Untitled 4 PENCASAL DR BP-2017-0648
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block:29-283 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: REPAIR BUILDING PERMIT
Permit# BP-2017-0648
Project# JS-2017-001057
Est.Cost: $25000.00
Fee:$202.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ACE FIRE &WATER RESTORATION INC 074416
Lot Size(sq. ft.): 12806.64 Owner SLOCOMBE DONNA L
Zoning: Applicant: ACE FIRE &WATER RESTORATION INC
AT: 4 PENCASAL DR
Applicant Address: Phone: Insurance:
18 ELIZABETH ST (413)750-5200 Workers Compensation
WEST SPRINGFIELDMA01089 ISSUED ON:11/9/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIRS DUE TO TREE FALLING ON ROOF
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 tt Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department 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.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 11/9/2016 0:00:00 $202.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0648
APPLICANT/CONTACT PERSON ACE FIRE&WATER RESTORATION INC
ADDRESS/PHONE IS ELIZABETH ST WEST SPRINGFIELD (413)750-5200
PROPERTY LOCATION 4 PENCASAL DR
MAP 29 PARCEL 283 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT o
Fee Paid �1 Q�,�
Building Permit Filled out 44
Fee Paid
Tvpeof Construction: REPAIRS DUE ' • REE FALLING ON ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074416
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
` proved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
s lition Del.
Sign. n e of rodding O' cial Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
mtxwApararar.
itifF 7Y371
City of Northampton , . .,� �„
a Building Department rl hi.n '" :31 r o- '4'
I '10.1 212 Main Street ` " 't -*r " i"A ke„:+ ?
Room 100 z ftri < :'-+7C'r r s t ''
,;' -_� Northampton, MA 01060 - ' 4 '` °.
ilk o�<,, phone 413-587-1240 Fax 413-587-1272 „/.. + . ' ' "�t,. ,c��
.. cal .>e '�" t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro a Address: This section to be completed by ofce
7 eA1 C42S4 L 'De. Map Lot Unit
F/arcAic c �//9n zone Overlay District
d/61 L Elm St.DiW1st CBDistrict.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owiin��er.. of Record:
6A/Ea L. SICI Com6 S/ AA,rrI.«.L —P/C, /o/eAno 114- theta
Name nt) I / Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
/r e174_t'//el4// 5t //''//N
G e z . s i 4/. ♦4 -�f 31,0/.ic.<;-�J,cS
Na Print) Current Mailing Address: ll
0/09
r✓ V//3- 7so-5Thaa0
Sig ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildinga
C,25. , O Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection O
6. Total=(1 +2+3+4+5) ( (01.5O t +-{,p= 20Z-SD Check Number /4 190 sfd(1J, 5-0
This Section For Official Use Only
Building Permit Number: Date
Issued
Signature:
Building Commissioner/Inspector of Buildings
Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage - ---
Setbacks Front - _--t ---- ---
Side L L R:b- L:=. - R.:_____i '
Rear
Building Height --- ---
L
Bldg.Square Footage _
Open Space Footage
(Lot area minus bldg&paved
parking) �J L_. ____ ____
#of Parking Spaces L_._! i_ ;
Fill
(volume ffil.ocatinn) _. __ ___ _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES O
IF YES, date issued:)
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW_ O YES O
•
IF YES: enter Book - Pages, I and/or Document#i
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued: 1j
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location: ' j
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO O
IF YES, describe size, type and location: ,
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over l acre? YES O NO 9
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition E Replacement Windows Alterations) I I Roofing FYI
Or Doors 0
Accessory Bldg. 0 Demolition 0 DI
I New Signs (DI Decks ID Siding(Di Other I
Work DescriptionBrief oKrp ed s c�r.m.o 4r. -kite (O. 4I i al O r, co T.02/f
Alteration of existing bedroom Yes ./C No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes /- No
Pians Attached Roll -Sheet
Ga.If New house and or addition to existing housing,complete tho foilowlgg,
a Use of building:One Family Two Family Other
b. Number f rooms in each family unit: Number of Bathrooms_,
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each_.,_,_
g Energy Conservation Compliance, Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? YesNo
I. Septic Yank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. Da.JtJCL Sterol* Ile_ .as Owner of the subject
property 11
hereby authorize /N
e, P r le/ T.-$ /n t;Q n,
Meet behalf, in II ma ers relative td work authorized by this building permit application..
