!_) Time l 1 Emergency Status Granted
Authorized by: (From Asbestos Control Bureau)
It), it
....
-;.B:;CONTRACTORLNEORMAUON'- , :,
Provide all intbnnarion reinserted below.
---------------
t. FEIN -PII -.-._.-.-.-._.-.-. 2. Asbestos Lit. No. g g - 01 4 8
-
3. Contractor Name and Address 4. Mailing Address (ifdiffarrnsi
I-In7orrinnc Climinntinn f':nm Gam
195H Central Avenue
Farmingdale, New York 11735
5. Duly Authorized Representative 6. Wij1.Su rontractotisl be used
j'lo D es (lfves.comole:e lines below)
Name Donald Gold Name
Vice President Asbestos Lic. No. -
Title m
Phone No. ( 6311 752-2898 Name
Asbestos Lic. No.
m - m
7. Party for Whom Work is Being Performed: Name The Cooper Group. Inc.
Address 666 Fifth Avenue, New York, NY 10103
C. EROJECTSITE'INFORMATION +, 5 ~ 7;'
Provide all injormarion requested below jar the buildingtsite at which the asbestos project will be conducred
S. Project Location: County New York
Name of building
Room or other specific location Entire Basement. 1st and 2nd floors, roof and facade
Street address 23 Thames Street
City, town or village New York, New York 10006
9. Building Information
Current use Commercial Building age
Prior Use Commercial Building size sq. fL
10. Building Representative-Site Contect: Nate Chanan Rozenbaum phone No. (21'2 208-4614
SH-t83 (10-03)
NYC-WTC 000134925
OCR can misread numbers and units. Confirm readings against the page image before using them.