1 HATHORNE CRESCENT - BUILDING INSPECTION M
. t
Pile COnnnomccaith of Ibi:u+;tchuscus
5 Baud I1gilding Regulations mid 5t.mJarJs Cl I'1 OF
t) � �iussuchusetts StMe Building Code, 190 CMR SALEM
Blllldlllg Peflllll Applirniun TO Construct. R¢puir, Itrnuv;Je Or Demolish a
Uuv-ur Tun-Piuutfr Dir vH ng
This Section For MrIe al Use 0 it
Building Permit Number. Dale A lied:
IIuJJmy OI1kIal IPnnt N;une) � �5 /3
Siystaturc Uule
SECTION It SITE INFORAIATI
I.I Pro�pperty AJJras:
H!J-i ti D 1 N P n a e n p f S 1.2 assessors p,ft Parcel Numbers
I.la Is this an acre ted street?yes no Nnp Numher Purcell Nunthcr
1.3 Zoning Information: 1.4 Property Dimensions,
Loniny"District1'mpuscd(Ivq Lnl Ann s III
1 4
1.1 BuIIJIn[Setbacks(R) Fmntaye 1111
From Yard Situ Yards Reyltircd I'roviJed Required Side
Rear Ywd
Reyuircd Provided
1.6 Water Supply:IM.G.I.c.40, §14) 1.7 Flood Zone Informatloa, I.[Sew- a Dls
Ihrblic❑ Private C3 Zone: _ Outside Flood Zone? [ posal System:
Chock if es❑ Munietpd Cl On s1h disposal s).umn 13SECTION 2: PROPERTYOWNERSHIPs
2.1 Ow sof Reeordt
_ gh l)h . k,e- i„r SQ/4-w Ala o/970
N,unelPnmCity.State./.IP
! orne Cir 978- 7�Y-tlzf
Nu.:Ind Street Pule hone
P kmuJ Address
SECTION it DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building(3 Owner•Oceupied O Repairs(s) ❑ Alterationts) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief D scription of proposed Work': Other ❑ .Specify:
SECTION 4: ESTIJI.ATED CONSTRUCTION COSTS
IIcn1 Estimated Costs:
(Labor and.Materialsl Official Use Only
I. building S 3 I. Building Permit Fee: S Indicate how tee is determined:
'. Flcclrical S ❑Standard CirylTu,�n Application Fee
I t Ptunlh;Ily S ❑Total project Cost'(Ilan 6)x multiplier _
'. Uther Fees: S_ \
J. \1a tic.d 111t. \('1 S Lis C.—
c:h.11l
� ? \Ianic.tl (Fire
`❑ I IN"i0nl S lard \II Fccs: S_ __-- —• _ .. .
t. lural Project C,)%,: f l� / C'hak Vu. _( heck .\nnnmt . _. _. . .
t ❑PaiJ m Fulll'.t,h \nnnun:
O DaisCutding Glal.mce Due:
M
SEC I'lIi t; coNS1'R11111 ION SERVICES
t.l Cbnstructioo Supenisur License K'sl•1 hate
dee, a ng /.. ....
icvow Nuuthar
.\.1"medl�{SLII, IJvr Ilsll'SLI){wl•evhvlo,tl..L.�1i�'� l�
I5 EJ - --- -'--- Ii pa dill
nin cu.
Na. .u1J Street it I�nfeitriovd(lhuWf u' Io 14,Ulll) 11.)
It Ile'VNIeJ IR? I dnlil I)wellin
I.it)7row it,Slaw.LII' µC Roollo 01i4rin
N'5 %iindoa,old sidin
•— SF solid fool Ilumind Appllanccf
9 78 � b+fululioo
I'vly hmw I mat ;1U....". D Demolition
�.1 rglstcred Iluma Ingsrovcritical Contractor(HIC)
`Qna 1,4 111(:lilf Itcglalruuun Numlwr lispirutiou Uatu
I I 'Campulq N,unc err ISII tirY+ il
a 11 0 0
limed aJJKff
No. at SQd4r/S X61/- 23/-o1Y%
rmle none
Ci -/Toll, n,State ZIP
2.
