Loading...
0055 HIGHLAND AVENUE - BPA-16-350 III SS. C-te— 390 S The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) S 'J'L No.and eet City/To'wn Zip Code fAme of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building'! Repair❑ 1 Alteration Addition❑ 1 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 as part of this permit application? Yes F No ❑ Is an Independent Structural Engineering Peer Review re aired? Yes ❑ No '5# � Brief Description of Proposed Work: �n - .- p ��- Q SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) 3S UU /0 .3 1I' 16 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ M. Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ 1 U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB XI IIIA ❑ II1B ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Dis osal Site Public Check if outside Flood Zone, Indicate municipal, A french will not be P Private❑ or indentify Zone: or on site system❑ - required or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: , Not Applicable❑ - Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: - Occpul2�ara Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: ]v {� 6--- ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM1OD/9YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cenlTlcate holder la en ADDITIONAL INSURED, the P011cy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rl9t to the certificate holder In lieu Of Such endorsement a. PRODUCER TGA Cross Insurance, Inc. NAME: TGA Crass Insurance Inc, 401 Edgewater Place, Suite 220 PRONE Wakefield, MA 01880 781.914.100) /vX No: 781.246.2601 MAIL switchboardOt across.Com NWW.tgacross.COm INSURER 8 AFFORDING COVERAGE NAIC M INBURERA; Travelers Indemnity Co.of Am.INSURED 25666 O'Connell Plumbing, Inc, INSURER B: Travelers Casualty Ins CO of Am 19046 19A Larchmont Street .INSURER°: Travelers Indemnity Com an 25658 Salem MA 01970 INSURER D: Hartford Fire Insurance Cc INSURER E: INSURER F: OVERAGES CERTIFICATE NUMBER: 2697 858 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TAR I TYPE OF INSURANCE POUCYNUMBER ADM 9M P EF 1 P 4 COMMERCIAL GENERAL LIABILITY YY Y LIMITS ✓ 6806D739057 10/28/2015 10/28/2016 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR P EMISE so Y an $ 300,000 MED EXP An one o,*on $ COCO PERSONAL ADV INJURY $ 1.000,000 rGEN'LOREGATE LIMIT APPLIE8 PER: GENERALAGOREGATE $ 2,000.006 ICY❑✓ JEC LOCPRODUCTS-COMP/OPAGG $ 2,000,000ER: 3 5MO81LE uasanv BA8D7491798/2016 ee I r $NYAUTO ,4eDS) 1000000 LLOWNED SCHEDULED BODILY INJURY(Per pareon) $ UTOSAUTOSBODILY INJURY(Per ecdtlenl) $ IRED AUTOS NON-OWNED AUTOS Pare R DA A E $ $ ✓ .UMBRELLA LIAB rI OCCUR OUP6D751046 10/28/2015 10/28/2016 EACH OCCURRENCE $ 1000000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I ✓I RETENTION 5,000 WORKERS COMPENSATION OBWECCN9789 10/28/2015 10/28/2016 H- $ AND EMPLOYERS'LIABILITY Y/N ✓ T TUTE ER AW OFFICEWMEMBER EXCLUDED? aN/A- - E.L.EACH ACCIDENT $ 500,000 (Mandatary In NH) - Ifppas describe under E.L.DISEASE-EA EMPLOYE $ 500,000 DESCRIP OF OPERATION9**low E.L.DISEASE-POLICY LIMIT $ 500,000 SCRIPTION OF OPERATIONS LOCATIONS/VEHICLES (ACORD 101,Additional Remark*Schedule,may be anechad 11 more apace Is required) eRTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Thomas 1 Gregory i 01986.2014 ACORD CORPORATION. All rights reserved. ORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 050 1 235763 1 13-16 GL, AU, UM, WC I sue Petro ( la/90 Hn,s o•ee.n ... .e•.m• ...__ -- . TARCO-1 OP ID:MK CERTIFICATE OF LIABILITY INSURANCE °Aoaioari 6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERF,Ih)CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES PELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(a). PRODUCER Phone:978-777-9394 CONTACT Dan Hurley Dan Hurleyreen,Suite 2A Insurance Agency Chestnut G Fax:978-777-3306 Pn"c°"No e.t 978-777-9394 No:978-777-3306 � ' Seven Federal Street ADD pIE�;dan@hurleylnsurance.com Danvers,MA 01923-3620 Daniel J Hurley . INSURERS)AFFORDING COVERAGE NAIL# INSURER A:Arbella Protection 41360 INSURED TAR Contractors.Inc INSURER B:ZurlCh American Attn:Andre Lemelin 2 Shamrock Lane INSURER C: East Kingston,NH 03827 