37 WINTER ISLAND RD - BUILDING INSPECTION (7) The Commonwealth of Massachusetts FOR
b Board of Building Regulations and Standards MUNICIPALITY
\ Massachusetts State Building Code, 780 CMR, 7`h edition USE
{ Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
4 One-or Two-Family Dwelling 1, 2008
U� Th' Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Corruri si net/Inspector o Buil i gs Date
SECTI 1: SITE INFORMATION
1.1 Propert,yy Address: 1.2 Assessors Map&Parcel Numbers
yJ(IYYe S�Cax C�
l.la Is this an accepted street?yes_ 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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
N � �p
Owner of Record ��
r Y-�
Name( int) O u 5�1t� ess£o Service:
j - � 1�24 - iogCA
t'--Signatuie-f Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: VC ^ GO
Brief Description of Proposed Work': 3
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building Q 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town 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 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number Expiration Date
Name of CSL-9 Holder ox List CSL Type(see below)
-Y�x 1� Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Only
roYr 1 - 4& RC Residential R oofin Covering
'-Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 RRegsAere�Home I upro��t Contractor(HIC)
H Company Name or HIC Regis t Name Registration Number
r- Q bob �-1 r� &AA G30-7n —t!?4 I 1i
AAlIdress /-
`\`.�7 Expiration Dale
Signature Telep one
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 Issuance of 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
****Owner to Sign****
12p� as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to w a ized by adding permit application.
31 �
�eSi`naNrre9w g5 Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
****Contractor to Sign****
('xoa S� A�—N " ` 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.
Q--4 CaY ICCf. CtV.� 1
Print Name
r re of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
SECTION 7c: HOMEOWNER LICENSE EXEMPTION
****To be tilled out when Homeowner performs work.****
The Mass. State Building Code, 7"Edition(780 CMR)provides that any homeowner performing work for which a
building permit is required is exempt from producing a Construction Supervisor License; provided that if the
homeowner engages a person for hire to do such work,that such homeowner shall act as supervisor.
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 and Construction Supervisor
Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
1 ,as Owner or Authorized Agent understand that
as the homeowner performing my own work,I waive any and all rights provided for in sections B,C.D of the Mass.
State Building Code and further,will comply with the Amesbury Zoning By-laws requirements.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
"Total Project Square Footage"may be substituted for"Total Project Cost"
I
INSPECTIONS:
It is the responsibility of the Contractor/Homeowner to notify the Building Official when work is ready for
inspection. No work should b e covered before it is inspected and approved. Scheduled inspections are as
follows:
o Footings prior to concrete placement.
o Foundation walls prior to backfilling(perimeter drains and foundation sealing required).
o Rough framing,prior to insulating(electric, plumbing and gas inspections prior to rough inspection).
o Insulation inspection
o Final inspection prior to occupancy.
o And on such occasions that the Building Official may designate.
REMINDERS/REQUIREMENTS:
✓ If installing a fireplace or solid fuel appliance, a copy of the specifications are required.
✓ Homeowner is to sign the application, in addition to the contract.
✓ Contractor to sign application.
✓ Drawings/Specifications are required when remodeling/building.
t� ✓ Setbacks are required when installing additions,decks, etc.
✓ You must enclose a copy of the signed invoice/agreement between the homeowner and
contractor.
✓ Copies are to be provided with the application. $.50 per copy will be charged per copy needed
to complete the application.
f'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investkations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrieians/Plumbers
Applicant Information Please
ePPrint
�Left
ibly
Name(Business/Organ zwon/Individual): ffy
Address �60
City/State/Zip b C� l N� Chore#:
you an employer?Che the appropriate boa: Type of project(required):
I am a employer wiffi _ 4. ❑I am a general cont-actor and I 6. ❑New construction
v —employees(full and/or part-ti
me).* have hired the sub-contractors
7- Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t ❑
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp-insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑We ate a corporation and its 10.❑Electrical repairs or additions
required-] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'coup. e.152,§1(4),and we have no l�R,apfrepairs
insurance requitrA l t employees.[No workers' 13.❑Other
Comp.insurance required-3
'Any applicant that checks box41 must also]ill outtlre section below sbowingtheir wo&m,compensation policy information.
t Homeowners who submit this affidavit indicatingthey are doing all work and then hire ,Wdc connectors must submit snow affidavit indicating sack
loonuadors that check this box must attached ao additional sheet showing the mime ofthu sobcaanactors and their wodccs'comp.policy udbrmatine.
