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B-20-812 - 0040 BRITTANIA CIRCLE - Building Permitr A The_ Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CW.) �( Building Permit Application for any Building other than a One or Two-Family Dwelling �(T1us Sechon'For Ofhcial UseOnl ) Building Permit Number + Date Applied Builduig'Official = -- SECTIONA gLOCATION(Please indicate+Block#and+lot#_foiylocahons for,wluch a street address is not,available)' a No. d Street City/Town Zip Code Name of Building f applicable .- SECTION I ON 2PROP.oSED 1NORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other Specify: Are building plans and/or construction documents being supplied,is.part.of this'permit application? Yes ❑ No X Is an Independent Structural Engineering Peer Review required? Yes ❑ No B."ef Description of Propos Work SECTIO1Vf3'C011%IPLETIs THIS SSECTION IFaEXISTING BUILDING UNDERGOING RENOV_ATION iADDITION�OIt CHANGE INdUSE'ORr.C1CCUPANCY _�� - Check here if an Existing Building Investigation and Evaluation is•enclosed(See 780 CMR;34)`O Existing Use Group(s): Proposed Use Group(s) - . __ _ _SECCTION 4 iBUILDING HEIGHT,`AIVD.AREA r Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft:)and Total Height(ft.) A. Assembly.A-1,1J A-2❑ Nightclub ❑ A-3 0 A4❑ A,5 0 B: Business 0 E: Educational 0 F. Facto . F-1❑ F2❑ H:,Hi Hazard ,H-1❑. .H-2❑ `H-3 ❑ 1­1 4-0 r .H-5❑ I:Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 0 R-30 R-4❑ S =Storage, S.4 0 S-2,13 U:;Utility❑ Special Use❑and.please describe below: Special Use: - ____ SECTION�6i CONSTRUCTION'-TYPE`(Check as pa p cable), IA .O IB ❑ IIA ❑ lIB ❑ IIIA ❑ IIIBO --IV VA ❑ VB ❑ SECTION 7 SI I`EdNFORMATIIONf'(refer9to 780 CMRr1110`fordetalls 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❑ required 0 or trench or specify: Private❑ or indentify Zone: or on site system permit is-enclosed❑ Railroad right-of-way: Hazards to Air Navigation:',' ,CIA Historic Commission Review Process: Not Applicable 0 Is Structure within airport.approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No I7. Yes❑ No 13 SECTION 8.'CONTENT OF<CERTIFICdATE OF OCCUPANCY` z AT ----- . "Edition of Code: Use Group s): Type of Construction: Occupant Load per Floor. Does the building contain an Sprinkler System?: Special Stipulations: --. — - A TO O SECTON9: 'P ONNR N. Name.and Address of Property Owner War Name.(Print)/' / 1r,U5,L No.and Street City/Town Zip Property Owner Contact Information: V-E- w qff-M-� rl � c�Mnpo—rowr� Title Telephone No.(business) Telephone No. (cell) e-mail address Cl--6 An If applicable,_the property owner hereby authorizes /rl a ..LLXuv-e - Name Street Address City own State Zip to act.on the: ro er owners behalf,in all.matters relative to.work authorized.by this building Permit application. SECTION 10,CONSTRUCTION CONTROL;(Ple'ase':fill out Appendix 2) ' ,ba dut is kless than35,000_cu,"ft.of enclosed-'-_ace and or not under Constiuchon{Control then check here,O and ski Sechon>10:1`_ g 10:1 Re "stared Professional,Res"_on4b!d'for Construction Contfot Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date AY— Co aany Na de Name of Person Res onsible for Construction License No: and Typo Applicable Street Address city' Town State Zip •. Telephone.No. business Tele hone.No. cell e-mail address _ SECTION:II:WORKE[Zg.COMPENSATION INSURANCE:AFFIDAVIT,(IV O, c:i 2,,g,,49 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 uance of the building permit. Is..a signed Affidavit submitted with this a . .lication?_ Yes .N; o 13 w$ECTION 12 CONSTRUCTION COSTS AND PERMITVFEE� Item Estimated Costs:(Labor and Materials) Total Construction Cost from Item 6)_$ 1.Building $ 12 PO,00 Building Permit Fee=Total Construction Cost x_(Insert here 2.'Electrical $ appropriate municipal factor.) 3.,Plumbing $ -- 4.'Mechanical.(HVAC) $ _ Note:Minimum fee=$ (contact municipality) 5.IVleelianical.(Other $ Enclose check payable to 6.Total Cost $ (�M, (contact municipality)and write check number here SECTION 13 SIGNATURE OF+BUILDINO PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury'that all`of the information contained in this apptication.is true and accurate to the b st f my kn ledge and understanding. SaAn G ,E C.)) e95-0 o a Please p hand si name J/ Title Telephone No. Date Street Address Ci Town State Zip = 8 � a Murucipal-Inspector to fill out this section upon application approval. flit m r MOWwo on ni , lofT'P-.,rt, J, n-. tict-e'n, slul T;e'l -d 'cif" Bul" in tion-s a 1,A, "d r 41, � a,',as, cz- J 4 06 7',,2 .