1 WOODSIDE ST - BUILDING INSPECTION (5) , ; �� a� �����---
;�. - , �
�, The Commonwealth of Massachusetts
Boazd of Building Regulations and Standazds CITY
-� � Massachusetts State Building Code, 780 CMR, 7`�edition OF SALEM
i � Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a I, 2008
��Q One-or Two-Family DweZling
�� This Section For Official Use Only ,
�- Building Pcrmit Numbcrs . � . - Date APPlied: __ , , ,
Signature: � �
Bailding Commissione � � e � u�ldings � � � Date ���� `�. � �
SECTION 1:SITE INFORMATION
11 Property Address: � �1.2 Assei�r�Map&Parcel Numbers �
� Woodsi de g + S0.1em (91RoZ
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)
. Fron[Yazd . Side Yazds Reaz Yazd
Requ'ved Provided Required Provided .Required Provided �
1.6 Water Supply: (M.G.L c.40,§54) 19 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Z°°e: _ � Outside Flood Zone? Municipal 0 On site disposal system ❑
Check iFyesO
SECTION 2: PROPERTY OWNERSHIPI
2.1 Owner ofRecord: �� �
1�1Qr{�hA. '{��� �n � V�/ O��Side S-} S0.�C,t�,
Narne(Print) Address for Service:
,Q�_(��t�i io c�a s� o- lo I o 5
Signature Telephone
» SECTipN 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition �O
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ: 11'l S�/'A l 1 $ 1�z p I Oc P m vrlt (.0 lrl d OW S
1Y�to r'XlSttr���, pPP��
m ,. „S�:CTiQN 4:ESTIMATED CONSTRUCTION COSTS � , .' " , ':'
�� _ ... • .
F.vlimnlyd ('utls.� -� :�. • • � . ,_ �. .. ....." ,�. .
ltem Labor and Matenals °°� � �r tlfflcial L7tie nnly
���
1. Building $ g50d•
, 1. Building Permit Fee: $ ��. , Indicate how fee is determined: �
O Standazd City/Town Application Fee
2.Slectrical $ ❑Total Project Cost�(Item 6)x multiplier x
3.Plumbing $ ''2. Other Fees: $ .. ... ... ...
4.Mechanical (HVACj $ �.ist:� .. . . _.��: . _ . � .,. � „ . .. ._.... ..� .
5 Mrnhanir.al (Fire � .. � . .. � .
Su ress;nn To[alAllrees: y --=
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 8`-�� • ❑paid in Full ❑Ouutanding Balance Due:
�'G��/ � � �O l v✓ �O r[ �,�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
2a0Gb II-Iq-Zoll
rn om Q S P F70 �- C)t\
License Number Expiation Date
List CSL Type (see below)
Name of CSL- Holder 6 (7C-14f�
a (.v C e da r Si
Addressf
I ype Description
U Unrestricted (up to 35,000 Cu. Ft.
R Restricted 1&2 FamilyDwelling
Si
M Masonry Only
a[ure
I Ir t Q 3a R 3ZX�
RC Residential Roofing Covering
Telephone
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor (RIC)
I (os
Newpfz)
Registration Number
HIC Company Name or HIC Registrant Name
7- Lo Cedar S'i WOb(_lrrn
t
5 5 l a
e
)I -i $1 Q � $ 3J0
Expiration Date
Signature Telephone
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
I, " O r +h Q -P_�i Qrl , as Owner of the subject property hereby
authorize PJ e woaa to act on my behalf, in all matters
relative to work authorized by this building permit application.
+/
.�- ) / %
Signature of Owner Z Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I, TI'IOMOS P � �, , 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.
Fox cy"N
Print Name
�� 7
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of e
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 and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, 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 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"
FATE (MMIDDIYYYI�
VCE `04/z2/MG
SSSUED ASIA MATTER OF INFORMATION
'S -NO RIGHTS UPON THE .CERTIF,ICATE
nFICATE DOES NOT AMEND, EXTEND OR
AGE AFFORDED BY THE.POLICIES BELOW.`:'
G, COVERAGE NAIC #
Insurance Co. _24198"
HE POLICY,P,ERIOD INDICATED. NOTWITHSTANDING.