Iam an employer that isproviding workers'eaatpensation insurance for lacy employee& Below is thepii and job site
' informadon.
Insurance Company Name:
POlioy#or self-ins.Lic.#: 1 AY ��' \S���rj _�`OZ1 Expiration Date' 2K4
Job SiteAddress:�5J L (V. � lJ G O 'ems k Citylstate/Zip• JP v
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 ofMGL c. 152 can lead to the imposition of criminal penalties of s
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 ofthe DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofpedury that the infornradon provided cave is true and correct
Si
\�c )
Phone#:
Oiic' use only. Do not write in this area to be completed by city or town ojJiciat
City or Town: Permit/1,icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Telephone: (603) 898,4468 CONTRACT Cell: (603) 235-7624
oli Free: (800)458-4468 Fax: (603) 598-6942
A.J. WOOD CONSTRUCTION, INC.
P.O.Box 1769
Salem,New Hampshire 03079
Email:info@ajwoodconstruction.net
Website:www.ajwoodconstruction.net
ROOFING•SIDING•WINDOWS•DECKS•KITCHEN&BATH REMODELING
Workmen's Compensation and General Liability Carried on All Work
Date July 30.2010
I (we), the undersigned, hereby accept your proposal to furnish Labor and Materials to perform the following work on premises
located at the following address:
No. 37 Winter Island Road Salem MA 01970
(Street) (City) (State) (Zipcode)
Owner's Name Plummer Home For Boys c%James Lister Telephone Number: (978)744-1029
Address Email• ifigff@plummerhome.org
SPECIFICATIONS OF CONTRACT
Strip of all existing roofing material. Install ice and water shield on all roof edges, valleys and roofing protrusions. Install GAF
Shinglemate roofing underlayment with 8"aluminum drip edge. Install 30 year roofing shingles with a Cobra ridge vent on peak. All
permits and debris removal included Homeowner is responsible for the protection of all trees, shrubs,and flowerbeds. We guarantee
our workmanship and provide a one(1)year Labor Only Warranty from date of completion.
There will be no chimney work or board replacement work done for free,it will be an additional cost.If chimneys are in poor
condition and are not addressed at the time of work the contractor will not be held responsible.
Required permits — The following building permits are required and will be secured by the contractor as the homeowners agent.
Proposed start and completion schedule will be adhered to unless circumstances beyond the contractors control arise. The contractor
will start the project within 30 days and the project will be done within 60 days of the start day.
The contractor aarees to performthe work furnish the materials and labor specified above for the
Total Sam Of$36 000 00(Thirty Six Thousand Dollars and 00/00) '
Payments will be made according to the following schedule
1/3 due with sieved contract: S12,000.00(Twelve Thousand Dollars and 00/100)
1/3 Due When Project Is 50%Complete; $12 000 00(Twelve Thousand Dollars and 00/100)
1/3 Due When Project Is 100%Complete:$12 000 00(Twelve Thousand Dollars and 00/100)
Additional Work To Be Considered
Lower Shingled Roof:
Strip of all existing roofing material. Install ice and water shield on all roof edges, valleys and roofing protrusions. Install GAF
Shinglemate roofing underlayment with 8"aluminum drip edge. Install 30 year roofing shingles with a Cobra ridge vent on peak. All
permits and debris removal included Homeowner is responsible for the protection of all trees, shrubs, and flowerbeds. We guarantee
our workmanship and provide a one(1)year Labor Only Warranty from date of completion.
The contractor agrees to perform the work,furnish the materials and labor specified above for the
Total Sum Of$3 000 00(Three Thousand Dollars and 00100) `
Payments will be made according to the following schedule:
1/3 due with signed contract: $1 000 00(One Thousand Dollars and 001100)
I
Alternative One:
Fully Ice and Water Entire Roof
The contractor a s to perform the work,f nmish the materials and labor specified above for the
Total Sum Of$4 000 00(Four Thousand Dollars and 00/00) '
Payments will be made according to the following schedule
1/3 due with signed contract $1 300 00(One Thousand Three Hundred Dollars and 00/100)
1/3 Due When Proiect Is 50%Complete: $1 300 00(One Thousand Three Hundred Dollars and 00/100)
1/3 Due When Project Is 100%Complete: $1,400.00(One Thousand Four Hundred Dollars and 00/100)
M Including all finance charges (•')Law requires that any deposit or down payment required by the contractor before any work
begins may not except the greater of(a) 1/3 of the contract price or (b) the actual cost of any special equipment or custom made
material which must be special ordered in advance to meet the completion of schedule.
