26 MOFFATT RD - BUILDING INSPECTION •' .i:' ^ate
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CITY OF SPLEM
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TO THE INSPECTOR OP BtA.DI M
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Workers' Compensation Insurance AffIdayit
- • with.a principal place of business at:
P��soSew'C�"�C( LP-) ta\fl. 6 kcl$ f
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do hereby certify under the pains and peniMes of perjury, that
() I am an employer providing workers' compentstbm coverage for my employees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in suty capady�
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation pollickc
Contractor Insurance Company/Poky Number
Contractor Insurance Company/Poky Number
Contractor Insurance Company/Policy Number
(} I am a homeowner performing all the work myself.
I wno"Wna mat a coot of"jua mr.wa br for..mora m aw Offe:e er k�*jww+of ow DIA for co.erate.erfteadwl sea an baser woe
ce.srarr as teorrro snow Sredon SSA of MGL 15 I can kad w ow ir�of crk"km oenaoa ear-sdm of a ace of oe 041.50040 Mohr one
rrart' inorwr.+wnt a no a c),i oraslda in me Iorrn of a STOP WORK ORDER awe a law of S 100.00 s an iteirat wL
SiLmed this , day of /
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.. iccrsctiFcrrnitctt Building Deparzr-cm
iSccnsing Ecard
Seiectmens Office
,e:ltfi Deprnmer,;
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PUBLIC PROPERTY DEPARTMENT
120 WAsHIN6TON STnm, BRD FLoon '
6ALSM,MA 01670
TO- (976)746-D696 Eur.360
FAX (976) 740.6646
STANLEY J. U60VICZ, JIL
MAYOR
DISPOSAL OF DEBRb4 AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I wlmowledge that as a condition
of Building Permit 0 , all debris resulting from the won activity
governed by this Building Permit sW be disposed of in a properly licensed soH&vlsste
disposal facility,as defined by MGL c nL S150A.
Mw debris wit be disposed of at: mr-L -�i s nose G
Location of Facility
Signala6 o>XT Dana
FULLY complete the following infon sum
(PLEASE mtw CLEARLY)
Name of asmitApplicant
savwc a.s 0J%GQ
Firm Name,if any
78 t�' eascwT ST, W e��aw�
Address,City dt Stara 0�ggrlo
7be above statute requires that debris Erom the demolition, renovation,rrhab or other
alteration of building or structure be disposed in a properly-licensed soli&waste disposal
facility w de coed by M(X cIM S I50A,and the building pamits or licenses are to
indicate the location of the facility.
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1:APPROX 1 7/8" BASE FILLER HERE
EP4898-1iiF
2: APPROX 1 1/87ALL FRIDGE PANEL HERE
3: APPROX 1 1/8" WALL FILLER HERE ,
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(TO KEEP REVEALS SAME ON WINDOW) 57
—i{---HANG CABS AT APPROX 90" FROM FLOOR. TO ��9 60Jl
ACCOMODATE 1 1/8" CROWN MOULDING =�
CASHMAN Design: C
All dimensions 8 size designations This Is ar cd®i-- ,j-�j�..,and mue I Scale: ma)dmum Date : 0,
given are subject to verification on not be re eased or cno;ed un,e6s :<RIST�N r--
job site and adjustment to fit job I applicable fee hA� hoer paid or jot
conditions. order planed, j 25 NURSEY ST. Designer
ZALEM MIKE