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3 RAVENNA AVE - BUILDING INSPECTION y�y-off The Commonwealth of Massachusetts t Board of Building Regulations and Standards I t)R Massachusetts State Building Code. 780 CMR. 71"edition MUNICiIP.\I.I'Il' L.SF W Building Permit Application To Construct. Repair, Renovate Or Demolish a Revj%,9/7mrudn One- or Tn•o-Froniiv'Dweliing 1. 'rx4Y This Section For' Official Use Only i Building Permit Number: ^Dade Applied: V\� Signature: IO \� y/ 8 8 \� Building Commissioner u/ Inspeor of Buildings �� Date SECTION 1: SITE INFORMATION 1.1 Propert dd :��h 1.2 Assessors Map & Parcel Numbers I.la Is this an accepted street'? yes_ no Map Number Parcel Nunther 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s stem ❑ Public❑ Private❑ Check if es❑ P y SECTION 2: PROPERTY OWNERSHIP' 2.1 OwnX1 of Record: Name(Pnt Address for Service: 15�( i`?�J Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Iteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ ,Other Specify: Brief Description of Proposed Work': T SECTION 4: ESTIMATED CONSTRUCTION COSTS EEstimated Costs: Official Use Only Item and Materials) I. Building I. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/I'own Application Fee 2. Electrical ❑Total Project Cost(Item 6) x multiplier x 3. Plumbing 2. Other Fees: $4. Mechanical (HVAC) List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount 6. Total Project Cost: $ :) ❑ Paid in Full ❑Outstanding Balance Due: ` � note SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name otCSL- Holder List CSL Type(see below) T Description Address U Unrestricted(up to 35.000 Cu. Ft.i R Restricted 1&2 Family Dwelling Signature M Masonry On RC Residential Roofinit Coverin Telephone - ` \" \VS Residential.-%Vi ndow and Stain SF Residential Solid Fu stallation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) �y HIC Co Na 'or stran Registration No ether Ad r D Expiration at St turc T I n SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.9 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance the building permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1P �Q�` ,fi as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I. , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print N Signature If Owner or Authorized gent Date (Si ned u er the ains and penalties of perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Horne Improvement Contractor(HIC) Program), will Mol have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. respectively. 2. When substantial work is planned, provide the information below: Total Floors area(Sq. Ft.) (including garage, finished basement/attics. decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halt7baths Type of heating system Number of decks/porches Type of cowling system Enclosed Open 3. 'Total Project Square Footage" may be substituted for*Total Project Cost" i yr - ate' MAR-18-2008 11:57AM FROM-Name Depaa4380 Salem 603 894 0414 T-562 P.004/004 F-326 HOME"APBOVUKENa.............. i �1 Said FlunisLca and TvaarLad dw: I T9D AI-Noma S11"cea,Ioe. Brew Name: S D Dam: . d/ola The Some ILagr AaHoote SeNicas 345AGraoswood Sheet,ww-m.MA 01607 � � '��O Toll Free(edbmB5i:e6Coia)9 to,Me,LW Fuc -2959 Broach Nllmbar:_�Job#"�� FNqul TP a 75 layaada R�O&—ry/b�1•�1y/6^993 WlA nll� ✓'l I�rlw sum j!p