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4 UPHAM ST - BUILDING INSPECTION S Z Lk z) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: L Data Building Official(Print Name) Si Date SEC ION 1:SITE F 1.1 Property Atidyess; , t ���� 1.2 Assessors Map&Parcel Numbers l.l a Is this an a ted s es , no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of d: 2 h 11yl.t Name(Print) v City,State,ZIP '. No.an Streety �� Teleo`� Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check al hat apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work: .— i SECTION :E -rtmATED CONSTRUCTION C STS Item Estimated Costs: Official se Onl r (Labor and Materials y 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Applica ion Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:_ 5.Mechanical (Fire $ Suppression) Total All Fees:$ heck No. i Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction SM rcen (CSL) " "T License Expimt n spl Name of CSL Hol r - r4�/�,/ List CSL Type(see below)_ 1�{ I _� No.and Type Description U Unrestricted(Buildings up to 35,000 cu.ft. �- R Restricted 1&2 Family Dwelling City/I'own,State,71P M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registe d ome m roved for{ — HIC Company Name or lAt/LrL� - '�I HIC R gstrati- ber Ex*,, me �HCIre is tNam S Email address NyMwn,State,ZHY P Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 Issuanc5oMe building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize �5a to act on my behalf,in all matters relative to work authorized by this building permit application. n Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION ent By 'ng my name below,I hereby attest 101der the pains V penalties of perjury that all of the information coNedthis a s true and orate est my owledge and understanding. 7ft Pris r uthorized Ag a(EI igna a ate NOTES: 1. 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 Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at Information on the Construction Supervisor License can be found at 2. When substantial work is planned,provide the information below: Total floor 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" r �, 08/28/2013 19:00 FAX R 001 HOMES)IMPROVEMENT CONTRACT PLEASE READ THIS Sold. Ivrnished and Installed by: Branch Name; Boston Dater 61,20/-3 TI ID At-I lomo Services,Inc. —(_j dAda The Home Depot At-florae Services q08 Boston•rurnpike.Unit I.Shrewsbury,MA 01545 Toll Free(800)657-5182; Fax (509) 945•6017 Branch Number, 31 Feduml ID 41 75-2698460;\IE Lic d C 02439 Ill Cont.L.ic# 16427 f`I Lic S I HC 0565511;.\MA I loin,•Impnnvemcnt Contractor Reg.8 126P9 InstullationAddress. ✓.) Cie!j•i . .. 7_'7�......_._._.._ . ._._._.SC?(eff t ... ... ,..., .....__�1�!_S�__ City Slate Zip Purcha,er(s): )York Phune: linen Phone: Cell Phone, �j/��v �:�.� : I I I lrryai �5r5 a y�8-• [ i I Home Address: (if different train installation Address) City State Zip U-mail Address(to receive proiect communications and Home (spot updates): .-.. .. .... .. . ....._.._..... ----------_—_ La1 DO NOT wish to receive any mnrkctinV,entails I'mnl The I ionic Depot Protect Informrtthm: Undcrsfened("Customer-),the owners ofthe property loraled at the#tore installation address, agrees to buy. kind TIiD At-Ilmne Services, Inc. ("The Home Depot") aprecs to furnish, deliver and arrange for the installation ('-Installation") of all materials described oil the bvinw ;mil kill the relivenced Spec Shea(%). all of which are incorporated into this Contract by this reference, along with any applicable Slate Supplement and Payment Smnmmy attached hereto and any Chmtge Orders(collectively. "Contract"): full#: rtmmaia krrn rr Producis: _ � ljcct Amount c Shcel(s)#: Pr 7(a9 7.2� 7 i kunfing ❑SidinE ❑Windows ❑ Insulaliun /1;G 6 r 2 ❑Uullers/Coven WGmn•Doors ❑ Q S .. - I S J j 17 ..._.._ i ❑Ro+ling ❑Sidin(_• ndows . ... . .. _ ❑R'i ❑IttxlrlatlOn 1 . UGutrers I Cover% ❑leery Doors ❑ . . _._ ... � l . ..._ .- .._.. . . ._ ❑ILtuling ❑Siding ❑Win-duwa ❑luwlatiuu :5 ❑('utters/Cm'ea ❑limy Dnnn❑.,—..._._..._..__._... ❑Roorinp ❑$idiug ❑wiadnw:N ❑]n�u)ndM) I .—.—_—._...