Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PIONEER TER - BUILDING INSPECTION
RECEIVED L At�1 s INSPECTIONAL SERVICES The Commonwealth of Massachusetts ® Department of Public Safety mik AOG 12 A II: 01 ' Massachusetts State Building Code(780 CMR) ^� Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) .. Building Permit Number: Date Applied: Building Official: - SECTION 1:LOCATION(Please indicate Block#and'Lot#for locations for which a street address is not available) Pioneer Terrace Salem 01970 Pioneer Terrace Development No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used 780 CMR/107 If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair El I Alteration El I Addition❑ I Demolition © (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes El No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No El Brief Description of Proposed Work: The work consists of replacing the windows,apartments doors and the screen doors through out the project Also,it includes demolition and re-building of the common stairs areas of all the buildings. SECTION.3:COMPLETE THIS SECTION IF EXISTING:BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): ...,SECTION 4:BUILDING HEIGHT AND AREA ., Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 2/building 2100 sg0/0 r Total Area(sq.ft.)and Total Height(ft.) 50400 sgft 20' SECTION 5 USE GROUP(Check as applicable) ' A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: - Special Use: SECTION6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ r SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) ' Water Supply: Flood Zone Informafion: Sewage Disposal: Trench Permit: Debris Removal: Public 13 Check if outside Flood Zone 13 Indicate municipal 13 A trench will not be Licensed Disposal Site 13 Private❑ or indentify Zone: or on site system Elrequired B or trench or specify:permit is enclosed❑ Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process: Not Applicable 19 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No© Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: No Special Stipulations: SECTION9:7 PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Salem Housing Authority 27 Charter Street Salem MA 01970 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Debra Tucker (978) _744 _4431 dtucker@salemha.org Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes New England Builders&Contractors Inc. 464 Merrimack Street Methuen MA 01844 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) , building is less than 35,000 cu..:ft.of enclosed space and/or not under Construction Control then check here❑and sl-jp Section 10.1 {l 10.1 Registered Professional Responsible for Construction Control Barry Buchinski (617L 720 _3599 bang@blackstoneblock.com 5254 Name(Registrant) Telephone No. e-mail address Registration Number 7 Marshall tree[ Boston MA 02108 Design Professional 8/31/15 Street Address City/Town State Zip Discipline Expiration Date .10.2 General Contractor New England Builders&Contractors Inc. Company Name Bernard Feghali /W gd 1 k Barn 24 o 4 7 6 0 0 - Name of Perq6n Responsible for Constru tion License No. and Type if Applicable 464 Merrimack Street Methuen MA 01844 Street Address City/Town State Zip (978)_ 685_ 3990 (603) _234 _ 9339 bernad@newenglandbuilders.com Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKE16'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 - A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes® No ❑ SECTION 12.•CONSTRUCTIONS COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$1,410,000.00 1.Building $ 1,387,000.00 Building Permit Fee=Total Construction Cost xO lj(Insert here 2.Electrical $ 8,500.00 appropriate municipal factor)=$ KA Qom°,,: 3.Plumbing $ 10,500.00 4.Mechanical. (HVAC) $ 4,000.00 Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to CITY n:'SRL�M 6.Total Cost $ 1,410,000.00 1 (contact municipality)and write check number here H SECTION 13:'SIGNATURE OF BUILDING PERMIT APPLICANT - By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Bernard Feghali �� President (978) _ 685 _3990 8/11/14 Please print and sign name Title Telephone No. Date 464 Merrimack Street Methuen MA 01844 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name - Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location(Please indicate Block#and Lot#for locations for which a street address is not available) Pioneer Terrace Salem MA Pioneer Terrace No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No O Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No © Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No O Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107.The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x'where applicable