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32A-164 (7) BP-2024-1296 61 HAWLEY ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-164-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-1296 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: Est.Cost: 14000 ANTHONY HAIRSTON 106121 Const.Class: Exp.Date:08/21/2025 Use Group: Owner: ROSSIER,CHELSEA &HUNTER Lot Size(sq.ft.) Zoning: URC Applicant: EXTERIOR CONSTRUCTION INC Applicant Address Phone: Insurance: 14 NOREEN DR (413)222-1775 R2WC420705 SOUTHAMPTON, MA 01073 ISSUED ON: 10/10/2024 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department BHA e«a} Final: Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 172_ Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner - ` ! IV ED i ?L OCT �02Q The Commonwealth of Massachusetts 1,., '_ FOR n r-r „:IN oard of Building Regulations and Standards MUNICIPALITY I�,/.' . ;,,-,ws assachusetts State Building Code, 780 CMR USE :u •• - t Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:6/9-ay- /a 11 Date Applied: 65 7, �� -1F.l p io"/O'zY wilding Official(Print Name) ature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers C9l 1-ta tAc 1.1 a Is this an accept street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow cry of$cord: °( 1 Name(Print) City,State,Z P /v'� f e,( hACALAAe VI C—Ir `114--`5 5\ 6)� C'v e\ cct Ie e e(r O% c `9 ajril .c.,� Rh.and Street Telephone Email Address SECTION 3:DESCRIPTI OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description n of Proposed Work': \n _-a C�v+n a c\ t-- ich� T1 0-- �' -�2 r .t� Sir 4�ja-�n� . r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ l 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All FeesQ -16 Check No.t1 9 Check Amount: • Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) t VO`D Ati\-t\40P1-1 License Number Expiration Date Name of CSL Holder '' A Ah " List CSL Type(sec below) No.and Street Type Description 13 U Unrestricted(Buildings up to 35,000 Cu.ft.) State,ZIP �,� R Restricted 1&2 Family Dwelling City/Town, M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances tAte c\� IC I Insulation Telephone Email address ti(`-AA D Demolition 5.2 Registered HomeImprovement(O Contractor(HIC) It o'OC teit)C /� r At+ 1Q r ` ����� �� HIC Registration Number Expiration Date C' HI om any Name or}JC egistrant Name LNA � .J"t..1 eX4e,-JV‘ .r_.t,,. Xo.aild Street Email address City/Town,State,ZIP 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 Issuanc f the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR rAPPPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize (,( k ,QV' ��LS �V to act on my behalf,in all matters relative to work authorized by this building permit application. t-Ltit-V4r- 10/.6 faL ( Print Owner's Name(Electronic Signature) Date 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. (� 'Mk\ILA^ idid) Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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. I42A.Other important information on the HIC Program can be found at www.ntass.gov/oca Information on the Construction Supervisor License can be found at www.mass.t;ov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished bascmcntlattics,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" �-•44 EXTER-1 OP ID:AM A C GP RL CERTIFICATE OF LIABILITY INSURANCE DATE(MM100IYYYY) �� 10/04/2024 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 have ADDITIONAL INSURED provisions or be endorsed. It 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 413-788-4531 ACT Amy Goding Chase Clarke Stewart/Goss PHONE 413-788�631 FAX 413-2144180 Physical 59 Bobala Holyoke (A/C,No,E:t): (A/C,No): P.O Box 9031Mass;agodingiachaseins.com Springfield, MA 01102 Robert A. Stewart,Jr. INSURER(S)AFFORDING COVERAGE NAILS INSURER A:Northland Insurance Companies INSURED INSURER B:Safety Insurance Company 33618 Exterior Construction Inc - Anthony Hairston INSURER C: 14 Noreen Drive Southampton, MA 01073 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._ MR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR DIM YAM, „(MMIDIVYYYYLIMMIDOIVY)00 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMSMADE I X I OCCUR 1 WS545055 10/08/2024 10108/2026 DAFAEG O� NTEoe) $I 100,000 MED EXP(Any one person) $ 6,000 PERSONAL&ADV INJURY $ 1,000,000 ,GEN'L AOGR UNIT PER: GENERAL AGGREGATE $ 2,000,000 POLICYwe 1 I LOC PRODUCTS-COMP/OP AGG-_$ 