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(p'Gcation"Fai,restolprovide
Workers Compensation Insurance affidavit must be completed and submitted with this a p
this atltdavit will result in the denial of the Issuance of the building permit.
Signed AMdavit Attached? Yes ..........
No....... _O
SECTION Tat OWNER AUTHORIZATION TO BE CODIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
61.)1
I, as Owner of the subject property,hereby authorize
rsllia de 4
to act on my behalf,in all matter,relative to work authorized by this building permit application.
Nile ✓1 51 eh Ali eDate
Print Uiincr'f Nwne(Electronic Jlgnui
SECTION ?b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the inforinntiun
contained in this application is true and accurate to the best of my knowledge and understanding.9 /L
1
,9 /O�lain .v� ss naw
I rim Owner'f or:\ulhorveJ `�nl v N,unv I IJ�itn nw `Ign mlml
vo'rest
1 InuOcgistered inbhelHume In pruvcmenttCuntr IcturIHICI Prayrantl.nv ll�rro thavehaaess tolthe arbiuntiun+treclur
grog;am ur guarana);fodt°��,un un the Cuosuuctiao Supers icor Li anselcwn be found an Prujru�n,:.�ntbel round at
\\'hen substantial Iwrk is pl:mneJ, prusiJc the inl'ohut%`ludinolova'e, IinisheJ basement aria.Jerks or porchI
g g� S
rotas floor ai 1iy. tl.l . ----"— ltlbitable room count -- -. -
Ai l iy. ll.l _. . -. Gunhcr otbcdruumf
lifuii liiing .....
\o11hvr ftircplacvf ,. .. _ \onlbvrol'halihntltf
\unlherothalhnwlus . . _ \wnhcrol'Jccki porches
I,pe 1
he. u,g
atui),leut (+pvn I'ncla,cJ
I)pe, l'vlahng ,�ilvm
11tc
I'n11tC1 $Ihlafl' I'a1q. 111.1\ I'e ,11h,11I111eJ tilt..hIILII �'fa�ed l ll,l"
�\ 1/fL l.rV//L//LV/f/YLNLL/i Vf {II NJJNL/iNJLLLJ
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):4»rOn.GP,� L4 clin
Address: / fiXn�
''
City/State/Zip: 7kti � - Phone #: 7�/�M 9 - 7L 8�
Are you an employer?Check the appropriate box: - Type of project(required):
1.u I am a employer with�_ 4. ElI am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t Remodeling
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 are a corporation and its
required.] officers have exercised their 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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.Q Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepo/icy and job site
information.
Insurance Company Name: ,,7 ey/ CD r
Policy#or Self-ins.Li/c.,4: f/iE'�/�O�t Expiration Date:021// //y
Job Site Address:/ //I I.T/[d r Me, C1 I r City/State/Zip:,90LJ FM., l a
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 hereby certify under the pain.cand penalties ofperjury that the information provided above is true and correct. _
Si nature:/l t) d, A�±� Date: 3 A Ay
01
Phone#:
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
Contact Person: Phone#:
information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofh';re,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cavy workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or
Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e, a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offiee of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE I
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
02/13/2013 J2:14 ' 17815955820 AMBROSE INSLRANCI PAGE. 1 ./06
.�—
Dan;tury 1111 oYY)
AMM. CERTIFICATE OF LIABILITY INSUFCANCE. _ ��, :a
PRODUCER THIS CERTIFTI,'.A1E L4 ISSUES AS A MATTER;;j;&
INPORFIAA','1.N
ONLY AND t1ONFEM NO RIGHTS UPON THE OPJtTIPQ[ TB
Ambrose Insurance Agy. , Inc. HOLDER. THIS CI RTIEICATE DOES NOT AMEND, EXTEW, :)R
56 Central Ave. ALTER THE (MVEIRAOI AFMDED .-' THE PDLICI69 @..'.;OW,
Lynn, MA 01901 INSURRPP$AFFORMNGI C ORIRAGE
NsuRaD .Delangis, William maUPtetln Prrx�R PrAfti±al_ g,�7',na_ Ce>n..._
American Door, Window & Xnaulatio INSURER P
15 Hailey Ave, msURERG:
Saugus, bM 01906 INSURER 11
ER
COVERAGES r.�.�.....r�—.-..
