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86 JACKSON ST - BUILDING INSPECTION Gls�. I ZZ 4s z-7 G-�r EP RECEIVED The Commonwealth of Massachusetts RVICE' t I'�r Department of Public Safety OCT � 1 `y4r� Massachusetts State Building Code(780 CMP.)1814 A Building Permit Application for any Building other than a One-or Two-Family Dwelling 9 - (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) 0 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here r check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out mid submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes gile No ❑ Is an Independent Structural CLE ngdmrk\eK7erm+�gP�e�erReview �quiredn? Yes ❑ eBrieffDescrip fPropoedWorkAq CQJ SO i (N�o�❑ 01 �^ 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(sit.ft.) I Total Area(sq.ft.)and Total Height(ft.) l 24 eo0 - 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❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L Institutional 1-1 ❑ f-2❑ f-3❑ 1-4❑ M. Mercantile❑ - R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA O IIB ❑ IIIA ❑ IIIB 0 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal: Water Supply: Flood Zone Information Trench Permit:Sewage Disposal: Licensed Disposal Site❑ Public 00/ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p required❑or trench or specify: - Private❑ or urdentify Zone: or on site system❑ 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 Co Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 1 t i SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner 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 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Re tram Tele hone No. e-mail address Registration Number �_�s� � 6h Street Address ity/Town State Zip Discipline Expiration Date 10.2 General Contractor Col any Name Ay'QQr,S(�� Namfr of Person Responsible for Cei truction License No. and Type if Applicable �t2 CQ/or Mr-1 R Stale Ay 04:1CA", A_1_,4 —0aW Street Address City/Town State Zip Telephone 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 is rice of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 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.Mechanical Other $ Enclose check payable to 6.Total Cost $ 3(]2 - (contact municipality)and write check number here SECTION 13: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. d\i�a2, en5�a �11eS:�cn�- �i 7ZY- , r (0.e pru Plea Fr n,R II � ,{, a [e Title Telephone � TTelephone Date Street Address 11 �f f t City/Town Statel- Zip / 40 Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location(Please indicate Block # and Lot# for locations for which a street address is not available) &s a&t m u�: sme.A.. O M zo z'T- 5AM9Le No. and Street City /Town Zip Name of Building(if plicable� For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107.The checklist below is a compilation of the documents that may be required for this.The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item - Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical S Plumbing include local connections 9 Gas Natural,Propane,Medical m other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation - 20 Other(Specify) 21 Other(Specify) " 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple tire original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number _ Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town - State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Z Discipline Expiration Dale i i The Commonwealth of Massachusetts h x Department of Public Safety o R' Massachusetts State Building Code (780 CMR) . Building Permit Application to Construct,Repair, Renovate or Demolish any FyM,_y;<a Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc. exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee maybe calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. Rightfax N2-1 9/15/2014 7 : 47:25 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDnyyYl T FICATE 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 REPRESENT TIVE OR PRODUCER.AND THE CERTIFICATE O DER. _ MPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. M SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME: JOHN E MCLAUGHLIN INS - PHONE FAX - 828 LYNN FELLS PKWY (AIC,No,Ext): (A/C,No): E-MAI L MELROSE,MA 02176 ADDRESS: 7291X INSURERS)AFFORDING COVERAGE NAM# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY ROGER A TREMBLAY CONTRACTORS INC INSURER B: INSURER C: INSURER D: 10 COLONIAL ROAD#7 INSURER E: SALEM,MA 01970 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 DESCF BED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLARAS. NSR ADD SUB POUCY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POUCVNUMBER (MmDD1YVYY) (MmD\YYYY) LIMITS GENERALUABRITY EACH OCCURRENCE Is COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. AMAGE TO RENTED $ PREMISES(Ea occurrence) WED EXP(Any