}...i..ra .sa++�•a { � � 3 Construction Supervisor Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991 cubic meters) of enclosed space. Failure to a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Cali (817) 727-3200 or visit www.mass.govldpl CO O4' aAU CERTIFICATE OF LIA ILITY INSURANCE 071 THIS CERTIFICATE 18 ISSUED AS A MATTER OF 1NFORAMMN Old YAND NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVEI.Y OR NEGAINW AMEND. OR ALTER THE COVERAGE AFFORDED BY THE POU CIES BELOiIiI THIS CERTIFICATE OF INSURANCE DOES NOT CON811ME AF-2 CT BETWEEN THE ISSUING INSURER(8),AUTHOR REPRESENTATIVE OR PRODUCEK AND THE CERTIFICATE MOLDER. IAD►ORTAN7: a flta telrttneatd holder N an ADDIfIQNAl. the poust have AO�TIONAL INURED provtatone be endorsed. If SUBROGATION 19 WAIVED.subject is the Was and eondhlone of theteln popsies Clay requtre an embmmenL A staleme�d a1 this owiffbals does not corder tights to the CoMeate holder W lieu of ndorse N PRODUCER Psufa Maftm.AAI,AC8R Clow Insunlrooporumo+de (80S)918d600 (ON)S70.1078 78 Ponaamude BNd. Beret Suffe 100 A Rms Paf mwm NH 0=1 OMURRA: ER:playasMutual IRS 00 oalURED OmIptBRse KIM EXTERIORS S RECYCUNO LLC(SEE I1.713" OMURERC: 10 HAZEL DR ai MM03 OaAgIERBe HAMPSTEAD NH 008 I-M R COVERAGES CERTIFICATE W AABER: =1 5181104M REVlgIObl ppmum; TMISTOCER IFYTHATTHEPOUCIEAOFINSURANCEUSTWSELOWNWE BED M WTOT MUOJRWNAMEDABOVEFORTNEPOLICYPERIOD OLOLCNM NOrMWAKOINGANYREQUOtB[BffMWCRCCNI)n=CFMV MFRACrOROTNEFtOOCLWWVMREPWTOVAMTKO fAErli'iCNEAWSE988UWCRMAYFERTAIN.TllSM tANCEAFFORDWBtt POUdE8 DESCFdBW K61BNtSSUWWYOALLTHETERMS. EXCLU&ONSArID CONDITIONS OF SUCfI POUGE4 LIMITS&tOf11M NAY H1gfE BY PAID CLAIMS. TvPEOPaLBtOtANCe Pi VISOMWER Lom e0039F IM.OEIOIRALLUUMM eACHOCCURRENCEi 1. 000 CLAM K40 ®ooaRl s 600.000 NWB)W = i 10.000 A swim 0718V= o"OVA021 PERSONX&ADVOUIOLY S 1A00A00 L0arAPPUPbPOt aaaBa�AsoaesATe i = POUCY®JEGT we PRODUCTS-CONPIOPAW a 2.KA30 RDENLACCREDWOWER: Lmiwjwewddb s tA00.oao AUTOMOSOAUABLUY s 1AW.000 ANrAlno Boauroulasra�e.oaaae s A W1038 07MV2D20 07A1f2021 BOCUR AWFIrtademO i Km NOMORNED AUUTOSOMY AU OILY i UR dsd no,1,11 i 1Am000 rR®R�naAUAe OCCUR eTiaieocua Ce $MOOD A EKCMLL48 CWNSLLAOE Sim 071m12020 07101f2a21 IAGOREL14E s a�o,0o0 aW I I RammoR s s wdao$rmcaoerOICOOM AND 'Lima= YIN A pLquO� Y� NIA 667t818 MA,NH.RI 07At/�20 07p1/1021 �� � i 1A00.000 1 OPERA100rOi0effr F.Lommse.pownwri 1.0mo00 A I Cow LbM S071688 0710112020 07101f2021 Ads 5100,000 OBStAPMOFOPEPATi0LIiIUWX MIVE1U=(AOOR M.Ad2i=dpAmdm a nrf�aaOt*Wvmm4pwb 11 Fa'EvMwm ON%fRse wm sffaddd by des pdMn deaae®W heedI M adjeatM d8 fame,andusiv.rrardre0os and=rgftmn of such pawn CATS HOLDER CANCELLATION SWULDAWOPIMASMOEBC I PCUCMSBECANCELLBDBSp m THE B7WfR MN OATS TNEROM NOTK:B WILL M 0>IIAVWM IN Evem=Day ACCORDANOBVWMIMPOUCYPROVISIONS. AUDMOOW REPRBSENWOM w 01888-WIS ACORD CORPORATION.AD dgko reserved. ACORD 26(WISW) The ACORD name and logo troregistawmeftdAconD The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Stree4 Suite 100 Boston,MA 02114-2017 www mas&gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITING AUTHORITY. Applicant Information Please Print Lgdbly Business/Organization Name:KTM EXTERIORS&RECYCLING LLC Address:10 Hazel Drive City/State/Zip:Hampstead,NH 03841 Phone#:603-895-0400 Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with 25 employees(full and/ 5. ❑Retail or part-time).' 6. Restaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no 7• ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees.[No workers'comp.insurance required]• 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, Residential with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **if the corporate officers have exempted themselves,but the corporation has other employees.a workers'compensation policy is required and such an organization should check box#I. lam an employer that Is provit ing workers'compensation Insurance for my employees. Below Ls the pollcy iq jormadom Insurance Company Name•EMPLOYERS MUTUAL INSURANCE COMPANY Insurer's Addms:40 Brittania Cirde City/State/Zip: Salem,MA Policy#or Self-ins.Lic.#51371638 Expiration Date.07101/2021 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 hereb wen*,under the pains and penalties of perjury that the lnformadon provided above Is true and correct Sign • Date:Cam► p�� S-q ao ature � �.