1D SPRUANCE WAY - BUILDING INSPECTION (2) RFUIVED CKSO
Z, INSPECTIONAL S e Commonwealth of Massachusetts
Department of Public Safety
Vj� 2015 JUN I A % u4 htassachusensState Building Code(780CMR)
UV Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
J Budding Permit Number. Date Applied: Building Official:
\�(p SECTION 1:LOCATION(Please indicate Block k and Lot k for locations for which a street address is not available)
` No.Al Street City/Town ` Zip Code Name of Budding(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used_ J If New Construction check here Cl or check all that apply fit the two rows below
Existing Building❑ Repairvt I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of occupancy ❑ 1 Other ❑ Specify: 4
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review myuirrf1? Yes Cl No C�
Brief Description of Proposed Work: {}�f` l�y y�r I/✓✓��fJ/ir/
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 CbIR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE CROUP(Check as a livable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
R Facto F-t❑ F2❑ H: Hi h Hazard H-1❑. H-2 Cl H-3 ❑ H-d Cl H-5❑
1: Institutional I-1❑ I-2❑ f-3❑ [-1❑ M: Mercantile❑ R: Residential R-t❑ R-2❑ R-3❑ R4❑
S: Storage S-I❑ S-2❑ U- Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as, plicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: ML_\I Ijstori�l)nnmis.i,m 1'_�_�_ii•uf:.r'kt C
Nut Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:_ (kcupant Load per Flour:
Does the building Contain an Sprinkler System?: Special Stipulations:
0 uJ _
y
SECTION 9 PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner.
g��
Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information: +
�at{rk grl
Title Telephone No.(business) Telephone No. (cell) e-mail address
If a plicable,t e property owner hereby thorizes
u ( c~ !lt4RLnn 61,
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Re ' tered Professional Responsible for Construction Control
K I
Natpe(R istrant) Telephone No. mail address Registration Number
`C r,.l ,, r� _
Stree ddress ity/Town State Zip Discipline Expiration Date
�Ix U 1�i
10.2 Genera!Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address - City/Town State Zip
Telephone No. business Telephone No. cell e-mall address
SECTION 11:4V0RKE1t5'COMPENSATION INSURANCE APFIDAVI I' M.C.L.c.1511 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 13 No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
d. `lechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanicid Other $ Enclose check payable to
6.Total Cost $ — (contact municipality)and write check number here
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 containcvi in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 41 , /U
Name Date
r
Department of Standic ards
tety
Massachusetts DeP `!
Board of Building Regulations
Construcfion Supervisor Speaalty
License: CS5L417O
a„ g
o a
7I pU&f �.
SAUGUAUB S MA 01406 ��
`ry a E Piration
1212712016
Condnissioner
Vf2e r0omvmorwreal�o�vv�mac/wgeCl
UVOffice of Consumer Affairs&Business Regulation
OME IMPRn: ,1 E 05 CONTRACTOR
egistration �5163106 Type:
Expiration--,611112017A Private Corporatic
WINDOW CHOICES INfy
VINCENT KILROW
1 AUBURN CT.
SAUGUS,MA 01906 -'
Undersecretary
C & D REPLACEMENT WINDOW CO.
Established in 1976 k—
Mail All Contracts Attention: BRUCE'McLEOD 8 Arnold Road, Peabody, MA 01960 0
Telephone & Fax (978) 531-0672 `/�✓"''
NEW WOOD - VINYL - ALUMINUM WINDOWS & DOORS �—
WORK ORDER Home Improvement Contractors
PRICES GOOD FOR DAYS t License 101891
Salesperson's Name AA if e E a 1 r� �c`oD Date J-1es, Uf
r
OWNER: ® f 141c—CRA 70j(1 J!"T-
Address Phone Number `
WORK I SPeaA4-ed S,.LCeq
' Address �. Phone Number jr
HO BUILT YR
� D ELIVER 14. �N.tuGiToL1' +0
❑ INSTALL �Gs�S u�N../r_-Y � .� ,CAy.6 -r�_.,�,lfu� si►Lr w Y Q c-sA ..