No. Item Submitted Incomplete Not Required 1 Architectural X 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC X 7 Electrical X 8 Plumbin include local connections X 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Welland,etc. 11 Specifications X 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance X 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other S ec' 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Barry Buchinski AIA (617)_720 _3599 barry@blackstoneblock.com 5254 Name(Registrant) Telephone No. e-mail address Registration Number 7 Marshall Street Boston MA 02108 Architect 8/31/2015 Street Address City/Town State Zip Discipline Expiration Date John C.Pierga (978)_486 _4301 info@blwengineers.com 48291 Name(Registrant) Telephone No. e-mail address. Registration Number 311 Great Road Littleton MA 01460 Electrical 6/30/16 Street Address I City/Town State Zip Discipline Expiration Date William J.Scanlon 45449 (978)_ 486 _43001 info@blwengineers.com Name(Registrant) Telephone No. e-mail address Registration Number 311 Great Road Littleton MA 01460 Mechanical 6/30/16 Street Address City/Town State Zip Discipline Expiration Date Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8r6 edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Salem Housing Authority-Pioneer Terrace Date: 7/29/14 Property Address: Pioneer Terrace, Salem, MA Project: Check one or both as applicable: ❑ New construction N Existing Construction Project description: Renovations to Elderly Housing complex. I William J. Scanlon MA Registration Number: 45449 Expirationdate: 6/30/16 , ama registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [ ] Structural [X] Mechanical [ ] Fire Protection [ ] Electrical [X] Other Plumbing for the above named project and that to the best of my knowledge, information,and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept,shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. �P�ZN OF M4SSA Upon completion of the work, I shall submit to the building official a`Final Construction Control t' o WILLIAMJ. a� SCANLON , Enter in the space to the right a"wet"or c0i MECHANICAL electronic signature and seal: No.45449 9p 9F S F4� FFSSIO L G Phone number: (978) 486-4301 Email: info@blwengineers.com Building Official Use Only Building Official Name: Permit No.: Date: Version 06 112013 b Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8 h edition of the 'g Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Door,Window,Trim, Stair Replacements Date: July 31,2014 Property Address: Pioneer Terrace 667-4—Salem Housing Authority—Salem,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Door,Window,Trim,Stair Replacement I, Barry Buchinski ALA,MA Registration Number: 5254 Expiration date: 08/31/15 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concemmg : X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information,and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: I. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. �tipED Aq� cx5 suc y�r Enter in the space to the right a"wet"ory�Ys`cC'� electronic signature and seal: m 0—s OST MA Phone number: 617-720-3599 Email: barry@blackstoneblock. om OF Building Official Use Only Building Official Name: Permit No.: Date: Note"1. Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, provide a description. Version 06 11 2013 Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Salem Housing Authority- Pioneer Terrace Date: 7/29i14 Property Address: Pioneer Terrace, Salem, MA Project: Check one or both as applicable: ❑ New construction LR Existing Construction Project description: Renovations to Elderly housing complex. I John C. Pierga MA Registration Number: 48291 Expirationdate: 6/30/16 ,ama registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [X] Electrical [ ] Other for the above named project and that to the best of my knowledge, information, and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together t comments, in a form acceptable to the building official. p�tN I Assa cy ONN Gr Upon completion of the work, I shall submit to the building official a `Final Construction D J C.� h4C.t. o ELECTRIC L w Enter in the space to the right a"wet'or No.4829 electronic signature and seal: 9oA AIS1 A Fs Phone number: (978) 486-4301 Email: info@blwengineers.c Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 CITY OF SAI.EM, NIASSACHUSETTS • BL•ILDLNG DEPARTstENT 130 W.ksH(NGTON STREET,3eD FLOOR TEL(978)745-9595 FAX(978)740.9946 KINIBFRf 1=Y DRISCOLL MAYOR THOmAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/EU:IIDING CO\zQSSIO,iER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name(Business,Organizationilndividual): New England Builders&Contractors Inc. Address: 464 Merrimack Street City/State/Zip: Methuen,MA 01844 Phone#: (978)685-3990 Are you to employer?Check the appropriate box: Type of project(required): 1.El lama employer with 10 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers'comp.insurance S. ❑ We arc a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL t LCI Plumbing repairs or additions myself.