� Phone#:603-895-0400 OfJlcial use only. Do not write In this area,to be completed by city or town offlciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department.3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia AGREEMENT This Agreement,made this 29 day of July,2020 by and between;KTM Exteriors&Recycing,LLC hereinafter, called the"Contractor"and Mariner Village Condominium Trust,hereinafter called the"Trust". Accordingly, Whereas the Contractor has entered into an Agreement with the Trust;and whereas the Contractor is in the business to perform such work consisting of roof replacement. Now therefore,in consideration of mutual covenants,promises,and provisions,hereinafter contained,the Contractor and Trust agree as follows: Representation:Contractor warrants and represents that it has carefully examined the premises and has made a complete study of the site which the work will be performed,is knowledgeable with respect to all applicable requirements of the City of Salem,Commonwealth of Massachusetts,safety standards required by its insurers, guidelines for proper application of materials required herein as is customary in the trade. Trust and Contractor hereby agree to: SUBUdARY: The Contractor shall supply all materials,equipment and labor required for the completion of the shingle replacement at the following locations at Mariner Village: a U2 Building 152(40 Brittania Circle) • Building 144(2 Brittania Circle) • Building 145(13 and 17 Brittania Circle) • Building 155(53,55,and 57 Brittania Circle) • Building 159(2 and 6 Good Hope Lane) The Contractor is responsible for any damages to the property as a result of such services described in this contract. The Contractor will provide advance notice to the property manager at least one week prior to work on the buildings to ensure proper notice to owners is given. All work shall be performed in a first class workmanlike manner. The Contractor shall schedule and coordinate the work to minimize any inconvenience to the building occupants and any disruption of the normal use of the building(s). SCOPE OF WORK: As defined in the attached proposal dated May 15,2018,marked as Exhibit"A"and this project shall include all work necessary for the completion of shingle replacement at the above referenced locations. Shingle Roof Replacement shall consist of the following: • install tarps to protect lawns,decks,plant material and all other property I N N •� f+ o e q r °' m E 12 v $ E 'o c'a •x v o 3 c N O p �$ NW v o t+ N 4- S22 'i 0. I s $ >, N w O � � c o y > Q N � c� 4 0 •, 0 v o o � L � b o m -v Si aNi ^ 0 C .0 O N N 61 Vl N N N at O �O cisC .S .tto[ c cotko .e 0 O O co '�: api O.d O. 3 0 cd 54 � 'a �E y . C.O. _ ,o:: y 0ai o d N . � isO C a " 4 y � O0 + U . o a N w .. -0 1 rN o"$ gN • ' o $ o � • aa & 4 a —0 NNao$ ats Ck.a �, 3 'o •v •^ � d 3 3 Na 0 .o �. ca a0 VA � � � .r d °a° ' ° c ° = _ O Q °In oo Is CA c >" .8 ,moo, a. y V o Of o c °' c _e "e•� c c c Q .a ao o as E w $ c �i .... � .... �.. .... r. c O 00 v � aD a> � 'ti y w O H W a� N N N °r� .� � � O � a' •C Z7 B «3 .°g N � c as - o go (a 2 2 s C o z ` odpp opOp v>�, a p � N cis'C 'dbC .1 j9vIfN CA 0 Z CC.. y adCr0.D aE� aa 0a;d; a7 cwaiaac.aa=wi -r � s0 � •E -oo 2 ac. sEdmmm O UV ocs s o> E i oboa.a a c u b o 0 o � s .. 4)Mbo 3 .n .0 N vv •vvv� av c V0 p �•Cd�. N -00 a a G7 3 Ey E ir. cv to the satisfaction of the Owner at the end of each day's work. • Any items stained or otherwise damaged as a result of the work shall be cleaned,restored or replaced at the satisfaction of the Owner. • Any vehicular damage to the landscaped or other areas around the building shall be repaired or restored to the satisfaction of the owner. • The Owner shall require a final inspection of the work,including final clean up. WORK SCHEDULE: The buildings will be occupied during the project. The Contractor shall take all reasonable measures to minimize disruption of the normal use of the buildings and inconveniences of the occupants. Work may be performed between the hours of 8:00 AM and 5:00 PM,Monday through Friday. No Saturday,Sunday,or Holiday work shall be permitted without prior consent by the Board or Managing Agent. CONTRACTOR TO SUPPLY:All labor,materials,taxes,fringes and insurance,all necessary equipment and materials. COMPLETION AND ACCEPTANCE: Contractor agrees to commence the work according to the time periods outlined in the"scope of work"section of this agreement. All work will be