You may cancel this agreement if it has been signed at a place other than the contractors normal place of business, proved you notify
the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than
midnight of the third business day following the signing of this agreement. See attached notice of cancellation form for an explanation
of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies of the contract must be completed and signed.One copy should go to the homeowner.The other copy should be
kept by the contractor.
• All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation—(617)973-8700
10 Park Plaza, Suite 5170
Boston,MA 02116
Owner agrees that the title or equity in this property is his and is security for this contract.
IN WITNESS WHEREOF the undersigned has(have)hereunto set his(their)hand(s)the day and year first above written.
Buyer(s)Acknowledge Receiving a Completed Legible Copy of This Contract
This contract[aaye voided by the Owners giving written notice to the Contractor by ordina mail within three full business
days followinate hereof.
g L.S.y
(Ric J. Smr esr en (Legal o er o o erty to be improved)
337 verhill Rd., Chester,NH 03036 Plumme fame For Boys
FID: 20-0487037
HIC#: 106603 t
�.Pyo(cuj
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
- Registration: 106603
_- Type: Private Corporation
Expiration: 7/2 412 0 1 2 Trk 297944
AJ WOOD CONSTRUCTION, INC. T
Richard Smith -
PO BOX 1769
SALEM, NH 03079 — --
Update Address and return card.Mark reason for change.
- ❑ Address ❑ Renewal ❑ Employment Cj Lost Card
DPS-CA1 Ca 50M-0/04G101216
Office'&1i airs Bilsi ess Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 106603 Type: Office of Consumer Affairs and Business Regulation
Expiration 724/2012 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
AJ' OOD CONSTRUCTION,-
-INC..-Richard Smith - -
4 RUSTIC LANE
DERRY,NH 03038 U
.. - —�
ndersecretap• Not valid without signature
Commonwealth of Massachusetts
>l;iss;ichu•ctu- Department Of Public Safe" Division of Occupational Safety �
7 Buard of Buildin_ Reculxtions and Standards
ervisor License HealherE Rowe,Acting CommissWer 1W
Construction Sup Deleader-Contractor
License: CS 70882
RICHARD S. SMITH
Restricted to: 00
Ex 07 Date / 1
RICHARD J SMITH Exp.Date 07/10110/11
r
PO BOX 1769 DC001721
SALEM, NH_03079 _ Membwc1 .O.N.ES.T.
BO II II
Expiration: 7282011 hill It III1III IIIIIIIIBOSTO
N-RENEW
Tr: 19314
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ACORD. CERTIFICATE OF LIABILITY INSURANCE C0311 IDI010
03/10YL010
PRODUCER- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
182 Parker St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Lawrence, MA 01843
978-681-1112 INSURERS AFFORDING COVERAGE NAIC#
INSURED A.J.Wood Construction,Inc. - INSURER A. Liberty mutual Ins.
P.O.Box INSURER B:
Salem,NH 03079 uRBURERc:
PLSURER O
NSURER E:
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
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR PDLICY NUMBER i POLICYEFFECTIVE POUCYEXPIRATIONDATE 000111DOMI LIMITS
GENERALLUIBILIrY EACHOCCURRENCE 15 _
COMMERCIAL GENERAL DABILOY PREMISESIM=1 S
I CLAIMS MADE OOCCUR I MEOEXP(Myvneparson) S
PERSONAL B AOV INJURY S
GENERAL AGGREGATE S
GENLAGGREGATELIMITAPPLESPER :PRODUCTS-COMP(OP AGG S
POLICY PRO- LOC
AUTOMOBILE LIABILRY COMBINED SINGLE LIMIT
ANY AUTO (Ea.o deN) S
ALLOWNED AUTOS DODILY INJURY
SCHEDULEDAUTOS (Petpvrs * S
HIREDAUTOS _ BODILY INJURY
NON-OWNSD AUTOS (Pwacddm) $
PROPERTY DAMAGE 5
(Pwaccidm)
I GARAGE LABILITY AUTOONLY-EAACCID£NT S
i
ANY AUTO - AUTO ONI-Y: EA ACC $
AUTO ONLY: AGG S
OCCESSAIMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR CUUM MADE AGGREGATE 5