WHICH THIS CERTIFICATE'WAY BE ISSUED!OR
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
[RATION LIMITS
2010 EACH OCCURRENCE : $ i DOD;DOO .
zQ1O DAMAGE'TORENTED :: $ 300' OO
MEDEXP (Any&&-orson)$ ' 15,00
PERSONAL B"ADV;INJURY $ -1 000. 000
�GENERALI?+GGREGATE $ 2, ODD', ODO
PRODUCTS COMPIOP AGG $ 21000,000
-
'CERTIFICATE OF LIABILITY
'X
IN
"
`PRODUDER 508.306.6161 :.:FAX ,508;366,,5,202
r THIS CER
Mackintire In3urance Agency;' Inc:
" 11'West;,Nain Street
'' ONLYANI
HOLDER.
ALTER TF
NON-OVMED A.UiOS
Westborough MA U58:1-1931,
'.
INSURERS',
-
INSURED'Newpro Operating LLC" :. :.-INSURER
A', P
,26 Cedar 5t S
INSURER B:
Woburn MA 01801
INSURER C '.
..
INSURER D
".
INSURER E.
COVER AGE!;
"THE POLICIES OF INSURANCE LISTED BELOWHAVE;BEEN ISSUED TO THE INSURED NAMED AE
ANY REQUIREMENT, TERM OR CONDITION OF.ANY CONTRACT OR'OTHER DOCUMENT WITH R
„per e66 hty
fMAY PERTAIN, THE INSURANCE'AFFOREIED BY THE POLICIES DESCRIBED HEREIN.IS SUBJECT
, r OLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.,
INSR
DD
NSR'.
-
•': lYPEOFINSURANCE
. t",POLICY NUMSERys.;DATE
-
POLICYEFFECTIVELTR
AUTO ONLY EAACCIDEN( $' >
GENERAL LIABILITY,CBP.:85883
70
12%31/2009
ANV AIIfO
X CCMMERCIALGENERAL LIABILITY
CQP•85895,77
12/31/2009
A
CLAIMS MADE 'OCCUR
t
AUIO NONLY tlAGG $
GENLAGGRE§ATE LIMIT APRIL IES
PER
POLICY ;gCa-T y
LOC'
,
'
',,:
R& 7d
-73%Z7 /JnnO
FATE (MMIDDIYYYI�
VCE `04/z2/MG
SSSUED ASIA MATTER OF INFORMATION
'S -NO RIGHTS UPON THE .CERTIF,ICATE
nFICATE DOES NOT AMEND, EXTEND OR
AGE AFFORDED BY THE.POLICIES BELOW.`:'
G, COVERAGE NAIC #
Insurance Co. _24198"
HE POLICY,P,ERIOD INDICATED. NOTWITHSTANDING.
WHICH THIS CERTIFICATE'WAY BE ISSUED!OR
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
[RATION LIMITS
2010 EACH OCCURRENCE : $ i DOD;DOO .
zQ1O DAMAGE'TORENTED :: $ 300' OO
MEDEXP (Any&&-orson)$ ' 15,00
PERSONAL B"ADV;INJURY $ -1 000. 000
�GENERALI?+GGREGATE $ 2, ODD', ODO
PRODUCTS COMPIOP AGG $ 21000,000
-
'X
'HIREDAUrOS',-
BODILY;eINJURY ` $
X
NON-OVMED A.UiOS
(PerccitlerR I
p
PROPERTY DAMAGE
"
„per e66 hty
.
FARAGELIARKITY
AUTO ONLY EAACCIDEN( $' >
ANV AIIfO
THEIR THAN EAACC $
AUIO NONLY tlAGG $
,
EXCESSNMBRELLA LIABILftY
CU 858257$-12/31/'
Pq9,
12/31%2010
EACH OCCURRENCEw •; $ 'S OOO'
X 'OGCtJR CLAVMS MADE:-
AGGREGATE .$ ''S, OOO O.