one person) Is ERSONAL a ADV INJURY Is GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICYPROJECT�LOC PRODUCTS-COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO - LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULEAUTOS (Per person) HIREDAUrOS BODILY INJURY $ NON-OWWNEDINEDAUTOS (Per accident) NON- PROPERTVDAMAGE $ (Per accident) - UMBRELLA LIAB 0 OCCUR - EACH OCCURRENCE - $ EXCESS LIAB Lj CLAIMS-MADE AGGREGATE Is DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WCSTATUTORv OTHER EMPLOYER'S LIABILITY YM UB-2E244266-14 04/23/2014 04/23/2015 LIMITS ANY PROPERITOR/PARTNEWEXECLTTIVE IN NIA E.L.EACH ACCIDENT $ . OFFICERIMEMBER EXCLUDED? SOO,000 (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ 500.000 It ye&desedbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED 1V THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIO _�._. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP RATItkJ:" II" fits reserved. ROGER-1 OP ID:AC ,a►�ol?0 CERTIFICATE OF LIABILITY INSURANCE D09/08/2014Y) 09/OS/2014 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(ies) 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). PRODUCER CONTACT Ironside Ins. Group, LLC PHONE Joshua Shotts 225 Franklin St Floor 26 , No .617-227-2400 FAX No: 617-910-2472 Boston, MA 02110 E-MAIL Joshua.Shotts IronsidelnsuranceGrou .corn Joshua Shotts. ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A:Safet Insurance 39454 INSURED Roger Tremblay Contractors INSURER B: C/o Courtney Tremblay INSURER C: 10 Colonial Road,Ste 4 Salem,MA 01970 INSURER O: 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. INSR rypE OFINSURIINCE ADDLSUBR POLICY EFF POLICYEXP LTR POLICYNUMBER - LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES Ea occunence $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ POLICY❑ PRO- JECT LOC PRO- PRODUCTS AGO $ OTHER'. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accitlent A ANY AUTO COM 6222851 04/15/2014 04/15/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident E AUTOS AUTOS ( ) NON-0WNED PROPERTYDAMAGE $ X HIRED AUTOS X AUTOS Per acodenl $ UMBRELLA LIAB OCCUR _ EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ —f DED RETENTION S g WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY -YIN STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERNEMBER EXCLUDED? NIA E.L.EACH ACCIDENT S (Mandatoryln NH) E.L.DISEASE.EA EMPLOYE $ Ito,Cescntoeundcr DE Ito, E.L.DISEASE-POLICVLIMIT 8 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Joshua Shotts ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ( a1 • ' a� TREMB-2 OP ID: MJ ,a►coRO CERTIFICATE OF LIABILITY INSURANCE DATE/08/2014 `-� osfoafzola 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(ies) 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). PRODUCER - CONTACT McLaughlin Insurance Agency NAME : 828 Lynn Fells Parkwayg y A„c NNo E.t,781-665-277S FAX Melrose,MA 02176 E-MAIL A/C.No: �a1-665-0295 John E.McLaughlin Jr. ADDRESS: INBURER(aAFFORDINGCOVERAGE flNAICINSURERA:AmTrust In t)nderwr.INSURED Roger A.Tremblay Contractors INSURER B:Hartford Inmpany Inc. 10 Colonial Road#7 - INSURER C Salem, MA 01970 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. IN$R ADOL TYPE OF INSURANCE BR POLICY NUMBER MMIDDNYYY MMRlONYYY LIMITS R GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY AE102736400 07129/2014 07129/2015 PREMISES Ea occurrence $ 50,000 CLAIMS-MADE XOCCUR MED EXP(my one Person) $ 1,000 PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC - $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accitlenp $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS PERACCOENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXDESSLIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ I$ WORKERS COMPENSATION )( WCSTATU-PROPRIETOR OTH- AND EMPLOYERS'LIABILITY TORY LIMIT ER B ANY OFFICERIMEMBER/EXCLUDED?ECDTIVE Y� NIA TO BE ISSUED BY CARRIER 0412312014 04123/2015 E.L EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 f yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Avary LLC is included as an Additional Insured as Required by Written Contract with the Named Insured under the GL. Waiver of Subrogation as Required by Written Contract with the Named Insured is provided for Avary, LLC under the CGL. - CERTIFICATE HOLDER - CANCELLATION AVARY-1 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 oRfk 5�aavz� I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CITY OF SALENt, NL-�SSACHUSETTS BUILDING DEPARTMENT • P• 120 WASHNGTON STREET,YD FLOOR TFL (978)745-9595 FA.-t(978) 740-9946 K1Jt3ERLEY DRISCOLL MAYOR THo.+tAs ST.PtERRa. DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONWISSIONER 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 1 11, S 150A. The debris will be transported by: (name of hauler The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant le — 7- /y date dcbrisuif.il,M -