taatallatt'a Addrew: --- Crry 1114 Pt01ta of W'e' Hama PbanC t•weharm(a): a-S&6 M µrop;vhaae: Booze Addrea. city Gity y'p (lfdiflbrmtitom oPludataa olld pmmu bdeaitotioniam ) : rioam Tram The HOma Depot): . p.ma0 Addrew(oereaaive located at ttw above insadiation udders%otter m the oweree of the prap:n(y protect faformadou: V WcNm("1'ama>+eal^)• to{ormoh•debvaf sad nnmlN for tho h"al"E"af:dl maletiela caatrau with THD AlrHatee Set 7Pne� iocu�¢d hamin by r0firmca ead made a Wt hereof: I do=i1xd ab the oluahad Spoo shad Im t dmrxmince that It flume Dopot r0l-v Or debt to""'I tole tgatroct )(Won re.tmpoetlaa of ro(age lob,/Some Depa abllgagom due to a atruatural Probt'm��t hmoe,prir erran or bcaluRa work eegptred w Cannot perform 1a the Spur Sheet or Covitracl ramploto the Job wall not iat4adad DjEP f PAYMENT OPf ($W.,,fitW Yd(WaoO Wwartmdr apluuA e.) $CN�aaaaer Omer r( Cmd:mtl914aa . CONTRACT AMOUNT S� l�PeyeykmtheluomDq�m} S ^' I -rya••uycramrlaM>m^Wk".pra.Paenaa•r tLE$5 DEYOSTT k bean S Yw taeant,ml aeoama BALANCE DUE rlaH,na DX CaWGd ONCOWLETION S 7Ta Honor Ctegottmoa hep:avemgetaa }Nfbdsamx.�A MCoatraQ pmunt drm apoa •:O New Aeewd VarrdagAeoanr tnB.&HPCC ONLY) aiaaritan eathb eostraeL ANMaM[]adla9� (111L@15DCC ONLY) t lddh"For Indkerte papmoe "`°° til•I�v f- P � BAT.ANCEDUC ON(^oMPtBf70N: NgmwueppwemmaC ..��•laie bp)ow,pWeea3�/7=a to allow Hame Depatm far lac dePaeh mdicetad. Of •waae yea peldda a etaA m wM°aa�``Om"1PO a.alma a 9v ome m aq Infarmmaa lame Yam dune gradme onetime elrim+aa 8m oemhr aam roec eewme w m aga9.'lfnw mymdam aaa maemcwa omaet rafes,bnruordronen aeeaemadYaw bd..nddyeyahaydw�rwe.'re d'aam InCC AuthmtlFaol✓n—Cod a!Pa m1t oAGIN . &mmHme6 � N Q will execute a Complaum Catificato and pay miry Frachava agms t)mt,immediately aPaa�comooppler{aa of the Kw blipo d and - belauce due Pidelmaer atao sgram m he JoiattY and eevrralry obb�ed ta.bsWe haeeardcr. C and This a$rcemear mad ins atmahmama.including A"fipmneift ogteement,tammrn the both a ap'eaoemt iretaeaa the padtae and emn ambe amended ormsdifiodwA n is writing m o aepaam agemnmrt signed hY both pmtrea NOTICE TO pUHCHASER Do out alga this rml.0 before You read IL You are eaWtad m e c0nm dy fitc,14,eaPY of toe coovaM at the ioye B m Protart ryow dshm. Do not mile a Coaplethm Irate berara this proJeet IN rompleta. few yuu also. I(scp n oo CerUllcsh ahead by the owner Our to pprahlbita home mpnlr codtrnetWm from raaaredug ar aaapd We atop.0ongdetwo of the work to be Perfornwd and-the eoatraat- omir-ot' Sao Too may Boual t61a traaeaedoo Say time peiur to o aRW of Me OdM budttwe day afar We data of tht• the rnah'aU N'tim of Coneellatlan for as esplonatlao of thie rw Then Well be a mi"I"charge equal to 10/ of .ou,"t if lob IS maadlad by Purcbsaar AFTER 00 third buelaerr ttayr but BEFORE matariale are ordm he cd•There wit assUffifils we"4eu ad, 60 a wrvite[barge egnel to25%of ilia coatrad�D AND THATut if job 6`'R(aaRwd hy pareloppax,��T MAY AFTER SUiJE( TO REVIEW BY MY/OIIR g7GNATURE BH(.OW,1/GVE OF MY/OUR CREDIT• }US10RY AND I1FJE AUTHOR R HOME lt�JT TO VERIIIY AND REVIEW MY CREDIT RF(7OIW WTTH AN INDEpMH)ENT O TTORNBSPOORR M=RS)••lVCY AND t(EI,.FASE TFffiM FROM ALL LL&BM TY INCURRED FROM INADVERTENT BELOW,IN10 AGREE'70 BE BOUND BY THE TERMS Op THIS CONTRACT. t/WE BY MY/OUD 910NAT11R0 WACO F THIS CONTRACT ANDTWOCOhfPt.T MCOPIESOFTHENtTfICEACI(NOWLEDGBOFCANCEECATI N. Dote:SMhff TTDBY:ACCRPTED0Y Dee. emmmaar NtyIICE:ADDITIONAL TERMS AND CONDITIONS ARC MATED ON THE REVERSE SIDE AND ARE PART OF"US CONTRACT . .._ .