,r
p DucT113C
s
X
RETENTION , 3'' 10, 00
—
"
WORKERS COMPENSATIONANO
K8645074
05/01/2009.:
O5%Ol/2010
WC STM
45
a?.
EMPLOYERS'.LIABILRY. -
',WC8645974
LOS/01/2009
05/01/2016
'EL,•EACHAIX=I> •$n =SOD 00
-
.A:
'.GEFICERmgMBEREXCLUDED[E'L'tOI$EASE=EAEMPLOYE
pNYpROPRIETOPIPARTNER/EHEfCUtIVE
..
`.
$e „• '''.gSO�.,OD
?
IL Yas 0a 0 15. untler ..'
SPECIAL PROVISIONSbelax"' <•• ,i
.,
`. '•
�, "...
.'-,.
,•
° E L.DISEASE` FGLICY LI MIT $ 500,00
.. i
OTHER ,., ... ..
..
..
..
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V'
`
DESCRIPTION
IAL PROVISS
OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONSADDEDBYENDOR$EMEW,ISPECION
SHOULD ANY,'OF THE ABOVE DESCRIDED POLICIES BE CANCELLED BEFORE THE
„
EXPIRATION. DATE THEREOF; THE ISSUING INSURER WILL ENDEAVOR TO MAIL
„
10DAY WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE YO MAILSLICH NOTICE SHALL IMPOSE NO OBLIGATION QR LIABILITY ,
' OF pNY KING UPON THE INSURER, T(S.AGENTS OR REPRESENTATIVES.
.
'Newp CO Operating LLC
... ,.., _._
;AUTHORIZED REPRESENTATIVE? '.-.-
^.. -
..
Ttimoth ` Mo'`na'h.
ACORD 25 (2001108)
OOACORD CORPORATION 1988 �"
realm
IO
-
. 0
® = Qualified In all zones
NEWPRO MANUFACTURING
SERIES G NEWPRO 2000
(NFRj
DOUBLE HUNG
Cellular PVC frame, Triple glazed,
National Fenaetradon
Low E coating (e=0.027, S2 & 5),
aelmp Caundlm
KryptoNalr filled
®
- 0EVd427.00030-00001
ENERGY PERFORMANCE RATINGS
U-Factor(U.SA-P)
Solar Heat Gain Coefficient
0.17
0.24
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
Air leakage (U.S./[-P)
0.40
0.1
Condensation Resistance
70
Manufacturer ell Wlehe ad these raonpe wnroan to appiwis NFAO pmoedurea fa degrminlnp wade
product partamtema. NFNC redl are detmmlmtlfork Waste! WronmenW pillion sea a
WINepooMa produdelee. NF2Ctloee ndoeoommend anyj ud and doeemlwemmmeeuaebalHdery
enNepecipo1101,eaaunmanufadurer'a m for dnaproduM pedamanm Ndarme 0ft-
www.nfx.arp -
1ne uommonweatirs oj lnunau�uuocuo
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
`, 7; www.mass.gov/dia
Workers' Compensation Insurance AffidaNit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Oreanizatiori'Individual): NEWPRO
Address:
(_EbAP ST
City/State,-Zip: W013dptj NW, 0180) Phone r
r7?1- 93," 4360 EXT a5/
Are you an employer? Check the appropriate box:
1. a I am a employer 1xith 50 .r 4. ❑ I am a genera] contractor and I
employees (full and/or part-time).* have hired the sub -contractors
?. ❑ I rail a cGic p:J'yi ctDr or partner- listed on the attached sheet. +
ship and have no employees Th b have
%corking for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
-myself. [No workers' comp.
insurance required.] !
ese su -contractors a
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 151 § 1(4); and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6' ❑ New construction .