_ �'orA /a/ ,�I�if/►'�s, sit �f G6.c%� G�/,�' C,,isuc.b �Q.r- a
r-
� r
I t
TOTAL PRICE $ 2 G o
1/3 TOTAL PRICE UPON SIGNING $
BALANCE ON DELIVERY $
BALANCE ON 50% COMPLETION $
t THE FINAL PAYMENT OF $
TO BE PAID UPON COMPLETION OF INSTALLATION.
Nothing else to be done unless agreed upon in writing by both parties, barring delays caused by circumstances beyond C&D control. Material and labor to be supplied
approximately 3-5 weeks from measuring.
WARRANTIES .^
All installations done by any contractors who do work for customers of C&D Window Co.will have liability insurance and installation will be warranted for 1 Year.
All materials are guaranteed by manufacturer ONLY. NO.OTHER WARRANTIES OR GUARANTIES, EXPRESS OR IMPLIED ARE AUTHORIZED UNLESS IN
ACCORDANCE WITH A STANDARD WRITTEN WARRANTY HELD BY A PURCHASER.The materials and items listed above are to be built to order for the purchaser and
therefore this agreement cannot be changed,varied,cancelled,modified or discharged or rescinded in whole or in part by the purchaser except without express written consent of
the seller.Seller does not guarantee performance in case of strikes,floods or other conditions beyond its control nor does any salesman or agent of the Seller have any authority
to change,in any manner,any conditions of this agreement as herein stated Not responsible for any pre-existing conditions in openings where new windows are to be installed,or
any painting or conditions or circumstances beyond its control resulting from or due to pre-existing contlitions.
Buyer agrees to pay for any and all legal fees required for collection of non pavment.
Contractor's Si naturel�'—/- "t .� Date��
DO NOT SIGN THIS g
IF THERE ARE ANY BLANK SPACES Owner's Signatureol Date
NOTICE OF CANCELLATION
Date of Transaction Sr 1_4 To cancel this transaction, mail or deliver a signed and dated copy of this
You may cancel this transaction, without any penalty or obligation cancellation notice or any other writeen notice,or send a telegram to:
within three business days from the above date. C & D REPLACEMENT WINDOW CO.
If you cancel any property traded in, any payments made by you '
under the contract or sale, and any negotiable instrument executed 8 Arnold Road, Peabody, MA 01960
by you will be returned within ten business days following receipt f'
by the Seller of your cancellation notice, and any security interest not later than midnight of •
arising out of the transaction will be cancelled. Date
hereby cancel this transaction.
Buyer's Signature Date
The cancellation date filled in on this notice is three days after the date of the transaction. In figuring the cancellation date: Sunday, New Year's Day, Washington's Birthday,
Memorial Day,Independence Day,Labor Day,Columbus Day,Veterans Day,Thanksgiving Day and Christmas Day should not be counted. t
The Commonwealth of Massachusetts
Department of IndustrialAccidenly
I Congress Street, Suite 100
Boston,NL4 02114-2017
www massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information �f Vs Please Print Le 'bl
Name(Business/Organizaa]tion/Individuu�al): l f`( 1y u i 'hu y
Address: I_Ag li 4 R h I -
City/State/Zip: 4 S - j. d��V la Phone M z o 0�G 6
Are you an employer?Check t e appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).• 7. ❑New construction
2.❑I am a.sole proprietor or parmetship and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t - 9. ❑Demolition
4.❑I am a homeowner and will be hying contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet ]3. Roof repairs
/r These subcontractors have employees and have workers'comp.insuranceJ 'e/
6.[�{We are a corporation and its officers have exercised their right of exemption pa MGL c. 14. Other �/IM
y yv f
A4 �52,§1(4),and we have no employees.[No workers'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.
tContmaors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontmctm have employees,they must provide their workers'c rip.policy number. '
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cSeasfpunder the pains and penalties ofperjury that the information provided above js true and correct.
Si stare: •����� Date:
Phone M � 2 �Gt7
Official use only. Do not write in this area,to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
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 certificate(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 permiMicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemut/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 dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 1 4-20 1 7.