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INCIR ATEO.NOTWITHSTM I n IG
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MAMCH THIS CSR'1'IpPCAfli MAY BE ISSUE I C R
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUSMT'TO ALL THE TIMMS,I=LUSIONIt ANO CONDITIONS OF Ic:H
POLICIES.AQI�REGAT6 LIMITS SHOWN PRAY HAVE SM REDUCED BY PAD CLAIMS.
TYPE OF INSURANCE Pa-IcvNUImBRIN _ _-...
OENE'IbII.WAN41Y "" EAOHOCOURRONOP. 4 !). .DOO
CONI106RMALGENERALUABILITY FIRE DAMAGE�fA�mn
CLAIMS MADS ❑ pOCUR
A CP120055334^00 5/28/12 5/28/1:3 PEREONAI.&M/IHAIRY
GENERAL AGIPRROA 1i
G12WL AGGREGATE LISW APPLIES PER' PROOUCTS,I?OMPIOP'ABG a _(;jl1 AAD
1. POLICY LCC
TH101g',I!
DILS WA89M
Y AUTO t ISI EaReINCP.E UNIrr a3"ColI . 000
L OWNED AUT09 PODPLM�JP�'
HEDULED AUTOS r
$ DAU709 47635400001 8/17/12 9;/17/1:3 1ODILy INAJp,,4.OLDA'x p�raPmeerq
PROPBRtY WMAGE S
(hlaaaidol)
QARA¢E LIARHIYY — nVM ONLY-FA A0I90ENT Is "._...
ANY AUTO �.`BA ...„ _
Rpjpj IAN . A06a
....
IRO LY! AEGIS
EIIOSSS UARdM _ EACH OODURPYPIOP
OOOUR EICLAINS MADE AGGREGATE
a
OEDI.MBLE g
RET"MON A .•••.••••••,•• a .-- .
VMRNERS CONPFTI$ATION AND I 1 I ^
EMPLOYERS'LUIeR.nY
E.L EACH ACGIMIC
C Binder 'B'. Z/S1I13 .Z/11/1�i{ E.L fASIU18E'EA ETMLOYE a Y,�; !il
OTHER ��� TtL,DIS6ASE®POLIGYIAIR S F(if�
�L'RIPTION OP OPFRATIDNgg000.T10NSA/ENH.2FSIElICLUSIDN9 ADDED BY PNDGRSa7P.NTISPSCIALPROVPS10N77 '�, •�����'�' '��'_•••
Carpentry 6 Insulation -
ERTIFICATE HOLDER ADDITIONAL MUREO;INSURER LETTER: CANCELLATIOItl ^��-....-
SNOULDANY GPTHE AEDVE DESCmDED PDUCRW DPI:ANCEI.LED ISIVIDRe TED:a S-RATION
City Of Salem DATE THEREOF,THE ISSUNG INSURER YIALL RI TO MAIL I.0_DAY! I,R TTEN
Attn. : Building Dept. NOnesroTHS eEwnPMATEHrnDIIRWAND TOTW11M.PUTFAILURS100c ,<.!,HALL
City Rall IRPOSE uo oPLmATION OR LwIuulrY ANV RRm IED NTH61NWIY0t R9 A<iru T9pq
Salem, MA 01970 RBPRESENTATNP.IL _
AvT"R=pA02J RTA
-01 Ir I
ARD 2"(7M7) 4� IS Ad.ORD C6RP0RAT1r7.C .��163
Registration: 111123
Type: DBA
Expiration: 11/256014, Tr# 234005
AMERICAN DOOR WINDOW & INSULATIO _
WILLIAM DeLANGIS _
15 BAILEY AVE
SAUGUS, MA 01906 _
Update Address and return card.Mark reason for change.