I
fSnot tette of p7 Date ////�4
1 4t5.' Rtte A)eI/ ,as Owner/Authorized
Agent hereby deotbre that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
4e &AL Je//e.
i'
P , a 1
,
‘Ma2d
SignA"AR e' erg•-nt Date
SECTION 8•CONSTRUCTION SERVICES
8A Licensed Construction Supe or: ,, / //{ Not Applicable 0
Name of License Holder 7 rry_e4Y 3
n
License Number
Address Expiration Date
Signature Telephone
S.Registered Home Improvement Contractor Not Applicable 0
Company Name Registration Number
•
Address Expiration Date
Telephone
_ I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C 152,§26C((0)
Workers Compensation Insurance affidavit 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
Signed Affidavit Attached Yes ❑ No 0
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor,CMR 780, Sixth Edition Section 108,3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-veer period shall not be considers a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the fob site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
as Massachusetts Department of Public Safety
V. Board of Building Regulations and Standards
License: CS-074418
Construction Supervisor
GARYARYBRBRUNELLE
PO BOXW 104
GRANVILLE MA 00n1054
�"- 1.� Expiration:
Co missioner 00/10/2018
Construction Supervisor
Restricted to: I
Unrestricted-Buildings If any use group which contaii i
less than 35,000 cubic Net(991 cubic meters)of
enclosed space. I
Failure to possess a current edition of the Massachusetts
Stats Building Code is cause for revocation of this license.
OPS Licensing information visit: W W W.MASS.00VIOPB
` , ' / r/'V -��GLGI/J'JCZ�/"(�G//J(�iGf/.I
'i,-- --,,F . t ��.Pi I / -,
■= e Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 151248
Type: Ltd Liability Corpor
Expiration: 5/23/2018 Trs 419291
ACE FIRE & WATER RESTORATION
GARY BRUNELLE
18 ELIZABETH ST.
W. SPRINGFIELD, MA 01089
Update Address and return card.Mark reason for change.
SCAT a 20M.05/11EAddress J Renewal El Employment fl Lost Card
J7e 6(Jmmonairedc$(r2'tzjja 4vae4j
Office of Consume Affairs&Bnsroess Regulation License or registration valid for individual use only
?� NOME IMPROVEMENT CONTRACTOR before Me expiration date. If found return to:
Rplatratlnn: 151248 Type: Office of Consumer Affairs and Business Regulation
Expiration: 5/23/2018 Ltd Liability Corpor 10 Park Plaza-Suite 5170
`* ' Boston,MA 02116
ACE FIRE&WATER RESTORATION
0 08-11-2016 8:26 AM Fax •Carel 0 1
a� CERTIFICATE OF LIABILITY INSURANCE 8;1TE`"G rel
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(ST AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the pollcype.)must 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 don not confer rights to the
certificate holder in lieu of such endorsements).
PRODUCER LU Al
James J. Dowd and Sons insurance Agency Inc. P�HnxONxE Mary ConroyFAX
11 Bobala Road ENB0.e fla:41 a-538-74 44 IAA NW:413-536-6020
Holyoke MA 01040 AIB/MECmxx owd.cOm
WSi9MER ID e:ACEFIRE-01
MSVRERISI AFFORDING COVERAGE NAIC r
INSURED INSURER A'.Everest Inde1111ty Insurance Company
Ace Fire & Water Restoration INSURERS
18 Elizabeth Avenue Inc. :Quincy Mutual Fire Insurance Compan 15067
West Springfield MA 01089 INSURER
INSURER D:
INSURER E'.
INSURER F:
COVERAGES CERTIFICATE NUMBER:377194240 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.
Rare lY OFINSURLY:% XO-ClUm Folic/Ern POLICY EYP yMITS
A E W A WO POUCY NUMBER 7I112OY'(YYI 711/20YYYYI
A GEtSRAL LµaRlTy DWENWISSS3 711/2016 711/201'1 EACH OCCURRENCE 51.000,000
A COMMERCIAL GENERAL LIIPbI L IT, EMISEE SSEa occurrwe) 550.000
CLAMSMAOE x OCCUR MED EXP(My one TENNI) 55000
PERSONAL&ADV INJURY S1.Pa0000
GENERAL AGGREGATE ST.]OJ,000
GENT AGGREGATE OMIT APPLIES PER PRODUCTS.COMPOPAGG 52,000,000
X POLICY PPRE ^II.00 .._... S
6 AUTOMOBILE LIABILITY AFV206610 7/1/2016 7/1/2017 DOWNED SINGLE LIMIT 51000,000
(Ea'aminenll
ANY AUTO WORT INJURY(Per person) S
ALL OWNED AUTOS BOLLY INJURY PJ HttpOO 5 ...
