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28 FOREST AVE - BUILDING INSPECTION t $qq, 1Lx The Commonwealth of Massachusetts ECEN Board of Building Regulations and Standards.; TY,,.OF :MSPEC-;Thal SEia'a �,i✓M UIT Massachusetts State Building Code, 780 CMR Revised Mar 2017 Building Permit Application To Construct, Repair, Renovate OaVARb4b A 11: 0.1 One- or Two-Family Dwelling n This Section For Official Use Only Building Permit Number: Date pp�lie�d: Building Official(Print Name) Signature Date' 11 SECTION 1: SITE INFORMATION UJ! 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers a S3 �o Res} A oe nTu� I.Ia 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 ogCng �I=. C' ,A-A & S'(2lev� . Name(Print) City, State,ZIP a g F'oRgTST Ayo)yC SC-7 -a�M No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: i S N /o k — I kiditjqi Lv i F C SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 3 1. Building Permit Fee: $__TmIndicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application 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: $ Check No. Check Amount: - Cash Amount: 6. Total Project Cost: $ `�o�-- 0Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructibn Sci eiyisor License CSL C (hr S(v e{te2'rs r�z�l p License Number Ex ira ion ate Name of CSL r1older p 1 1 °t( A tt' ���� List CSL Type(see below) lit No. and Street Type Description ,Sa f e iyl A 0 U Unrestricted(Buildings up to 35,000 cu.R) R Restricted 1&2 Family Dwelling City/Town, Stat , I M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2Registered Home Improvement Contractor(HIC) /0/k? ,/n a jq �A 1�—AU s ce--S HIC Registration(Number E irati Date HI �Corypany,tV m Ar�I�IC Re s rant Name No.as St_ �eet/�\JJ Km,4 © � n D Email address City/Town,-'nSta e, ZIP 1 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 Issuan of the building permit. Signed Affidavit Attached? Yes .......... V 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 A � 4 to act on my behalf, in all matters relative to work authorized by this building permit application. Sc�c cok ^aC{- ") /(, Print Owners Name(Electronic Signature) at SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name JElectronic Signature) ate NOTES: I. 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 www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.sov/dps 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" All A �+�p�/�/�zCOcr A & A SERVICES, INC. A&A SER V CES 115 NORTH STREET. SALEM, MA 01970 IN as • • • 9 Telephone:(978) 741-0424 IF..: (979) 741-2012 Contractor Registration No. 101609 Construction Supervisor No.CS057733 Federal EIN: 04-3090162 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Bu eqs Name Date of Contract E1J gLiC 114 1 1 5- 2-Ica, Bu ors Street Atltlress, Cit ,State and Zip Code 28 ES ✓LS S r 970 Da ime Tele M1one Number Evening Telephone Number Mobile Tele hone Number E-Mail Address Ifs— YN— 2877 The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with the prices and terms described on the front and the reverse of this agreement and any specification sheets(this'Agreement').and Buyegs)have requested that such goods orservices be installed or provided at Buyer's address listed above.A&A Services,Inc.("Contractor').hereby agrees to install or cause to be installed the products or services listed in this Agreement at the Baryons)address written above.This Agreement represents a cash sale of goods and services.The Buyer(s) agree to pay in cash the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase. //�� Purchase Price: 7/32 ESL Starting Date!F'-2(o —/ I Ad Dove Payment. Z F 38c, Est.Completion Date:7 Cash Amount Due on Start of Job Check Q Credit Card Amount Due onof Completion: No. Amount Due on of Completion: Expiration Date' Balance Due on Upon Completion 1 CVC Code: It is agreed and understood by and between the Parties that this Agreement, front and back and any addendum, constitute the entire understanding between the parties, and there are no verbal understandings changing or modifyingany of the terns of this Agreement Buyers) hereby acknowledge that Buyers)has read the front and the reverse of this agreement and has received a completed,signed and dated copy of this Agreement,including the two attached Notice of Cancellation forms,on the date first written above.Buyers)also(i)acknowledge