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APPLICAln= FOR
PIPSWTO
LOCATM
I"I�iSOn �/TL�Pi�•
PEFMT GRANTED
747
MOTCM OF IPLOPM
400 CITY OF SALEM9 MASSACHUSETTS
_ PUBLIC PROPERTY DEPARTMENT
120 wASHINGTON STREET, 3RD FLOOR
( SALEM, MA O1970
! TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVrr
In accordance with the provisions of MGL c 40, S34,I aclmowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Pemut shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S 150A.
The debris will be disposed of at:
Location of Facility
51
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
1�
t r-24�C7SL-o (/� OS
Name of Permit Applicant
C 14�,� �
Firm Name,/if any
g5
Address,City& State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
-- OmaNhnsl�tl�p
k 600 Washington Street, lab Floor
Boston,Mass. 02111
ys*Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
name,
�`Jr✓dl� � �S
address. 2S"I !�✓ r�"r^i-rSr �i' i
Url ?n6e�
city ��li-'� state t`N�' zip:d phone
r4 site location(pull reccl-
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
❑ 1 am a sole proprietor and have no one working inany capacity. ❑Building Addition
❑ 1 am an employer providing workers'compensation for my employees working on thisiob
X
company wMMMM`
address:
city 1
el am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers''compensation ponces:
company name: 9 /S Z �S'
address• 9Gy/ g>w,fl�L
city
# ✓
-. .: ... ..�. ... \.";L. .N.}.±.:♦ 16+y�.;;�. N HT�f�?��#��C?Ss-F'W,TA!tr�
address:
city. t A -rJlq +Fyn—91 n ¢� ca es^T—i
ianneal Y
A
Failure ta won coverage"required under Section 25A of MGL 152 can lead to the Impoaitloo of criminal penalties of a ftae op to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Oake of Investigations of the DIA for coverage verification.
I do hereby cert F the Palmiandiornalties of perjury that the information provided above is/me and correct
Signature ✓—=�— Date
Print time 5`� Phone a
��a q3 z-8lr�
omcial use only do not write to this arts to he completed by city or tows ometal
city or Iowa: permittlicase a ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Omre
❑tleslth Departmest
contact period: phone a; ❑Other
oa sal Sept]n)1