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
i•
XFINfT'Y Connect Pasc 1 of 2
XFIN"Connect mcteodb@comeastne
+Font Size-
30 5pmance Way-window approvar.doc
From:Rose McGrath<Rose.McG;athons*.Ianalgric.mm> Mon,Jun 08,2015 0836.An
Subject: to Spniance Way-wirdnw approval.doc 4 2 attarhmeib
To:mcleodhgnccmrast.net
Here you go,3ruce. Have a niece day?
Rosemarie McGrath
TO: 11)Spruance Way
FROM: Jennifer Pappas, Property Manager
RE: Window Replacement
DATE: June 5, 2015
'k]Yy%KKa'JI�Y.A'Y[%KMA'*�.YW*X'Y YXk WX'*WW#�**'Y.YW#Y*''KYrPMY•#KYR#•KYIp�[*.W I% K'MX, LXX A*xk+Y.*�Kk
Please be advised that the Board of Trustees for Pickman Park has approved replacement
windows for the above referenced unit. 7 his approval is contingent upon them matching the
existing windows and that they fit in the existing opening. Installation of the windows roust
be campkfed from the interior of the mnit and they must be the same in appearance
from the exterior. Should the installation be completed from the exterior of the unit, you will
be responsible for any damage that your contractor might cause (this includes painting). The
Board will not allow windows with grids, crank outs, etc. Should you contractorfrnd any rotor
damage during the window installation, please make sure that it is reported to my office
immediately,
We also require that permits be pulled in advance (regardless of what your contractor may tell
you), and then a copy of the final approved per., once completed must be sent to APT for
the unit file as well. We also recommend that owners obtain a certificate of insurance from
the licensed contractor.
You will need to bring a copy of this letter to the Salem Building Department in order to
receive your permit.
Should you have any questions or require additional information, p!ease feel free to call me
https:;7web.maiI.comcast.neV7 cobra,^i/printrnessage^id=690440&:tz=AinericalNew_York&,... 618i2015 r
id ZLgO- gar luewwlpldalsAropu.A..,4'�-n
A��rt•, MTE MMIDO'CERTIFICATE I YY 1
_ E OF LIABILITY_ _A_BILITY 6NSURANC_E
�L �.12ziI !THIS CERTIFICATE 14 ISSUED AS A MATTER OF GATIV LY A ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TFOg
CERTIFICATE DOES NOT TEOFINSURANCE
AFFIRMATIVELY OR NEGATIVELY AMEND, (�J(TE ND TR ALTER THE COVERAGE AFFORDED BY THE POLICIES
j REt01N. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 8
REPRESENTATIVE OR_PRODUCER,AND THE CERTIFICATE HOLDER, BETWEEN THE LSRLANG INSURER(S), AUTHORIZED
I" _----1._.__.__.._.__._
IMPOf7PAN1`. d the ceRifrcat¢holder i3 an ADDfROMAL INSURED'thee poO lea) must be endOrg¢d. If 5 BR ATION IS- AIVED,su the terms and conditions of the policy certain p011640ITHY Inquire an endorsement. A statement bo t to
Oertific_nte balder in Iles'Of such endora¢mentls). nt on flea cardfi�te tices not confer rights to the
PROWLER OONTACT
Ralph J. SJui.nn Ins. Agency nMpI.E'E Raln2i, uinn "
I 15 Mair. Street (781) 395_8400 _• L061) 393-8DR3
Mec9ford, MA 02155
�IDDREg RJQuinnInsu=anr_e@nntsr_ape.nei_.
INBUREIBS)AFFOROING COVERAGE
-_---. —'-" NSU ERA:F�rs Finang:ial n3 CO 1.1177
INISURIVID ----
WiNDCW CHOICES ZTC _ INR�RERa:JU) Mouth Rock AssurancS, 4 !(1104154
1 AUBURN COURT al I%JRERC:p',M MUtt." �
--- --I—
SAUGUS, MA 01906 INSURERCL�_
COVERAGES CERTIFICATENUMBER: REVISION NUMBER; i
iIS IS TO CERTIFY THAT THE POLICIES OF INSURr,NOE'!STEO BELOW HAbg BEEN ISSUED TO THE INSURED NA MED INDrATI37. NOTWITHSTANDING ANY REQUIREMENT,TERM OR -,0N..rN7ON OF ANY CONTRACT OR OTHER❑UCUMt w'H RESPENJE FOR CEITULW YmP�IQS
CERTIF;L A,TE MA" BE ISSUED OR MAY PERTAIN. THE INta.IRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
ER.,LUSCNS ANDCON_DITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS,�� 'y EFF IN
IX
RT IPF,OF INSURANCE _ itNRRI W.D POU C''NUMBER MMICO'YYYY IIMMIDD'YY TI _
�p GENERAL LIAEIIJTY LIMITS
.-C CBC20000426OU0 i 4/27/151 4/z7/16 EACN OCrVB ! -?