[No workers'comp. c. 152,110),and we have no 12.E Roof repairs insurance required.]t employees.[No workers' 13 Other comp.insurance required.] •Any appliaua that dualut brat pi must also rill out the edim below stowing tbea worker'compensation policy iniotmatioo. 1 tmnwuwtsaa who submit this affidavit indicating they am doing all work and thm hire omstde contractor mttn-limit a nmv affidavit indicating rut$ 'Coma unz that check this box must attached an additional sheet showing the mane of the auh.wvntraccpata and their wodtetaI ramp.policy infamutdon. l am an employer chat it providing workers'compeniollan Insurance jar my employees. Below Is the policy oad job site injormadou, Insurance Company Name:_Acadia Insurance Company Policy 4 or Self-ins.Lic:'p: WCA0355905 Expiration Date: 10/13/2014 Job Site Address: Pioneer Terrace City/State/Zip: Salem MA 01970 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigaliuns of the DIA for insurance coverage verification. l do hereby certify under the pains an enaiflea.of WASthat the injormailoe provided above is true and correct Date: 8/11/14 mane X: (978)685-3990 oJJlcial use only: Do not write in this urea,to be completed by city or town gjylchd City or Town: PermidUcense# _ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone p: bP A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.1 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Danielle Rice NAME: THE ROWLEY AGENCY INC. PHONE (603)224-2562 FAX 139 Loudon Road E-MAIL AIC No:(6031224-8012 P.O. Box 511 ADOREss.drice@rowleyagency.com INSURERS AFFORDING COVERAGE NAIL N Concord NH 03302-0511 INSURERA:Union Insurance COm an INSURED 5899 New England Builders s Contractors, Inc. INSURER B Acadia Insurance Com arr 31325 969 Merrimack Street INSURER C INSURER D INSu RER E Methuen MA 01699 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR WIND R LTR TYPE OF INSURANCE $ POLICY NUMBER MMIODmYY MMIODmYV LIMITS GENERAL LIABILITY EACHCCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY A 0 MISES NTE PE.decurnerre E 250,000 A CLAIMS-MACE 1z OCCUR PA002835527 0/13/201310/13/2014 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- PRODUCTS-COMPIOP AGG $ 2,000,000 FXXEZLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1 000 000 ANY AUTO AALL BODILY INJURY(Per S AUTS OWNED X AUTOSULED 150042929 10/13/2013 10/13/2019 BODILY INJURY(Per .accident) $ X HIRED AUTOS X AUTOSNON-OWNED AUTOS PROPERTY DAMAGE $ Per accident X UMBRELLA LIAB X $ OCCUR EXCESS LIAe CLAIMS-MADE EACH OCCURRENCE S 10,000,000 B DED X RETENTIONS 0 DA008438321 10/13/201310/13/2014 AGGREGATE $ 10,000,000 B WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN X WC STATU- OTH- ANY PROPRIETORIPARTNERIEXECUTIVE IS OFFICERIMEMBER EXCLUDED? a NIA E.L.EACH ACCIDENT S 500 00C (Mandatory in NH) CA0355905-14 10/13/2013 10/13/2019 if yes,describe under EL.DISEASE-EA EMPLOYE $ 500 000 DESCRIPTION OF OPERATIONS below 3A States: MA 6 NH E.L.DISEASE-POLICY LIMIT I$ 500,000 A Leased S Rented Equipment PA002835527 10/13/201310/13/2014 emit. $150,000 Installation Floater Lmit $300,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks schedule,if more space is required)Work Plan: 258025001; DHCG FISH 258066; Scope of Work: FF: Doors, Trim, Windows and Community Room Accessibility Pioneer Terrace 667-4. Salem Housing Authority and Department of Housing S Community Development are additional insureds on all liability policies, except workers compensation, when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem Housing Authority ACCORDANCE WITH THE POLICY PROVISIONS, 27 Charter Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE Danielle Rice/DJR -- - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rim nnstm Th.CCnGn name_H Innn ao woniict—rl.n arbe nF AnnRn CITY OF SALEtit, �'L�SS.�CHUSETTS • BL'II.DING DEPARTMENT ' 120 WASHINGTON STREET, 310 FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KISfBERL.EY DRISCOLL IMAYOR T Ho&us ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUII-DING COMMISSION ER Construction Debris Disposal. Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris wi 11 be transported by: All State Waste (name of hauler) The.debris will be disposed of in : Champion City Recovery (name of facility) 138 Wilder Street Brockton,MA 02301 (address of facility) signature oCp6rmit applicant date dcbriwiT.duc