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT-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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTq TYPEOFINSURANCE - POLICY NUMBER MMIDDNY MWFT DI�YV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 8500062043 04/012016 04/012017 PREMISES Ea " co $ 100,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 X POLICY 7 PRO LOC $ MRINED SINGLE LIMIT 1 000rgg AUTOMOBILE LIABILITY Ea accitlent $ C ANY AUTO 1020034449 10/0W015 10/06/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ .AUTOS X AUTOS NON-OWNED PROPER DAMAGE $ X HIREDAUTOS X AUTOS Peraccitlanl UMBRELLA UAB X OCCUR EACH OCCURRENCE S 5,000,00 A X EXCESS UAB CLAIMS-MADE 4600062044 04/01/2016 04/01/2017 AGGREGATE $ 5,000,00 DED I X I RETENTION$ 10000 1 $ WORKERS COMPENSATION X WC STATU- X OTH- AND EMPLOYERS'LIABILITY T RY LI B ANY PROPRIETOR/PARTNERIEXECUTIVEY/N N/A 6ZZUB-2E11033-9-16 03/312016 03/31/2017 E,L.EACH ACCIDENT $ 1,000,00 OFF[CERIMEM(Mandatory Eft EXCLUDED? N SEE NOTES - E.L.DISEASE-EA EMPLOYEE $ 1,000,00 (Mandatory in BEF If yea describe under E.L.DISEASE-POLICY LIMIT $ 1r000r00 DESCRIPTION OF OPERATIONS bebw DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) As per policy terms and conditions. WC insurance coverage applies only to the workers compensation laws of the state of Massachusetts. CERTIFICATE HOLDER CANCELLATION NADEAUC - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN K.D. Nadeau Construction LLC ACCORDANCE WITH THE POLICY PROVISIONS. 2 Groton Road Nashua, NH 03062-1033 AUTHORIZED REPRESENTATIVE wL ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ' 7 ® DATE(MWDDNYY17 A'M v CERTIFICATE OF LIABILITY INSURANCE 1/29/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE.CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ios) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CON CT Donna Peirce PRODUCER NAME• Foy Insurance Group - Nashua PHni�ONE . (603)883-1587 FAX e.(dU3).S3-0997 350 Main St AEi%'LESS.donna.peirce@foyinsurance.com INSURERS AFFORDING COVERAGE NAICd Nashua NH 03060 INSURERA:Ohio Security Insurance Co 24082 INSURED _ INSURER B.'Unitied Financial Casualty Co 11770 R D Nadeau Construction LLC INSURERC:The Ohio Casualty Ins Co 24074 2 Groton Rd - INSURER D: INSURER E Nashua NH 03062 INSURER F: COVERAGES CERTIFICATENUMBERXaster 9/2015-2016 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. pp POLICY EFF POLICY EXP ILTRR TYPE OF INSURANCE POLICY NUMBER MMIDD MIDD LIMITS GENERAL LIABILITY M ENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY c—a- E 300,000 A CLAIMS-MADE X❑OCCUR R556719128 9/2/2015 9/2/2016 one person) E 15,000 X CG8910 4/2013 dditional Inured endt CV INJURY S 1,000,000X CP9142 11/2009 stom Protector Plus REGATE S 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: OMPIOP AGG E 2,000,000 X POLICY X PRO LOC E COMBINEDSIN LE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea amdent BODILY INJURY(Per person) $ BIx ANY AUTO ALL OWNED X ASCUTOSULED 04461188-5 12/4/2015 12/4/2016 BODILY INJURY(Par ecdtlen0 $ NON-OWNED - PROPERTY DAMAGE E HIRED AUTOS 'Y AUTOS Per accident Business Ez edance Discount E X UMBRELLA LIAB X OCCUR - EACH OCCURRENCE E 2,000,000 `. EXCESS LIAR CLAIMS-MADE AGGREGATE E 2,000,000 LIED JXJRETENTIONS 10,00 S056714128 9/2/2015 /2/2016 S WORKERS COMPENSATION ERTIFICATE NILL BE ISSUE VJCSTLIM ATU OR - OTH- ANDEMPLOYERVIUABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE UNDER SEPARATE COVERAGE E.L.EACH ACCIDENT E OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) AM NILL BE RECHIVBD E.L.DISEASE-EA EMPLOYE E If yes,descr(be under HORTLY E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS below T. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,0 more space Is required) Operations usual and customary for a drywall/wallboard contractor. A request has been submitted directly to Insurance Carrier to issue a certificate of insurance as regards Workers Compensation for the Commonwealth of Massachusetts. This certificate will follow under separate cover shortly. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Donna Peirce ACORD 25(2010/05), _ ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(minpmni Thus An non name and Inne,ara memietarod mar4e of Arnpn SECTION 9: PROPERTY OWNER AUTHORIZATION Name and t6iddress o Property weer, f� DATO Name(Print) No.and Stre City/Town Zip Pr,qperty Owner Contact Information: Title - Telephone No.