completed when all conditions described in this Agreement have been performed the by Contractor to the satisfaction of the Trust. PAYMENT: The Trust agrees to pay the Contractor agrees to accept for the full,dutiful and prompt performance by it of the work described herein,the following sum: $59,520. Payments will be made as follows: • 33%($19,840)(1/3 upon delivery of stock) • 33%($19,840)(1/3 at halfway complete) • 33%($19,840)(1/3 final payment after receiving roof warranties) INSPECTION&DEFECTIVE WORK: All workmanship and materials entering the Complex shall be subject at all times to.the inspection and approval of the Trust or their Agent. Contractors will cooperate with the Trust or their Agent to facilitate these inspections. STORAGE OF EOUIPMENT: Contractor,at his own risk,may store materials on site in such locations as the Contractor may propose and the Trust may accept. TERMINATION OF AGREEMENT DUE TO CONTRACTOR DEFAULT: Should Contractor fail in any respect to prosecute the work with promptness and diligence or fail in the performance of any of the agreements herein contained except for causes beyond its control,which include:strikes,natural disasters,etc.,the Trust shall be at liberty to provide any such labor or materials and to deduct the cost thereof from any money then due or thereafter to become due to Contractor. Said Contractor,for itself and for its subcontractors,and for all parties working through or under them,covenants and agrees that no mechanics'claim shall be filed or maintained by it,or any of them against the above described real estate. No notice of this Agreement shall be filed or recorded in any Registry of Deeds of the Commonwealth. All subcontractors and material will include the above provisions with respect to liens and fees or Contract as contained herein. REGULATIONS.PERNUTS AND COMPLIANCE WITH APPLICABLE LAWS: All services and materials furnished hereunder and all work performed by Contractor under or pursuant to this Agreement shall comply with all applicable laws,codes,ordinances,requirements orders,directions,rules and regulations of the Federal,State,County and City governments,and all other governmental authorities having or claiming 3 jurisdiction over the work to be performed hereunder,and all other respective departments,bureaus and offices of insurance,underwriting board or insurance inspection bureaus having or claiming jurisdiction,or any other body exercising similar functions and all insurance companies writing policies covering the work to be performed hereunder on the site or any part thereof. DAMAGE TO WORK.PREMISES AND POSSESSIONS OF TRUST: The Contractor shall effectively secure and protect its work,the premises and the possessions of the Trust,his tenants or invitees and shall bear and be liable for all loss or damage of any kind of which may happen as a result of Contractor's own,his employees',suppliers'or subcontractors'actions or omissions to Contractor's work,the premises and the possessions of the Trust of the premises,his tenants or invitees at any time prior to final completion and acceptance of the work. The Contractor agrees that before final payment is made all areas shall be inspected for damage and the cost of said damage will be held until the areas were damage occurred are corrected. If the Contractor cannot complete repairs in a reasonable period of time the Trust shall contract for the work on its own and withhold an amount equal to the repair work from the final payment. SUBLETTING CONTRACT WORK: The Contractor agrees to provide a list of all subcontractors,if any,to be used to perform work on the site. ADVERTISING: The Contractor will not be permitted to display any sign,poster,etc.,on or around the structures or premises. SOCIAL SECURITY,UNEMPLOYMENT,SALES TAX: The Contractor,for the Contract Price herein provided for under the section entitled"Payment",hereby accepts and assumes exclusive liability for and agrees to pay Last saved by APT. APTwhen due and shall hold the Trust harmless against payment of: A. All contributions,taxes,or premiums which may be payable under the Unemployment Insurance Law of any State or the Federal Social Security Act,measured from the payroll of employees,by whomsoever employed,engaged in the performance of the work included in the Agreement B. All Sales or Use Taxes,arising out of the furnishings or installing by the Contractor of any kind of personal property