__..... . ._. . ❑Uuecn/C'ut,`rs [Jl3ntry Dnon ❑ � 'S Minhmrm2 %DLptuit of Contrvti.meant due apart execution of this cuntrxai, Total Contract Arnwtnt $ Maim Purchasers may nol depo4t lure limn rue-third of the Contract Amount. Customer agrees that, immediately upon completion of the work for each Product. Cwtalner will execute it Completion Certificate (one for each Product as defined by an individual Spcc Sheol) and pay any balance due. As applicable, each Customer under this Contract agrees to he jointly and wverally obligated and liable hereunder. The Home Depot reserves the right lit issue a Change Order or terminate this Contract or any individual Product(s) included herein. to its discretion, it The Hume Deficit ar its aulhol'iftli service provider determines that it cannot perform its obligations due to a suvclulal prohlent with the home, environmental hazards such its mold, asbestos or lead paint. other safety concerns, pricing errors ur becauso work required to complete the job was not included io the Contract. Payment Sualmary: The, Payment Smnulary # r//LSD'3 —.—_—, included as pan of'this Contract, sets forth the tolol Contract amount and payments required for(tic deposits and haul payntetlts by Product (as applicable). NOTICE TO CUSTOMER Ymr are entitled to a completely BiktLin copy of the Contract in the time you sign. Do not mgn a Completion Certificate(note, there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product fs complete. In the event of termination of this Contract, Customer aRmes to pay"I lie!loom Depot the costs of materials, labor, expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. 1T1E(TOME DEPOT MAY WI.1.111101.0 AMOUNTS OWED TO THE HOME DEPOT FROM THP DEPOSIT PAYMI-'NT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Accentunce and Authorization: Cusnnner agrees and undcrsmds that this Agwomeul in the emirs ugroenu0nl helwoen CIlxtlnllet' and']he Home Depot with regard la the PA111LAUS;end hmInlllamll tierv:eex and slllter:-selle%all pr fur ili%cussion5 and a"leenlents,either and or writlon. Minting to said Products and Installation. This Agreement cannot he assigned or:intended except by it writing signed by Customer and The Ilonie Depot. Custmlxr acknowledges :red agrees that Customer has rend.understands,voluntarily accepts the terms of and has received a copy of this Agreement. 08/28/2013 19:00 FAX 2002 ................ __sees.------- — — — (fl'dil'fcrent 111L11 fnsntll:pi )n Address) Oily Stntc Zip E-mail Address(it)receive project communications and Home Depot updates): ®,I DO NOT wish to receive any marketing entails t}om The Monts Depot Prated Inlbrmation; Undersigned("Customer').the owners of the property located at the above installation address,agrees to buy. ;rid l'HD At Houle Services. Inc. ("The Halm Depot") agrees to tarnish. deliver and arrange tin'the installation("Instullalidii') of all materials dosr dbud on the below told on the refctcnced Spec Sheclis). till ul' which are incorporated iut/ this Contract b'y this � reference, along Willi any applicable State Supplement and Payment Sunnnau'a munched hereto and any Change Orders (collectively, "Contract"): .tub#: ti.ne"d za,,,.„•. Products: Slice Sheel(s)#: Project Amount ❑Rarling ❑Siding Q Winth,ws ❑ Imnlatiun 16EV es—' r.�^7 ��9 �•�.,� 7 I ❑Clutters/Covers PEmq Doors [_f .._..........._....... . p tJ J J o sees------------- T❑Roofing ❑siding ❑Windows loa Ulioll t ❑Clutters I CON CD iItanry Ihwrs ❑ _sees... ... .. ..... .. ... .... ..._ . ._sees,sees. ❑Renato& ❑Siding: ❑Windows Insulation ❑Guitars/Cutters ❑[ntq�Doer,❑—_,,,,,, ,,,, M ❑R,ndlog ❑Siding ❑Window, ❑Insulation ----- ❑Guuea /Cove.N ❑Larry tours ❑ Minbam 25%Deposit of Comruct Amount dins uptinexeculionofthRetmaracl. Total Contract Amount 1; S53o'_ Maine Pcuelautt's nW riot deposit more than ont-thine or the C alract nniount. Customer agrees that, immcdimcly up(rt completion of the work fn' each Product. Customer will execute it Completion Cenificate (tine liar each Produce as dePucd by uu individual Spcc Sheet) and pay tiny balance due. As applicable, each Customer under• this Contract agrees to be jointly and severally obligated anti liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein,id its