(business) Telephone No. (cell) e-mail a d ss If applicable,the property o er hereby authorizes ' Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) - If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Re 'ster d Professional Responsible for Construction Control ffiuv� ittc 0. 1� 3 i'7 o� ul ar �1q Nam (Registrant Telep�o5 0. e-mai addles () II.J`ji1 Registr ti�rfN ber treet A ress City/Town State Zip d U Disciplinel Expir tion ate 10.2 General Contractor Company Name lam. :o 1r 1�t1 Cs- OR\`In l Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 6aS Ft113 le e)�5- kUNc �, c ornrn<-�-- ne '�- Tele hone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes I$ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) 1.Building $ Building Permit Fee=Totai'Construction Cost x (Insert here 2.Electrical $ ly SSG - appropriate municipal factor)_$ 3.Plumbing $ 1 556 4.Mechanical (HVAC) $ 0 Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION IS:SIGNATURE OF BUILDING 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 application is true and accurate to the best of my knowledge and understanding. nGt„e:l Asa�^----/ \��, a s L03-Sigr- 5 1 a /2h(. Please print andsign name Titl� e`Telephone No. Date J� C-16 0n QCA �('G�. N H nan�•. Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date ` r Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-081901 Construction SuWrvisor !•, �. DANIEL J NADEAU �.� 2GROTON RD NASHUA NH 03462 - Expiration: Commissioner 0912312017 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 36,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. `• - DPS Licensing information visit: WWW.MASS.GOV/DPS CITY OF SiUENI, 1, SSACHUSET rS BL:tLD4NG DEP M(EINT 120 W.ksHINGTON STREET,r FLOOR o� TEL (978) 745-9595 FAX(978)740-9846 KINiBERLEY DRISCOLL MAYORTHoNIAS ST.PIEm DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CO%L%BSSIO.iER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A130 icant Information Please Print Leavibly Vane(Busim-sOrganizatioNlndividual): t . �(7 �Tt VJJI.\(� LI.-V Address: 2 p City/State/Zip: hone #: ) rJ 1 a.� Are you an employer?Check the approprial t pox: Type of project(required): 1.❑ 1 am a employer with 4. [�T] I am a general contractor and 1 + have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.0 1 am a sole proprietor or partner. listed on the attached sheet.t ?• J Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI 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 that checks box#1 must also rill out the section below showing their worken'compensmion policy information 'I tomeownem who submit this affidavit indicating they are doing all work and then him outside contractors most submit a new affidavit indicating such 'Contractors that check this box must anached an additional sheet showing the name of the sub-comracton and their workers'emnp,policy information. I um an employer that Is providing workers'compensation insurance for my employeex Below Is the policy end job site informatiom Insurance Company Name: 00 Expiration Date �/f /� Job Site Address; City/State/Zip: J�.('eM f I I ! F /) 9 70 Attach a copy of the workers' ompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of 1IGL 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. I do hereby cerr jy under the pains and penalties of perjury that the informadon provided above is true and correct. Simatura Date: Ll ll�/o�Ul � Phont: G S' 9- R'1a3 Official use only. Do not write in this area,to he 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#: CITY OF S.0 ENI, NIASSACHUSETTS BCIIALNG DEPARTNIM IT 130 W 1SHNGTON STREET,3"FZAOR TEL (978) 745-9595 FAX(978) 740-9846 KIS>BERI_EY DRISCOLL I MAYOR �tOMAs ST.PmRR& DIRECTOR OF PUBLIC PROPERTY/BUTEMING COMNUSSIONER 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, l 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : ��u�l �-��s-kf S�c,�,o.� �q�a-wt h1,5� � •�c:.�, ConS1(�ut..�luf1 (name of facility) (address of facility) C signature omit applicant C) date acbri,vira