under this Agreement. C. All or any excise,property,transportation,income or other similar or dissimilar tax imposed by any present or future law of the Federal Government,any state or any subdivision thereof on any materials, articles,receipts,services or income earned by or furnished by Contractor including but not limited to assessments or charges for hospitalization,pension and welfare funds which may be payable under union agreements as now or hereafter in effect. FAIR LABOR ACTS: The Contractor is familiar with the Fair Labor Standards Act and/or any State or Local Acts,if any,in relation to wages and hours,and where such Acts apply to the work or materials fumished under this Agreement the Contractor agrees to comply with the terms and provisions thereof,and agrees to hold the Trust harmless from any violations of the same. INSURANCE—PROVIDED BY THE CONTRACTOR: Contractor agrees to take out and maintain the following insurance in a company or companies satisfactory to the Trust: The contractor must furnish a certificate of insurance,naming Mariner Village Condominiums an additional insured,evidencing workers compensation(at least$500,000),general liability(at least$1 Million)and auto coverage(at least$1 million)before any work begins.Statutory Workers'Comp.Insurance and Employer's Liability Insurance to be carried by the Trust. Contractor prior to commencement of any work hereunder,shall furnish to the Trust Certificates or copies of 4 r policies showing that such insurance is in force and the premiums due there under have been paid. Certificates or policies shall specify that the Trust shall receive 30 days prior notice of cancellation or material change. In the event of the failure of Contractor to furnish and maintain such insurance,the Trust shall have the right at its option to terminate this Agreement or to take out and maintain the said insurance for any in the name of the Contractor and Contractor agrees to pay the cost thereof through the deduction of funds due him,and to furnish all necessary information to permit the Trust to take out and maintain such insurance for the account of the Contractor. The contractor assumes complete responsibility to ensure all employees working on Trust clients/properties have gone through security checks for drug/criminal and have successfully completed prior to working on our property has the right to audit any employee file at anytime for the duration of the job. Contractor shall submit a letter before work begins to assure that the above proper security checks have been performed. DISCRIMINATION: The Contractor will not discriminate against any employee because of race,sex,creed, color or national origin. The Contractor agrees to comply with all Equal Employment Opportunity Laws, regulations,and directives,as required by any governmental body or authority. PERFORMANCE OF THE COVENANTS: The parties hereto for themselves,their heirs,executors, administrators,legal representatives,successors,do hereby execute the full and complete performance of the covenants as required NOTICE: Any and all notices served pursuant to or with respect to this Agreement shall be delivered by hand or by certified return receipt,with respect to the Trust; Mariner Village Condominium Trust c/o Crowninshield Management Corp. 9 Atlantic Avenue Marblehead,MA 01945 With respect to the Contractor;KTM Properties LLC Any notice regarding default under this Agreement shall be confirmed in writing,but in order to expedite corrective action a telephone call shall be deemed notice of default and after receipt by the defaulting party,said defaulting party shall correct the default or otherwise respond within four(4)hours. Witness: Whereof the parties have duly executed this Agreement the day and year above written. Contrac r: Tara ton,for KTM Exteriors&Recycling,LLC By: Title: 'de t Trust: Mariner Village Condominium Trust By- As and tin ' iduall f By- As Tmstlond not individually Re.Roof Reptacment Agreement 2020 5 CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL: 978-745-9595 KIM13ERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Construction Debris Disposal Affidavit (requiredfor all demolition & 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, S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111, S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) ( 0 t4p L (address of facility) Signature of applicant (today's date)