-.- ,..-.- aawm._waaan Fite yailew-Creamer PIMr_3alea CmnuadM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print Legibly Name (Business/Organization/Individual): //p rM F Ve 0Qc j Address: o3 '1 5-5- P4 c if s �e R c� G City/State/Zip: I I lta h t 4 G 30 3 31 Phone #: G U() - E S 7- 5/ N Are you an employer?Check the appropriate box: Type of project(required): I.B I am a employer with /0 4. ❑ I am a general contractor and I 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. o workers' com right of exemption per MGL y [N p. 12.❑ R repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other r comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the nacre of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ( / [J t Insurance Company Narne:_/U e i_j - fl @ WP_5 I '� _T11 s- CO / Policy#or Self-ins. Lic. #: oZ 9 7 5 S Expiration Date: ^7 Job Site Address: Z�I eh,r,, City/State/Zip: fk_ ���R � 0 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify nd e p ns and penalties of perjury that the information provided ab ve is tru�and correct. Si natur Date: _ Phone#: _ 6'? - 02 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# in circle one Issuing Authority :( ) 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certifrcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia DATE 02/26/08 I PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IMarsh tisA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE i { .�. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certreguest@marah.com ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 INSURER'S AFFORDING COVERAGE NA.IC# F. (212) 948-0901 - — INSURED INSURER A.S taad:ast Ins Cc 26387 Boma Depot U.S.A., Inc. Zurich American Ina Co 16535 The Bose Depot, Inc. IN$URERB. —._ 2455 Paces Ferry Road INSURERC:Illineia Natl Ins Co 23817 Building C-8 Atlanta, GA 30339 IPISURER D:American Rome Assur Co 19380 INSURER E:New Hampshire Ins Co 238#1 III` COVERAGES 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 II POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY NUMBER PDATEY EFFp CTIVE PDATEWMI�IDT I LIMITS LTR NSRC TYPE OF INSURANCE A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACHOCCURRENCE $4,000,000 X DAMAG O N 1,000;000 COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS PREMISES Ea occurence $ CLAIMS MADEOCCUR "OF SIR: $1,000,000 PER CC"' MED EXP(Any one person) $EXCLUDE➢ PERSONAL&ADV INJURY $4,000,000 GENERALAGGREGATE $4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $4,000,000 g X POLICY PRO- LOC B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT $1,000,000 1 (Ea accident) X ANYAUTO ALLOWNEDAUTOS BODILY INJURY $ I P.,person) SCHEOULEDAUTOS HIREDAUTOS BODILYINJURY $ NON-OWNEDAUTOS (Peraoddent) X SELF INSURE➢ AUTO - PROPERTY DAMAGE $ N PHYSICAL DAMAGE (Perawieen0 GARAGELIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHERTHAN EA ACC $ AUTOONLY: AGG $ I1 A EXCESSIUMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE g5,000,000 f X OCCUR CLAIMS MADE AGGREGATE $5,000,0001 S DEDUCTIBLE $ p RETENTION $ $ C 03/01/09 X WC STATU- OTH- 7 C WORKERSCOMPENSATIONAND 1928757 (FL) 03/01/08 V D EMPLOYERSLIABILITY 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE E OFFICERIMEMBEREXCLUDEDT 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 Ifyes,deso'ibeunder E.L.DISEASE-POLICY LIMIT $1,000,000 SPECIAL PROVISIONS beb OTHER 03/Ol/OB 03/Ol/09 Occurrence/SIA 25M/2M P TX Employers Excess TNS-C45197967 (TX) D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS -FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2455 PACES FERRY RD., N.W. BUILDING C-8 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA (07 ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 NFRC— National Fenestration s,.;, L;kX:LAatafa i Si:. vidri:� i �i::3 •_ Rating Council® _ 5iu. Cri_la Can? r4is,,2'.1 s ENERGY PERFORMANCE RATINGS EVALUACION D—r A'NDINHENTO ENERGE71CO U-Factor Solar Heat Gain Coefficient Factor-U Caeficiente:Gwaancia de Energia Solar li 1 . L 0 . 24 lu it 11 d(Metrics/Sp ADDITIONAL PERFORMANCE RATINGS EVALUACION SUPLEMENTARIA DE RENDIMIENTO Visible Transmittance Transmision de Luz Visible 0 , 4� Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product performance.NFRC ratings are determined for a fixed set of environmental conditions and a specific product size.NFRC does not recommend any product and does not warrant the suitability of any product for any specific use.Consult manufacturers literature for other product performance information.ve w.nfm.org _______________________________________ Este fabricante estipula qua sates valores cumplen can los procedimientos aplaables do NFRC para determiner el rendimiento total del producto.Las valores usados per NFRC son determinados par un conjunto his de condiciones ambientales y un humans de producto especifico.NFRC no recomianda ningun producto y no gamntiza quo at producto sea adecuado para on usa especifco.Consults con el foliate del fabricame pars el use apropiado de sate producto.vnwv.rfrc.org Unit qualifl¢si for ENERGY STAR raglion(sI ; Northern, North . - Central, Sos:th Central, Southern. a £idEfviP STAA La unidad caliZica pass la(s) r¢gitin(¢s) ENERGY STAR: Nort¢, STC: 29 Sur Central, 5=. ` » . • IND: Rain Gal Glass 1f8"/H—LC23 " T¢st¢d Sir¢: 48" x 80^ IN➢: Re1u¢rro 0a/Vidrio 3.18 mm/H—LC25 DP • +2S —2S Tamat[o probado: 121.9 em x 203.2 em 6929649- g312a HS Farr¢ll 3606129 Keep this label for possible ENERGY STAR®rebates.To learn more visit www.energystar.gov Guorde esta efiqueta poll posibles reembalsos ENERGY STAR®Palo conceal rods aeerta de esto,visits w anergystacgay. Jogeugsfutwpl+ 6E£OE VO'b1NbW)/ i OZ#.w' `d121311H'J 8800 OOZE i a # 3NOl1Vd ONVHOW ' ➢waS awoH IV lDdaO awoH 3Hl r i... pae0 guawalddns ad61`: _. 3 y . BOOZ/E/A .ueitjeiliix3 {' f 21010V211N001N3W3/YONdW13WOH ' spIupuugS pus suop¢InSay dulplmH go p.zuog O CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT l_- VP.\i11IXtCJr�:3EET • j.\L!N, MANNA('.;d ,L C,i 'CFI:`i7&Ni-•)i95 r.%x; 979.74G9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 7SO CNIR section 111.5 Debris, and the provisions of IAGL c 40, S 54; Building Permit # _ is issued with the condition that the debris resulting c this work shall be disposed of in a properly licensed waste disposal facility as define by v1GL I 11. S 150A. The debris will be transported by: (name of hauler) fhe Icbris wilt be disposed of in (nar,:e or fa�i ty) .ulyd:�, tf I'x:� I;JI