that they were orally informed of their right to cancel this transaction;and hn request that they be contacted via their telephone numbers or email,as listed above,in the event Contractor believes Buyers)would be Interested in any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. A&A Ser i Se Inc. Buyer(S) By: Signature 0 _ Signature " 6V/i x ���) fill I- Cd-A76 Print Name Print Name Signature Print Name You,the Buyer(s), may Cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the following Notice of Cancellation form for an explanation of this right. AaslTRnnorv:Tne contractor one me noleowmer home,mmaally agrre in adyama mat b ma evam eiNerpanr has a dispute concerning mix remind.darter party may submit such dispute ill a prlvala amemoron service wnidl has been approved by me Seared,erne Esecu9ue office of Consumer Anmrs am Su4 regulefons end me oiler panv a1a1 be andired lu sulmYt to auon aushered as prover In M.GL c 142A. 4 Cnnt ials Xt� Nor Imkls pare S=2> Cgut-/(e mac NOTICE OF CANCELLATIONNOTICE OF CANCELLATION Oere W TrenseC40 �2k'/�� YOu may Ce cal Iliz Irenset4on.vnlloN any penally o Date M TranseNOn-5—2lo I You may ca cal this musallon,would any penalty o cbligetiOn.vAthin three bYYness days/morn the aMvedate. Ilyou Cenrel.anvprolterrythoodln, obligation,valrom three business days form lie above late.if you cancel,any propedy traded in r any payments made by You under the CmIRn or Sale,and any negotiable instrument ezecvled any payments made by you under the Contract or Sale,and any negmiable Ins✓u lord executed by you will be relemed vntlin 10 days blloo f receipt by me Seller of your cancellation notice, by you Will be returned Milan 10 days following receipt by the Seller of your Unwllarm,notice, and any security inu ed arising out of Ile transaction air he cancelled.It you cancel,you must and any security interest arising out of the transaction will be cancelled.II you cancel.you must make available b the Seller at your residence,and substantially in as good confirm,as when make available to the Seller al your revdanm, on-damemlly In as gold condition Me when received.any goods delivered to You under this Contract or Sale:or you may,it you year broadly remold.any goods d livered to you underthts Contract or Sale.or you may,if you xisb comply all Ile'msluisions of the Seller middle,the return shipment of the golds el the Seller, with me insvucdons of the Seller regarding the room shipment of Ile goods at Ile Salters Andante and risk.If ye do make the goods availabN to the Seller and Ile Seller does rid p,G anythee and risk;If you do(rake to.debts Bveilable to the Seller and me Sailer does nor park Nam up Malin 20 days of rile dale of your fill of Carouser.sec.You may retain or dispose of the them up within 20 days of the date 0 your Notice of Coachman.you may retain or dispose d goods without any luMer obligation.If you fail to make the goadeaveadre N Ne Seller.or it you the goods foNON any further obligation.IlyW fail to make the goods avalable to the Seller.or it egradio ,or,me goods t.Na selkr and.it mdo m.ihen you remain fable for performance of you agree to return the goods to the safer and fall to do so.then you retrain liable No performance all obligations under theContact.To cancel this transaction.mall ar daily,a signed and dated of all obligations under the Control To caneal this 0rdidetion.mail or deliver a signed and doled copy of me mncegauon notice or any other canner notice,m send a ive ram to A Servbes, Ad of me canbellauon notice or any in.,mined nonce,w send a lava ,to ABA Su rverat 115 of Slrect Salem MA 01970,NOT LATER THAN MIDNIGHT OF — b 115 Noll Shea(Salem MA 01970,NOT LATER THAN MIDNIGHT OF ^—Z f Ind., Intel I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION Consumers Signature Gate: Consumer s Signature Dale: ADDITIONAL TERMS AND CONDITIONS Contractor Responsibility.The Contractor will issue its formal warranty upon full payment,which shall constitute the Contractor's warranty for the labor and materials provided to the Buyer.Contractor agrees that all work done pursuant to this contract shall be of a workmanlike manner using professional quality materials and supplies.Warranties are available for inspection at the time of signing of the contract.Contractor accepts no responsibility for any damage resulting from structural or other defects