❑ Address �! Renewal i Employment G Lost Card
scat
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
,-:cense: CSSL-100824
WILLIAM J DELANGIS _
15 BAILEY STREET
SAUGUS MA 01906
zo:raaor �
05/05/2014
Con:n•ss�one±
r
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 100095-I
98 Main Street Work Order Date: 5/2/2013
Peabody,MA 01960 Ownership:Renter
Phone: 978-531-3810
American Door,W indow,& Insulation Auditor:Doug Cranford
15 Bailey Avenue Email:deranford@nscap.org
Saugus MA 01906 Cell: 978-335-7154
Email: wdelangis(alcomeast.net Phone: 978-531-0767 x135
Phone:781-731-0244
Jean Matson NGRID Electric $3,194.46
1 Hathorne Cir Total $3,194.46
Salem MA 01970
Safety I:ssue(s):Knob&Tube Wiring/Lead Paint Possible
� �� a/ I �;
I'• I�{ �I ( i �!:eI�I�)
lie
I�": � �Ei�l� .a. .i ! �!I t� . .il. lel l
� Ni�i�
Fixed N-veep 4 $15.75 $63.00 4 $63.00
R-5 Drctwrap or R-max on door 1 $51.00 $51.00 1 $51.00
Repair i.ZclitDoor 1� $52.00 $52.00 1 $52.00
711th -strip s/Q-Ion or equali 4 $45.50 $182.00 4 $182.00
eln'hN ,m9 � i
N�l I1���!tl��- �
Domes I'c water pipe wrap 6 $2.63 $15.78 6 - $15.78
'°NL. !N�,I!N!�i�� II iN� i!I h11N!'Im f Nl
NINE` NIINi Moe iG!! kNNI!N I, llill,S N INS {N AGN 11 ;
Attic s-+;ling with two-part loam 3 $75.00 $225.00 3 $225.00
I`I ;INiI�' iINNi.N !I!INIC fNNNII iN INi I'!N!.iNNI"'p �, �Ni�IN . iNN N . � Ni r iiiNN'
Double trailed asbestos/ 1128 $2.31 $2,605.68 1128 $2,605.68
11
(dense i.aclr)
Total r $3,194.46 $3,194.46
Date: 2,'2013 Page 1
J -" -
WAIII Work Order: Job Number: 100095-I
Contra clor Instructions:
Befor_,_carting the Job: During the Job:
1.Ple 1:e notify us 24 hours before starting a:r scheduling a job. 1.This residence was built before 1978.Lead safe practices are
2.Obi ain required building permit. required.
2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Certif(ate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes NIA (Circle One
Where Polled:
Contr I as r: --.-----.—Date:- -WAP Auditor: Date:
Energ,:Director: Date:_ Fiscal Officer:
--Date:—
]FOR,
ate:]FOR,AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer I _ _ If Yes,indicate language:
Stove CC _ Occupany change in last 18 months? Yes No (Circle One)
H2O l't nk CO Comments:
Heath,;;S fstem CO Number of windows -
Ambi it CO - Number of rooms
Blow,r Door
Date: i 2,1-1.013 Page 2
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 100095
98 Main Street Work Order Date: 5/2/2013
Peabody,DIA 01960 Ownership: Owner
Phone:978-531-8810
American Door;Window,& Insulation Auditor:Doug Cranford
15 Bailey Avenue Email: dcranford@nscap.org
Saugus MA.01906 Cell:978-335-7154
Email:wdelangisfWcomeast.nec Phone:978-531-0767 x135
Phone:781-231-0244
Helen Sienldewius NGRID Electric $3,647.21
1 Hathorne Cir Total- $3,647.21
Salem MA 111970
978-744-1175
Safety Issue(s): Knob&Tube Wiring/Lead Paint Possible
it
,i ,! I 'III:IG,xI;EhI.