Z { Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.71 Electrical repairs cr additions
11.❑ Plumbing repairs or additions
12.7 Roof repairs
13.❑ Other
•Ani a, plic., 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 their workers' comp. police information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
informarlom
Insurance Company Name: % ackinfirc. Insurance_ AOt�nCtV
Policy= or Self -ins. Lic. r: W G 8 toy 5994 Expiration Date: 5 - 1 - 2 0 1 0 .
Job Site Address:
W nods t d e s1 City/State/Zip: SCI arm Me --
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S'_50.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DI.A for insurance coverage verification.
I do hereby cernfy u er rhe pains andpenalties ofperjurl, that the information provided above is true and correct
t=na r.tetAl Pa n nate
r191-q53-RtL4
Oficial use only. Do not write in this area, to be completed by city or town official.
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
Phone
Board of Building Regulations and Standards
HOME IMPkkOVEMENT CONTRACTOR
Re9istratiAtt,, 146589
Eityiratittn ��12011 j
lugalt.- �.r,}',M ....S3GpementCard
NEWPROOPEws'�s}es
THOMAS FOXO '
28 CEDAR ST. F±a Administrator
WOBURN, MA 01801
Massachusetts - Department of Public Safe"
Board of Building Regulations and Standards
Construction: Supervisor License
, ..License: CS 29090
RestrictedtQ 09-,,-o-,0111
THF
230 WALNUT ST =
READING, MA 01$67
Expiration: 11/19/2011
r Tr#: 8950
I
MA Reg #146589 rromourxometolomr... Federal ID # 20-26251 9
CT Reg#060521dAPR 2 9 2010dMOING
N
RI Reg #26463 Windows, Siding and More 6 O 5
Corporate Headquarters, 26 Cedar St, Woburn, MA, (P) 800-342-2211 (F) 781-933-9626, www.newpro.com
TII P�NTRACT MADE THE _ day of
L
(Home
of
the "Owner" and NEWPRO Operating, LLC, "NEWPRO".
20,Z�Lbetween
vnone)
F1The job address is a condominium.
NEWPRO hereby agrees that it will for the consideration hereinafter mentioned, furnish all labor and material necessary to install the following
described work at the premises located at
(Job Address)-tp_main
TOTAL
Additional
Model
TOTAL
Windows Purchased
NEWPRO
Work
NumberQt
CASH
PRICE
Window Color In: Out: Sliding Glass Door
Capping Color
���
Steel Securi Door
Door Color In: Out:
DEPOSIT
WITH
ORDER
33 OU
Model Name Model Numb s Qty Sidelites
Double Hung New Construction Unit
Picture Window
Storm Door
BALANCE
DUE AT
Cpsement Obscure Glass T BOTTOM
2 Lite / 3 Lite Slider
Screens AL FULL
INSTALL
77
Ba / Bow Frame
Please Initial:
Roof: ❑
Soffit: ❑
Customer understands that NEWPR does not
CASH
Garden Window
do any painting or staining. (ie: when removing
Balance paid rat installation
Awning
or replacing interior stops or.Mm)
Hopper NEWPRO® is not responsible for conditions or
Shaped
circumstances beyond its control including con-
FINANCE
Other
densation resulting from or due to pre-existing
Bank completion form signed at installation
GRIDS
Colonial TSDL Euro
conditions.
DESCRIBE WORK:
. Z
Est. Start Date: - /S Customer understands this is an "estimated date" f ^, Est. Comp. Date: G'-
mna s
Initials u Customer understands all steel security doors will have a 3/4" aluminum threshold installed over existing threshold.
It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement, as the Owner's Agent. The Owners who secure their
own construction -related permits, or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. All Home
Improvement Contractors and Subcontractors shall be registered by the Director and any inquiries about a Contractor or Subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton PI, Room 1301, Boston, MA 02108, (617) 727-8598. If the
Owner is obtaining financing by way of a Retail Installment Sales Agreement, such Agreement shall include a time schedule of payments to be made under
said contract and the amount of each payment stated in dollars, including all finance charges. The Retail Installment Sales Agreement shall be incorporated
herein by reference. If the Owner is obtaining a revolving credit line to pay, in whole or in part, for the contract amount herein, the terms of the revolving
line of credit including interest rate and payment terms, shall be clearly set out on the credit application. The portion of the credit application referencing
a time schedule of payment, to be made under this contract, and the amount of each payment stated in dollars, including all finance charges, shall be
incorporated herein by reference.
NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of $100,000 - $300,000.
If the Owner refuses to permit NEWPRO to proceed with the work herein, or in the event of any breach of the Owner of this agreement, for any reason
whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid, as fixed,
liquidated and ascertained damages, and not as a penalty, without further proof of loss or damage.
NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorizedon behalf of the owners to enter
into this agreement.
This contract represents the entire agreement between Owner and NEWPRO and cannot be changed except in writing signed by both the Owner and
NEWPRO.
You are entitled to a copy of the Contract at the time you sign. Keep it to protect your legal rights. We, the
aforesaid owners, certify that immediately after the signing of the aforesaid agreement, a copy was furnished to us.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the
seller, which may be his main office, or branch thereof, provided you notify seller in writing at his main office or
branch 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. (Saturday is a legal business day). See the attached notice of cancellation
form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
FIThz owner has seen "sample"'warranties that will be provided by NEWPRO upon installation. Sample warranties provided toOwner.
IN WITNESS WHEREOF, the parties have hereunto signed their names this 1) :) day of 20 V
EIN# Signed
Marketing Repre rin Name Owner
Accept, PRO ,rating, LLC
4
By Signed
Owner
CORPORATE OFFICE WARWICK BRANCH OFFICE
26 Cedar St 24 Minnesota Ave
Woburn, MA 01801 Warwick, RI 02888
(P) 800-242-9974 (From NE) (P) 800-356-3312 (From NE)
(F)781-933-0717 - (F)401-732-1371
WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy
US -15 S Lq Oc)sP R0508
C�E� E�MnNOO�rt VEO®
JOB# r
CUSTOMER i�kr r^ 61 ti
E-MAIL ADDRESS
# OF DOORS
WINDOW COLOR,
DATE
WINDOWS
#OF BOW/BAY/GARDEN storm, steel, Patio
ADDRESSr
CAP COLOR
CITY, STATE CC f}C.0
h M
CUT
PRODUCT SPECIALIST
I-) i\ BRANCH:
of/
HOME PHONE (e0,4 S16 — G/ o C,
WORK/CELL
(Circle one)
BEST DAY TO INSTALL: M T W TH F
(please circle one)
ESTIMATED START DATE --�' —d /a
TOTAL # OF
# OF DOORS
WINDOW COLOR,
U.I.
WINDOWS
#OF BOW/BAY/GARDEN storm, steel, Patio
Nside/Out.ide
CAP COLOR
NO.
STYLE
OPENING SIZE
W x H
U.I.
LOCATION
GRIDS
SCR
STOPS
ADDITIONS
OPENING
CUT
IN
OUT
yi
lip6
d
x
x
—aid-
da
1
6
x
x
13
A25r
34 G
40,
GA
x
x
iM
t
a
-
x
x
®
ll-
x
x
9a
6
x
x,
36)
t )
k3
3 Q
b
!�
x
x
Sub
3/15'3
3 1q1
6
'x
47
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Measureman:
Initials Date Crew Size Needed Time Frame to complete job Capping Type
Special Installation Instructions:
J.
Directions to site:
1051 _/tirJ�r+�l ✓�� �o(�r5 G✓evlil /.yc/r�NCt
Revised vol
,t
� CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"I'NIENT
4-74 i.0}95 ♦ P %Y: 9'1 174 5- G
Construction Debris Disposal Affidavit
(r«luired lir all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section I 1L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The/debris will be transported by:
(Umme of h uler)
I'he debris will be disposed of in :
-- (natneotf'acility)
(address ur facility)
"Id" I,,!! !,.c
signature of permit app( icai
7a7 d
date —