2,000,000 OTHER $ COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY -(Ea accident) $ ANY AUTO 6915450 12/18/2023 12/18/2024 BODILY INJURY(Per person) $ _ _ OWNED SCHEDULED _ AUTOS���p ONLY : X AUTOS BODILYBODILY INJURY(Per accident) S _ X AUTOS ONLY X AUTOS ONLY OPERdTeYn M)DAMAGE $ $ , I_ UMBRELLA LIAB —OCCUR EACH OCCURRENCE $ j EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION PER 1 AND EMPLOYERS'LIABILITY I� STATUTE R ANY PROPRIETOR/PARTNER/EXECUTIVE IYI I 'E.L.EACH ACCIDENT $ OFFICER/MQM R EXCLUDED? I N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S — 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 Chelsea&Hunter Russ ier ACCORDANCE WITH THE POLICY PROVISIONS. 61 Hawley St Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Robert A.Stewart,Jr. ACORD 25(2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC(Tc RD f7 DATE IMMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 10/04/2024 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 have ADDITIONAL INSURED provisions or 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 CONTNAME: Amy Amy Goding CHASE CLARKE STEWART&FONTANA �G Nc For (413)788-4531 FAX ,No): E-MAILodin chaseins.com ADDRESS: ag g� PO Box 9031 INSURER(S)AFFORDING COVERAGE NAIC* Springfield MA 01102 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B: —EXTERIOR CONSTRUCTION INC INSURER C: INSURER D: 14 NOREEN DR INSURERE: SOUTHAMPTON MA 010739548 INSURERF: COVERAGES CERTIFICATE NUMBER: 1051948 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 IADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wvD POLICY NUMBER 1MMIDD/YYYYI (MMIDD(YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE j OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) S N'A PERSONAL&ADV INJURY S GENT AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE S _ POLICY ,JECT L j LOC PRODUCT S•COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED N/A BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S _ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LABAIMS-MADE N/A AGGREGATE S DED _ )RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE I ERA A OFFICER/MEMBER ECUTIVE N/A NIA WA R2WC420705 12/28/2023 12/28/2024 EL.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE S 100,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B. no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Chelsea Hunter Russier ACCORDANCE WITH THE POLICY PROVISIONS. 61 Hawley St AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD gm- Commonwealth of Massachu.etts Division of Ocruplional Licensure Board of Building Requ'atior,s and Sta.idards Constructiu ie r S ecialo CSSL-106121 Eires: 08/21/2023 ANTHONY HNRSTON 14 NOREEN DRIVE SOUTHAMP? N MA 01073 ij• 1k`. Commissioner C. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration )5.� _ Type: Corporation Registration: 180100 EXTERIOR CONSTRUCTION, INC. Expiration: 10/06/2026 14 NOREEN DRIVE SOUTHAMPTON, MA 01073 • ..._ Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Begiatlon ExpsratL2rs 1000 Washington Street -Suite 710 180100 10/06/2026 Boston,MA 02118 XTERIOR CONSTRUCTION,INC. { t . - NTHONY L.HAIRSTON C 1 4 NOREEN DRIVE i,^ , U!y�ru oUTHAMPTON,MA 01073 Undersecretary t valid without signature EXTERIOR CONSTRUCTION INC ANTHONY HAIRSTON 14 NOREEN DR MA HIC#180100 SOUTHAMPTON, MA 01073 MA CSL#106121 CELL#413-222-1775 CT HIC#0666057 Construction Site:61 Hawley St Homeowner: Chelsea & Hunter Rossier Northampton MA 01060 Phone#774-521-6290 Email-chelseareneerossier@gmail.com • ROOFING PROPOSAL: Entire Roof. Remove existing layers of shingles. Install GAF 6ft ice &water barrier from eaves. Install GAF ice barrier in valleys, walls and all penetrations. Install GAF synthetic underlayment over all other areas of roof. Install GAF starter course shingles. Install F8 drip edge color; White Install GAF architectural shingles color, Pewter Gray Install GAF snow country ridge vent. Install new step flashing where needed. Install ultimate pipe boots where needed. Remove all existing gutters. Install 5in 0.32 seamless white gutters. Install 2x3 white downspouts. The roof will have a 15yr labor warranty. Debris will be removed with dump trailer. Permit will be pulled prior to start. Shingles will have a 50yr manufactures warranty through GAF. Additional Comments: If any plywood needs to be replaced it will be 80.00 per sheet.We will take pictures and bring them to homeowners' attention once discovered. TERMS OF PAYMENT AS FOLLOWS: 4,667.00 upon contract signing. 