discretion,if The Home Depot or its authorized service provider dciermincs that it cannot perform its obligation,(Inc!to a structural problem with the home,environmental hazards such us mold. asbcsios or lead paint. other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: "I he Payment Summary #...?.116-;p 3 included as part (it' this Contract, sets forth the total Ctimruct amount anti payments required for the deposits and final payments by Product (its applicable). NOTICE.TO CUSTOMER You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Complctiml Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product is complete. fit the event of termination of this Contract,Customer agrees it)pay The Home Depot the costs of materials, labor, expenses and services provided by The Hume Depot or Authorized Service Provider through the date of termination, plus any tither amounts set forth in this Agreement or allowed trader applicable law. THE. HOME.DEPOT MAY WITHHOLD AMOUNTS OWED TO THE: HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTIIER PAYMENTS MADE., WITHOUT LIMITING THE HOMF,DEPOT'S OTHER REM HDIES FOR RECOVERY OF SUCH AMOUNTS. Aceentance and Authorization: Customer agrees and miderNhnds that Ibis Agreement is the entire ugrcenu tit between Customer and The Home Repot with regard to the Products:rod Installation services anti supersedes till prier discutisious and agltenn+nlz. cithar oral or written. relating to said Products uml Insiallation. 11iis Agreement cannot he assigner) or amended except by a writing signed by Customer and The Hnme Depot. Customer acknowledges and agrrces that Customer has read, undcrstnnds, volunwrily accepts thr, terms of and bus received a copy ol'this Agreement. Accepted by: - submit hv: — .(. sees war ... ----......__ ....... sees... _ _. . . g/26//3 Customer's Signature w� Sales Consultant's Signattrr Date x'-"—'------'--`----- --._.—.....-....._._.— Telephone No. Customers Signature Vine Sales Consultant License Na. CANCIiLLATIOM CUSTOMER MAY CANCEL THIS nnppti"'I't`'I AGREEMENT WI'TIIOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME i DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AI•"PER SIGNING THIS AGREEMENT. THE STATE. SUPPLEMENT ATTACHED HERETO CONTAINS A VORM TO USP: IV ONE. IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE.. NO. RT.:A1113I1'll INAL'r1iRNS AND CONUII'IONS ARE ST.10 ED ON THE.REVERSE SIDE AND ARE YARI't)f'1-11IS('ONTRAC'I' 10-11-12 White-BnnchRe Yellow-Customer f i.`..'� 9.'2 •l t�,„-'�Y.J37 rat :tip i.i ��xZS;zia. e-;$:i::, ; t "irtt For-1 •'�.'�,�_� �,�y73J7"�+rt;'ftt ��+ldt&,S' la'y/<�,{,gd� ryi',� d` H n „k Bfisto.n, KA 02 114- 01 i Workers' 'Conaa➢CZ:snfion Ins$3rnncx. AffIfLi '3 . Builtat,"rs13��'?r`:{ r��a��nt°�I�t��7i'ar�ti�4isir�t �iz�s = "riser �.e• ua�i} � Name '^'38 P l � Address: a „ " + f _ — � .. v , 4r.v City/Stale/Lip: �➢' � � Phone #: ; � Are y an employer? Check the appropriate box: 'Type of project(required): 1, I am z employer with_ _ 4. .❑ I am a genera'_contractor and I employees(full and/or part-time). ' have hired the sub-contractors 6. ❑ Nev✓.construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ha ve ave ship and have no employees These sub-contractors8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.+ 9. ❑ Building addition [No workers'.comp. insurance comp, 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 L❑ Plumbing repairs or additions myself. ' right of exemption per MGL Y �o workers comp. 12.❑ Ro IF repaJus insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13. Other 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 name 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 thepo/icy and job site information. Insurance Company Policy ii or Self-ins. Lic. Expiration Date: € h — -- - . Job Site Address: City/State/Zip: Attacha copy of the workers' cortaapePA times po➢icy declaratioan page(showing the pokey number andexpiratfiois date). Failure to secure coverage e.s required under 5A of.MGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisontnent, as well m 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 for insurance coverage verification. d do hereby certij and r dig pal. antipenalties of ray that the information ovided above is tr*e and correct, -- - Si ature: Dater Phone#: Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License# Issuing Authority(circle one): - &.