X SCHEDULED AVi65 PROPERTY DAMAGE
X HIRED AUTOS (PR acaoenp S
X NON-OWNED AUTOS 5
S
A X UMBRELLA LMB X OCCUR EF4CITOOS13151 7/1/2016 7/1/2017 EACH OCCURRENCE 51,000.00P
EXCESSUAB CLAIMS-MADE AGGREGATE 51,000,000
X�DEDUCTIBLE S
RETENTION 510.000 5
WORKERS COMPENSATES( TORY Si Mu. , OF
J
H.
G
AMCE EMPLOYERS LAWNN
ER
ANY PRoMETORMARTNEExEORI6 '1(11 E1..EACH ACCIDENT $
MrjERTh II0EREXctu0E01 ❑ NIA
Nil F.L.IISEASE-EA EMPLOYEE 5
SYe.ee:vae Lost
DESCRIPTION OF OPERATIONS belnW EL DISEASE-POLICY LIMIT 5
OESCRPUON OF OPERATIONS(LOCATIONS:VEHICLES NNW ACERB 111,AddX4W Rwn eke Schedule,N munapxct N cSWMedi
Workers' Compen sat ion Certificate of Insurance to fol Low separately from the carrier.
CERTWICATE HOLDER CANCELLATION 30
SHOULD ANT OF THE ABOVE DESCRIBED POLICIES U CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
Ace Fire & Water Restoration IN ACCORDANCE WITH THE POLICY PROVISIONS.
18 Elizabeth Ave
West Springfield Ma 01089
AUTHORIZED REPRESENTATIVES , �(LL
DVS
0108E2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2008108) The ACORD name and logo are registered marks of ACORD
ACO d CERTIFICATE OF LIABILITY INSURANCE DATE SAWDI 16
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(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 lieu of such endorsement(s).
PRODUCER LONTACT
tams Laura O'Hara
JAMES J. DOWD AND SONS INS AGENCY INC PHONE , . (413)43]-1020 I PAI`
AIC Nc:
'MARE imiarandowd.com
14 Bobala Road INBURERs)AFFdoo.G COVERAGE NAICS
HOLYINSURED E MA 01041 IxsufleRA: AIM MUTUAL INS CO 33758
NSURED
INSURER O:
ACE FIRE &WATER RESTORATION INC INSURER C:
INSURER D:
18 ELIZABETH STREET INSURER E:
WEST SPRINGFIELD MA 01089 INSURERF:
COVERAGES CERTIFICATE NUMBER: 76602 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 POIJCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTR TYPE OF INSURANCE ADDL SUBR POLICY Err POLICY UP
VWO- POLICY NUMBER IMMIOOM'YYI IMMIOIIM'WI LIMITS
COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE $
lCWMS-MAOE I OCCUR PREMISETO RENcED
i PREMISESIER NTED el S
MED EXP(AyOne perspnl I S
N/A PERSONAL&AW INJURY S
GENL AGGREGATE LIMIT APPUES PER GENERAL AGGREGATE 5
POLICY jECOT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY (CEOMBIINEEDDISINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS N/A BODILY INJURY(Per accident)
$
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS - AUTOS l (Per acckeM)
if
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $
EXCESS LIABI
cwus+.MOE N/A AGGREGATE $
DEO RETENTIONS $
WORMERS COMPENSATION X STATUTE ETH
AND EMPLOYERS'LIABILITY
A ANYPROFFICILMETORIPAC ERIEXC�VE WA MIA WAEL EACH ACCIDENT IS 1,000,000
taMldMoy In Nm VWC1008014d]]2016A 07/01/2016 W/01/201] EL.DISEASE-EA EMPLOYEE $ 1,000,000
It yes describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 1,000,000
NIA
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional'Remarks ScheduI.may ba attached N more epee 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 govllwdMorkersmmpensation/investigations/.
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.
AUTHORIZEDREPRESENTATIVE
Daniel
Cr CPCO Vice President—Residual Market—WCRIBMA
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
From: 11/09/2016 12'30 #094 P.002/002
11/09/2016 11:04 14135B71272 NTON BLD DEPT PAGE 02/03
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: -/ Pent' ' g set/ Z:),".The debris will be transported by: W'4tJe7/„ f/I
17, 6
The debris will be received by: _"l;(-4 or, e /; ),/l
Building permit number: £P- l r/- G `/g
Name of Permit Applicant fe(- �� e /J eesZ rz4c&)
Date Signature of Permit Applicant