S
I
DEDUCTIBLE S
RETENTION S S
WORN COMPENSATION AND WC231S353819029 02/13/2010 02/13/2011 ` WCSTaTu DR
EMPLOYERS!UARBUTY EL EACRACCIDEW 5 50()000
ANY ECUTIVE
OFRCRERNIEMBER EXCLU°DEE07 E.L DISEASE-EA EMPLOYEE 5 560000
II Yam.DBSCIDe IXMw
SPECIAL PROVISIONS Wo. EL DISEASE-POLICY LIMIT 5 500000
OTHER
DESCRIPTION OF OPEMTONSI LOCATIONS)VEHICLES I ESWSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
CERTIFICATE HOOD ' __ CANCELLATION
SHOULD ANY OF THE ABOVE DESCR®ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL__ DAYS WRITTEN
.. - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHA,I
NPOSE NO OBLIGATION OR LIABILITY OF ANY MND UPON THE INSURER ITS AGENTS OR
R@RESENTA
AUTHORQED "-
-- -�
ACORD 25(2001108) O ACORD CORPORATION 1988
T •d dZS =EO OT LT .JeW
ATQi010/FEI 02:49 PM P. 001/001
-PL• DATE(fdMIODIYYY
D CERTIFICATE OF LIABILITY INSURANCE '0
5/7/2010
f PROWCEIt (603)432-6414 ,FAX: (603)432-3852 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
(Financial Insurance Services Ina ONLY AND CONFERS NO RIGHTSUPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 950 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA'Feerless Insurance CO
A J mood Construction Inc weuRER s:
PO Box 1769 NSURER c
INSURER D
Salem NH 03079 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTH E 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 INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES-AGGREGATE LIMITS SHOWN MAY HAVE BEEN.REDUCED BY PAID CLAIMS.
INSR WUL POLICY NUMBER POLICY EPFEcnV POLICY uPIRATION
PIRATKJN LIMBS
YEIMMIOMMM 1311
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES(E,a�u� I $ 100,000
A CLGLUSNRDE nX OCCUR eP8706685 8/16/2009 8/16/2010 MED ExP An ass Palms) S 15,000
PERSONAL a ADV INJRY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GENLA.GGREGATE LN9T APPLIES PER: PRODUCT Plop
AGO S 2,000,000
X POLICY � LOC
AUTOMOBILE LIABILITY COMBINED SINGLE tRAIT $ 1,000,000
ANY AUTO (Ee ecddeldl
A ALL OY,NED AUTOS BA8693505 7/8/2009 7/8/2010 BODILY INJURY $
(Parpan:onj
X SCHEDULED AUTOS
X HIREDAUTOS BODILY INJJRY
X NON-O`A6+MEDAUTOS (Paeaidud)
PROPERTY CA!AAGE S
(Px ecddsN)
GARAGE LIABILITY _ AUTO ONLY-EAACCIDERT $
ANY AUTO OTHER THAN EAACC $
ZrO000 ONLY.' AG6 c
r
EACH OCCURRENCE $ 1,000,000
OCCUR CLAIMSMAOEA DEDUCTIBLE o8766767 4/14/2010 4/14/2011
$
RETENTION $ Is
WORKERS COMPENSATION I
I&R TABU O.P
ANDEMPLOYER9'LIABBITY YIN
ANY,PROPRIETORlPAPTNERIMCUTUr E.L.EACH ACCIDENT
OMCER1MEMBER EXCLUDED?
If y n EL OBE.EE-
Y $
(M dm In NH)
_Ls
W Ot
SPEAPROMN EL $_._
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES J EXCLUSIONS AIDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
(603I S98-6942 SHOULD ANY OFTHEASOVE DESCRIBED POLICIESSE CANCEL LEDB30RETHEEXPIRATION
DATETHEREOF,THE ISSUING INSURER WILL EDEAVORTO MAIL 10 DAYS NRn7EN
NOTICE TO THE CERTIFICATEHOLOER NAMED TO THE LEFT,BUTFAILURE MOO$0 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER RS AGENTS OR
REPRESENTATIVES.
A(RHORIZEDREPRESENrATNE
Sam Fragala/DBBR.
ACORD 25(2009101) 01988-2009 ACORD CORPORATION. All rights reserved.
INS025(2cmi) The ACORD name and logo are registered marks of ACORD
1%. 1 M
CITY OF S.U.&%I, TANSSACHUSETTS
• BUILDING DEPARINIENT
120 WASHLIIGTON STREET, 3'FLOOR
4j TEL (978) 745-9595
FAX(978) 740-9846
KIN
iBERL.EY DRISCOLL
"MAYOR THor w ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER
f
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 will be transported by:
(name of hauler)
The debris will be disposed of in
I -- L, 9
(name of facility)
(address of facility)
signature of permit applicant
to
date
debrisaild,w