VMERCIAL GENE PAL OAB I DAWCETO gE~'iI1'Eri j _DD�" OO
"' W ANDF• J Isar(-ate B l 000�J LJc ncitlR I i � -�--i- 1r_44, ,
ER ADV T—nn
Fso wLS Iµ1JRy Iµl ,I ��1-,900.
3WI GGRI.iiw1TEOMT IUE__.NfPFLAG C-RELATE S'12 OD OOO
Af,'P L'E3 FER
I 1�
"� PF{O4UCr0. CO T]P AfiG i$ 12,Qy�O O,Q)0 .
•.AUT0IJgaILiIL*ERl"Y 7- ' ; .. .
Y .�RAOOD 0116394 /x9/1s T/19J 6 iacubarA I "�L J' ..
vdYAU'M1v '1 SgDIL !NJLIRY(Per I-MM) I' 7
fLL O1'JNEU .•^C+EDULCO
AUTOS x r �L��OQ�I OO
tl0lI,OVAAEC !•eCShILY IN LIRV(PA ymlu+rU1 t
�" HIREDAUTrs x l'OH-O .PROPE47f'CM1gJt,'Rr -1 3O G1-O G.OM
1 '�-�-- __ "�I.L4rITCP1t1 OJ
i UAf¢RE11A L!A9 L UC()LIR �W •i
EACH OCCURRENCE g
-�—
_ PED RETE/�SLvE_
C i riUP.1fER5 COMPENSATION
ANP EMPLOYFRR'L14nItITy dWC-100-•60183..2-201 2/29/15 2/28,�i 6'r CSFi AT,u- "TpI-H-
SW FROPRIETUR'PARTNEMYE-'C;Thf Y(N '
WI:,ER?,1EMBER EJRr:.LOEOC I N
ArOI-Ory In NH) !AI EL CH AC^ 'M_ SOO,000>�
- I
Ia^ne�mL�under I E ,�Ise9SE- am+PIO�EEi3__ 100i000, 1
_�r'�_t`RIPTON O�-OPF jti roN$Je;n'u
A •ATITONOBIT.E LIABILITY - `-�- E.L D!E EASE POLICYL(MIT i s 5 Qi00�i
—� NIRFt' AUTO CBC20000426000 4/27/I51� 4/27/16IOCCURFINCE
NON-OWNEE) 1;000,000
_LAGGREGATE _2_C40,OUO
OESCRI'nJNOF CJ+ERATIDNSI LOCATICNS'VEHICLES (AaeM ACORp'iD1.AM11oIMl Reim Rn BMedWp„T A'ae Brace grcgNrNOI —
I
i
%EPTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUC'IES BE CANCELLED BEFORE
THIS CEItTIPICATE OF INSTJRANCR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
IS PROVIDED AS A CURRENT AMCIRDANCE WITH THE POLICY PROVISIONS.
EVIDENCE DF INSURANCE AUTHC.R4Eh Pr_PREs4NranvE —=--a
AS OF MAY 21, 2015
QUINN
'CORD 25(20TOItTSI The ACORD name and logo are re;Tletered arks of2ACORDORU CORPORATION. All rghts res¢rvad.
'One! (8'77 )47-3639 Fax: (866) 280-3621 E-Mail;
QTY OF SALEM, MASSAaR SE TIS
BUILDING DEPARTMENT
120 WASHMTON STREET,3'D R.00R
TEL(978)745-9595
FAX(978)740-9846
KINIBERLEYDRIS�LL
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBIJUROPERTY/BLIIE DING ODO&SSIOMR
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
li✓�/�i% uti
(name of facility)
(address of facility)
0
Signature of applicant
Date