in the property at which the installation is carried out, Buyer acknowledges Contractor's products do not correct or cure structural problems.Contractor shall not be responsible for(a)any damages arising in whole or in part from strikes,fires,accidents,floods,governmental actions or any other causes beyond control of Contractor or(b)any damages including without limitation,lost profits or reduction in value of Buyer's property,arising from Contractor's delay in performing under this Agreement or due to its breach of this Agreement. CondensationlMold:The contractor is not responsible for conditions beyond its control,such as condensation which may form on or within a window or between windows resulting from pre-existing conditions in the Buyer's home and external temperatures.Some condensation may also form on the frame or portions of the roof.Reducing the humidity in your home will often remedy any condensation problems.The Contractor is also not responsible for existing or developing spore or mold growth.Mold may be due to condensation which may form on or within walls or other surfaces resulting from[pre-existing conditions in the Buyer's home and internal or external temperatures.Buyer indemnifies and holds Contractor and its employees,authorized contractors and their subcontractors from any claims as to the identification,detection,abatement,encapsulation or removal of mold,asbestos,lead based products or other hazardous substances inside or outside of the structure being improved. Permits: In Massachusetts,the Contractor is responsible for applying for and obtaining any and all necessary permitting. Homeowners who secure their own permits will be excluded from the guaranty fund provisions of Massachusetts law. Delay/Unknown Conditions:Events beyond the control of the Contractor,such as Acts of God,labor strikes, inclement weather,material shortages,Buyer's inability to qualify or obtain financing,delays by local government authorities in issuing or otherwise approving inspections,permitting or other required authorizations for the job,or other events resulting in delays in performance of this agreement do not constitute abandonment and are not included in calculating time frames for performance by Contractor.In the event the Contractor determines that this Agreement cannot be performed as intended by the parties due,for example,to incorrect pricing,unforeseen structural defects or pre-existing conditions to the Buyer's property,the Contractor may cancel this Agreement within 30 days of its execution,notify the Buyer of such a cancellation in writing and return all monies paid by the Buyer.The Contractor and the Buyers)have determined that a definite completion date is not of the essence to this Agreement.Contractor will not be responsible for any work not specifically listed in this Agreement or the Addendum. Late Cancellation,Late Payment/Default: If Buyer attempts to cancel this Agreement at any time subsequent to midnight of the third business day after the date of the Agreement,as more fully described on the Notice of Right to Cancel form,and Contractor accepts such late cancellation,then Buyer agrees to pay Contractor a cancellation fee equal to(i) 15%of the Agreement's purchase price to offset Contractor's incurred labor,administrative fees and material costs;plus(it)the Contractor's costs for any specialty orders or any custom manufactured items.Buyer agrees to pay 1 %%per month on all amounts due and owing from the buyer to the Contractor accruing from the date due and running to the date the payment is made. If Buyer is in default of this Agreement,Buyer agrees to pay Contractor's attorney fees equal to 15%of the defaulted amount or as otherwise allowed by applicable law. Buyer also agrees to pay any other costs or expenses of repossession,collection,or realization on any security including court costs,to the extent not prohibited by law. Security Interest:This contract may result in a lien on or security interest on your residence.Buyer grants Contractor a security interest under the Uniform Commercial Code and other applicable law governing security interests in the property purchased pursuant to this Agreement,including a security interest in any proceeds from the sale of such property. Buyer agrees that the property purchased under this Agreement is,and will remain,personal