9,334.00 upon completion. TOTAL 14,000.00 THIS IS A LEGALLY BINDING HOME IMPROVEMENT CONTRACT. Acceptance of contract the above prices specifications and conditions are satisfactory and are hereby accepted. Exterior Construction Inc is hereby authorized to do the work as specified. Payment will be made as stated above.A fee of 2%(18%annually)will be charged on accounts over 30 days past due. If legal action is necessary to collect all amounts due,or to enforce this contract, all costs, including reasonable attorney's fees will be added. Any arbitration will be held in Massachusetts and Massachusetts state law is to be applied. If any penetrations are made in roof after installation,warranty will be voided. The homeowner has the right to cancel contracts up to 3 days after the contract is signed. NOTE: Saturday is a legal business day in Massachusetts. Homeowners Signature Date /o 3 .q7 Q‘;'`-k Contractors Signature (�/ n;"t..,., Date '0ii4t—f The Commonwealth of Massachusetts Department of Industrial Accidents ray I Congress Street,Suite 100 • Boston.MA 02114-2017 •?.� www.mass.gor/dia % as ken'(compensation Insurance Af idasit:Builders,('ontractort,Elertricians'Plumbers. ft)BE FILED WITH CHE PERmifl'1'IMG Al'1'l1UKITl. Annlicant Information Please Print Letibh Name(husu►caa,Organization IndioidealI: 11nn6- ONC.- OLPS t' ✓�_ 1�---- addresS: `Lk V1/4„ e.c✓1 -CO City/State —CO --CA /VA )anti 0, #: .3).- -- 1-lib' Are you employer?(bet the appropriate bona /� Type of project(required): 1. I am a employer with V employees(full and or part-tine 1-• 7. New construction 20 I am a sole proprietor or partnership and hate no employees working for me in 8. Remodeling any capacity.[No workers'eomip.Monona: requited] 30 I am a homwner doing all work mys►lf.(Ku waxLis'comp irouraace required 9. ❑ Demolition eo 10 Building addition .4.0 1 am a homeowner and w ill be hiring contractors to conduct all w.ak or.any Fr.petts 1 wit axon that all contractors cater hate workers'eusTCasab.m msarance.r az.,.de 110 Electrical repairs or additions proprietors w ith no employees. 12.0 Plumbing repairs or additions InI am a general contractor and 1 have hued the sub-contractors listed on the attached sheet. 1hesc sub-contractors hate employees and lute workers'comp.unurance. 130 Roof repairs 14.0Other 60 Vic an a corp,raa:on and its otYiccn has a exercised tine net of exemvtcri pet\tr&c — 1<_' Q llil.and we has no cntplu}res (NA,workers'comp insurance required I *Any applicant that shooks has al must also fill out the section below show ing their workers'compensation policy information. i Ikimeownen who submit this affidasit indicating they are doing all work and then hire outside contractors must submit a new anidasit indicating such. :(contractors that check this h.must attached an additional sheet showing the name of the sub-contractors and state whether or not those unities have employees. If the sub-:emtractars lose curio!.ccs,they must provide their workers"comp policy manlier --s l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � �'V' Insurance Company Name: ^ J✓Y01/ACe — Policy r ur Self-ins.Ltc. = aWCLA pL{T1 Expiration Date: \ _ c•Mr_ Job Site Address: 10` ocmA z S� City State/Zip:� 1 ao Attach a copy of the workers'compensltion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152.*25A is a criminal violation punishable by a fine up to S1,500.00 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance co%crage verification. I do hereby c ify he pains an penalties oJ`perjuryy that the information provided above is true and correct. Sign:tturr: Date. V k 6_1 Phone»: "\ " Official use only. Do not write in this area.to be completed by city or town official ('it).or Town: Perniit/License Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.('ityll'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other 1 Contact Person: Phone#: City of Northampton 0-0.--P j\. `� Massachusetts �,.. . ''(� d`', I t ; 4. t�j DEPARTMENT OF BUILDING INSPECTIONS I �... i �'" 212 Main Strut a Municipal Building yJ,.. cD \'\^"'i`� Northampton, MA 01060 ssi� 3,j�1`� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: V C11`-e.. F-c-C Li CN\ The debris will be transported by: Name of Hauler: C.-ic w- (A ✓\ 4x-YA,010 4NbAni- a ,Signature of Applicant: Date: `13 (v (a(A