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Numbing Inspector 6.Other Contact Person: Phone#: A �® CERTIFICATE ®F LIABILITY IIV URAIVCE DATE12013 YY, 01J272013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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 MARSH USA.INC. NAME: TWO ALLIANCE CENTER fAIC.No PHONE E t_ qIC No) 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 aOOReSS: - INSURERS)AFFORDING COVERAGE NAIC p 100492-HomeD.GAW-1314 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zunch American Insurance Go 16635 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C,New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NIN I INSURER o:Illinois National Ins Co 23917 BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUMBER:7 .. 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 TYPE OF INSURANCE ADDL SURR POLICY NUMBER MMNOIYYYY MMIDO/YUP LIMITS RINSR Me A GENERAI LIABILITY GL04887714-03 03%2013 0310112014 EACH OCCURRENCE $ 9.000,000 X - pAMAGe TORENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISE Ea omurrence $ CLAIMS-MADE OCCUR LIMITS OF POLICY XS - MED UP(my one person) $ EXCLUDED OF SIR:$IMPER000 PERSONAL B ADV INJURY $ 9,000,000 GENERALAGGREGATE $ 9,000,000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 9,000,000 X POLICY PRO- LOC $ JECTB AUTOMOBILE LIABILITY BAP2938863-10 0310112013 03ro112014 COMBINED SINGLE LIMIT 1,000,000 Ea accitlenl X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED F7 SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS - NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per ocadenl UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS.MADE AGGREGATE $ DIED RETENTIONS $ C WORKERS COMPENSATION WC033575314(ADS) 0310112013 0310112014 X we STATU- OTH- AND EMPLOYERS'LIABILITY TQRY LIMITS ER G ANY PROPRIETOWPARTNEWEXECOTIVE YIN W0033575315(AK,AZ) 0310112013 0310112014 EL'EACH ACCIDENT $ 1,000,000 D OFFICERIMEMBER EXCLUDED? NIA WC033575316(FL 0310112013 0310112014 1,000,000 (Mandatory In NH) I EL.DISEASE-EA EMPLOYE $ If yes,describe under 1,000,006 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 8 C WORKERS COMPENSATION WG033575317(KY,NC,NH,VT) 0310112013 0310112D14 (EL)LIMIT 1,000,000 C - WC03357531B(NJ) 03/012013 031012014 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD101,Additional RemarksSchedule.Itmorespace is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION - THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING C-20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA too. Manashi Mukherjee �Knuaoti: �}+4�a1[-names ._ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ,. .CJ9e l�cru�r4r sr2tttLfi, o� ///l r.2eua:ta r � Ofree of Coasamer AfSnv Bnsin s Regui i4inn Lice use oa icgsira'iioaa Yaisz ffor iaeda�aUo9 use o:sly �I�IImo ' IOME IMPROVEMENT CONTRACTOR ; befueAbe ext,iradoaa.rant If found return to: s Office of Consumer Affairs P a .grass Iiegnlatar: Registration 126 93 Type�= a 4 /Y 10 Park Plaza Suite 5170 Expira°ron g/3i2014 Su, lenent 3ard 2 !P Boston,Pt3A 0_116 ., - The Home Depot At sortie SeFvices . RICFIARD 2690 CUMBERLANiD PARKWAY S A'fTLAI�4`A,GA 30339 - Undersecretary, _ lot valid vNthout siignaturx q CITY OF &U ENI, UNSSACHUSETTS BU:ILDL\G DEPARTMENT 120 WASHNGTON STREET,31°FLOOR TEL. (978) 745-9595 1 X(978) 740-9846 Kl,%jBHAI.EY WUSCOLL MAYOR THOMIS ST.PIERM DIRECTOR OF PUBLIC PROPERTY/BU uzr NG COSL\IISSIONER Construction Debris Disposal Affidavit (required for 0 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 will be transported by: (name of hauler) The debris will be disposed of in ( —_ --IAname 1 I�me of f"aci'lilly)) (address of facility) Si tore of ermit applicant *at dcbriwtl7 due Massachusetts - Department of PUS { -rtv i . . 9oa;d of8uiiJing Regulations ans 5t3nd ras _.i,-ense. CSSL-099699 RO�BppEp�g8'e¢F�yCZ eBp91p@ 172 V HAL6'i1VS WIUlV 1I� r . ;Scakm MA 01970 ( ' a Jaw+ �A4.W.ny ..G, =ir;.it!e.R rcnnstjisti�uncr .��t�al���a�c �