property, regardless of the fact that said personal property may become attached to Buyer's real property. No Set-Offs or Retentions.Upon substantial completion of the Contractor's performance,Buyer shall pay all amounts due under this Agreement in accordance with its terns without any right of set-off or retention.Substantial completion is defined as the job being materially completed,functional as intended,and a final inspection,permit or occupancy certificate,as the case may be,having been obtained.If after making full payment,the Buyer alleges that the work is defective in any respect,the Contractor,without waiving any of its rights,shall cause an inspection of the premises and perform any remedial work to the extent the Buyer is entitled thereto under this Agreement or the Contractor's warranty at no cost to the Buyer. Buyer's Representations:Buyer represents and warrants that(a)any credit information furnished by Buyer in connection with this transaction is true and complete;(b)no person has promised or offered to pay,credit,or allow to Buyer any compensation or reward for the procurement of an Agreement with others as an inducement to enter into this Agreement;(c)no person has offered,delivered,paid,credited,or allowed to Buyer any gift,bonus,award,money, merchandise,trading stamps,or cash loan as an inducement to entering into this Agreement;(d)Buyer is the owner of the property where the goods and services are being provided. Miscellaneous:Problems and inquiries can be directed to the Contractor,who may be reached at the telephone number on the front of this Agreement. In construing this Agreement,the gender and number of words used may be changed to meet the context.Any part of this Agreement contrary to law of this State shall not invalidate other parts of this Agreement.This Agreement is to be governed by the laws of the State in which it is performed.All contractors and subcontractors must be registered by the administrator of the Massachusetts Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to the Director,Home Improvement Contractor Registration One Ashburton Place Room 1301,Boston,MA 02108 Tel:(617)727-8598.This Agreement and any accompanying documents represent the entire agreement between the parties and there are no prior or contemporaneous oral or written agreements or representations on which either party is relying.Any modifications to this Agreement shall not be effective unless in writing,signed by the Buyer(s)and a President or Vice President of Contractor.The section headings contained in this Agreement are inserted for convenience only and shall not affect in any way the meaning or interpretation of this Agreement. /7D4 A & A SERVICES, INC. AB,A SERVICES 115 NORTH STREET,SALEM,MA 01970 Telephone: (978)741-0424 fax: (978)741-2012 MWILTA WMA N• Contractor Registration No.101609 Federal EIN: 04-3090162 Construction Supervisor No.CS057733 MISCELLANEOUS SPECIFICATION SHEET Buyer(S)Name Date of Contract i�:-D + ggoc_1 -} CRtiT6rL 15 - 26 - I Buyers)Street Address,City.State and Zip Code Z8 T AvZ7- M4 0/c170 Daytime Telephone Evening Telephone Mobile Telephone Number E-Mail Address 78--7 qq-z S-7-7 The Buyer(s)listed above hereby jointly and severly agree to purchase the goods and/or services listed below,in accordance with the prices and terms de- scribed on this specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which the Specification sheet is a part. �12.ov-T L✓rnrOlnly + ,$'�1%/2S /� SPECIAL INSTRUCTIONS fiFY)eyc-, f o/S p0S Lr aF r2ur- T Lrs-ryrJJ y fS 714//LS , L7e r,5 ^/ 27 5-roE7 Z._ P/PC 214/LL/nl Cj S 7b 7i H-/A,/ . Gory cn eF-W Fca 7)rV Z/S 7D C crpg- , f /7VS 1 _ n/e-Lv 2Y 8 PP7,6Sss✓fL-� Tgey1-jb'� T. ez kfrVl� rrc,�w� E > rn T- P0Yz-1d . /1y.S Xl f— y ) /tee / L x y P. %. AS )5 Tb Ma-w r� 6-. -fn/S '✓77Z'C_ e)C rs _/_?Jr- f P PLS JZA) L/ A/er 7-0 A/PW Pcs j. x/Z— S7)3/ 2 S7YLiA-1r, ?l2 S P l r• //VSP4LL /VLSI /x 8 P T. S7Y?12 /L/ SCEYLS //VS Z9-vt- NZ�L N P T �LSZ-lC/rJLr T73 L/4wbtoy6 tS174i2S, -- /N S ryll' LC-, NtsLv 2 x L( P %, L✓{T r c g- Fn-�tr"try /i PT LfI-772 C- , /�� i� B P T Tx/rV7 /3yY,,L_o_c L-47-n c_e, - ��YI—WI , l I S /.v c i. ✓D� . n � /C LLB/L P/L.t Glt = � 71 S Y Sr 0)scc-,,,,— FA, CEr =,g77) 32 . m De-p eT = 23SO , It is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT, constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying and of the terms.This contract may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and the Contractor. Buyers)hereby acknowledge that Buyers)has read the Specification Sheet, Contractor Initials: _� Date: 5-2(,c Buyer's Initials- > Date: ���� f/. Certificate No. A044298 THE COMNIONWEALTH OF MASSACHUSETTS I r'; E.l'ECUTIVE OFFICE- OI'LABOR AND WORKFORCE DEVELOPMENT DEPARTMENT OF LABOR STANDARDS 19 STANIFORD STREET,BOSTON, MASSACHUSETTS 02114 DELEADER CONTRACTOR LICENSE A & A SERVICES, INC. 115 NORTH STREET SALEM MA 01970 I I LICENSE: DC000440 EXPIRES: Saturday, June 2S, 2016 I IN ACCORDANCE WITH M.G.L. CH. 111, y 19713(b) AND 454 CMR 22.03, THIS LICENSE IS ISSUED BY THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF ENTERING INTO OR ENGAGING IN DELEADING WORK. I I i THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR. THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING WORK IN ACCORDANCE WITH M.G.L. CH. I I l y 19713(b)(2) AND 454 CMR 22.03. I I i I If r/ WILLIAVI D.MCKINNEY,DIRECTOR Massachusetts Department of Public Safety - Office of Consumer Affairs S Business Regulation Board of Building Regulations and Standards i ; fJOME IMPROVEMENT CONTRACTOR """t"'"i"�� S"�'s�,�sor. - �"' IReglstratlOn: 101609 Type: License CS-057733 :Expiration: 6/26/2016 Private Corporatio' CHRISTOPHER Tb F/6. 4&A SERVICES, INC - tIf 115 NORTH ST fa Salem MA 01970 %'% Christopher Zorzy r 115 North Street Salem, MA 01970 Undersecretary ���-' Expiration Commissioner 05/26/2017 A & A SERVICES, INC. 1 15 NORTH STREET SALEM, MA 01970 CITY OF S.U.EMI NL-kS&A CHUSETTS BuMJ:) tG DEPARTJIENT • p 120 WASHINGTON STREET, 3ao FLOOR ka.<a s TEL (978) 745-9595 FAX(978) 740-9846 KI\fBERIEY DRISCOLL MAYOR - T HONLks ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BL'II.DLNG CO.\L\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Le ibly Name (Busim-s.:Organisatiorvindividual): Address: II �- mneu, 1 n n City/State/Zip: Phone #: Are you an employer?Cheek the appropriate box: Type or project(required): LEI❑ I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. El New construction 2_❑ 1 am at sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These subcontractors have S. ❑ Demolition workingfor me in an ca aci workers'comp. insurance. y P ty. 9. ❑ Building addition P workers'comp. insurance 5. ❑ We are a corporation and its required.] Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions myself.(No workers'comp. C. 152, §1(4),and we have no 12•❑ Roof repairs insurance required.) t employees. (No workers' 13 ❑ Other comp. insurance required.) 'Any applicant drat checks box Of must alw fill out the section below showing their workers'compensation policy intormmion t I bsrneowriets who submit this affidavit indicating gtry ate doing all work and the hire outside contractors must submit a new affidavit indicating such =Comrousars that check this box must attached an additiorml sheet showing the name of the subcontractors and their workers'comp.policy information. /um an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and jab site information. ) Insurance Company Name: YZ A Policy#or Self-ins. Lic. #: a� Expiration Date: 9 Job Sire Address: o�� r0r,. s+ I�/�1\ Ciry/State/Zip: Eller 1 A Q) q Artacb 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 S 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 S250.00 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. Ida hereby certify at er the�p?ai and penaftles ofperjury that the information provided abov is a/e and correca . i •net [re' %' v Date. a 10 Phone#: qrl — Official use only. Do not write in this area,to be completed by city or town oJrciaL City or Town: Permit/License# 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#: CITY OF S.U.FEM, NLASSACHUSETTS BUELDNG DEPARTMENT 4 130 WASHINGTON STREET, 3iO FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KISjBERLEY DRISCOLL NiAYOR THO%LkS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BunDLVG CObORSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions of N1GL 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 ( 11, S 150A. The debris will be transported by: (name ofh er) The debris will be disposed of in (name of facility) IC Va�i'� woul Me!j toSe w1,,4 oa I `) /V � f (address of facility I ✓��'� S 01990 signature of permit applicant (n 2 Q d�e dcbrisaffdm