Sill tv a-part foam w/fiberglass batt 140 $2.20 $308.00 140 $308.00
i
ol�iy{i'I
,
Fixed'weep 3 $15.75 $47.25 3 $47.25
Weatherstrip s/Q-lou or equal 3� $45.50 $136.50 3 $136.50
.' '" ! ' ' , . , I , ' il: !�� ! !
Clothn� dryer vent including -l. $89.00 $89.00 1 $89.00
Exhat 51:[)net
OEM; �+iii!II!NIiI111iii11�118iII��!f�N1911i1111!111 N111111�i1il��i!'.::III�� 'I.I� �IIN!�tilil����;ll�l!!NI�N!I �" �h > I���� II MIN
IN
Dome❑:ic water pipe wrap 6 $2.63 $15.78 6 $15.78
lit 11 IN Sfflffi I111111
Baserr Ent sealing with two-part 3 $75.00 5225.00 3 $225.00
foam
Clean (Gutters 1� $120.00 $120.00 1 $120.00
I
Date: 12;2013 Page 1
WAP Work Order: Job Number: 100095
l ' �I�11910 ny911 n I jll111 �'�� 1 II'NI I�I P1111� GII'3 NNl I I� 1 INIIiIMI�Ai ,1�.. .1 Itll IH i WIN
Building Permit 1 $100.00 $100.00 1 $100.00
la12, 't I���II �� ilk ��� ��� �� �� atil���� �� I l ���{]� � r�l �� ���I '�1tIm"119R ° j,I 111111 n
Dou t le united asbestos/aluminum 11:8 $2.31 $2,605.68 1128 $2,605.68
(der se pack)
Tota I� 53,647.21 $3,647.21
Cont tctor Instructions:
Befor_ Sttrtinp the Job: - During the Job:
1.Ple;i;c notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978. Lead safe practices are
2.Ob t in required building permit. required.
2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Addil ional Contractor Instructions:
CertiP,t ale of Insulation posted? Yes No (Circle C'ne) Attic Inspection form attached? Yes N/A (Circle One)
Where I'NIed:
Contr I:tin•: _ Date:_ WAP Auditor: Date:
Energ,Director.___ _ Date: Fiscal Officer: Date:
Date: 52,M3 Page 2
WAF" Work Order: Job Number: 100095
FOR AGENCY USE ONLY
Pre Rost Language Other than English needed? Yes No (Circle One)
If Yes,indicate language:
Sic t e i'O _ _ - Occupany change in last 18 months? Yes. No (Circle One) .
H2 I Tank CO __. Comments:
Hu a i ng System CO _ _— Number of windows
An t lent CO Number of rooms
Bic v•er Door
Date: 2,_?013 Page 3
CITY OF 5.1.Cam, 1 WSACHUSETI'S
t 4 BLILDIatG DEPARnONT
��„��•
120 CU.%SHLYGTON STREET, 3 FLOOR
Tti. (979) 745-9595
F.vx(979) 7-109345
:<1J(i3ER!EY DRISCOLL
,I t;;YOli T l0-%G SST.PIERRB
DIRECTOR of PLoLIC PROPERTYAL'ILDLNG COSWISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Coda, 730 CMR section 111.5
Debris, and the provisions of tbIGL e 40, S 54;
Building Permit It 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�*YIGL c
I 11, S 150A.
The debris will be transported by:
�n wn n
(namC of haul¢
The debris will be disposed of in
(name of Facility)
signature of permit apptiant
3
ilatc "—