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19 NICHOLS ST - BUILDING INSPECTION �(s Wr r iA *wM vfio ar ' CITY OF S .EM Deb plawly Loom !1 0 r�t,r_�e sue, b mob 0lrYloH„ YrAr_No_• ftudims —�'yl Lamod in• OwwMwrpnAwrt �.� BIML — PNIrMT APPUMTM POft Pum loc Oft Madohmumlow hoof, Re" him ftWVW.Oeok, ShiK Pry . RrpWRrplroo. PLMAMM P"UH LMfM11.Y&COMPLE lLY TO M MI OMLAY=N PROON�M TO TM INBPEGM OF BURDMM- hu ft apples.for a pm* to bM aawn Yp to tln foIewYy O~e Name 25�Q Q,2 T(n)j rz -p ,2 Ad NW A Phone IQ V'i ch o U (q?b 1'7 y o a Sq . Amhkm a Nerve Ad*M A Phone Meawroe Nerve Tf2 0� s j3o�ti 4 id Addiw a Phone )2O 3S- 2e/ 3 MorW d Oiii�t l t)ov r q,for now=W kvmoot -THY• wn e�aotMorr a rrrt �. S Moot `--� N a . roeM. dbv J grNowwo• N A e111e r_CS6 303 DMit 110N OP WOJK TON D CFPWWFW N f' mm PMMIT c f S S-r S�lz i,, a, 7 ,' =+ , �: f _ � .� � � 4 < � b � �� N •� � ' .o � . �., _. � 5- � � :... � . 'Yr.". .. � � . V ,..', �, . - w.., } n`� • �. r tV'Y�. �. ;;J_� �;< � . ', � , �� ,. a;. r. . , '�� ' q.:• .. � .4 � .� {. ' A. •.�., . �'r a .. n PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 6ALEM,MA 01970 t TEL (979)745-9595 EXT.360 FAX (976) 740-9646 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition of 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 a III,S150A/ The debris will be disposed of at Sg Gc M /-x✓5 F r STo:T� Location of Facility 9- Signature of Permit Applicant Data FULLY complete the following information: (PLEASE PRINT CLEARLY) ni't--S d Name of Permit Applicant y Firm Name,if any r1 �y �1 a �O.Ke i /Z© iv�.a 4d-7 /✓�4- d /F G d Address,City&State l 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, S150A, and the building permits or licenses are to indicate the location of the facility. M Comm»nuJr� of Il/a�nchuss>� a�-v JJrpa,loesal./.ldralri.f..�sais.ab• . coo ryw�. L.16.SWal James lcunobse 01111 commaaiaw Workers' Compensation Insurance Ada* .la / haJyvt-S /3y�.c�4-� . . wish.& principal place of business sc: 6n s,,tT - /ZD h 4F6 o O`y 0 e4l dd� 41 � / . . luvnw✓Lp do hereby certify under the pains and penoldes of per*ys thm () 1 am an employer providing workers' compensation coverage for my employees workbag am this job, a6yc» uQZ 7 Insurance Company Polity number I am a sole proprietor and have no one working for me in any rapackye () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who-have the following workers' compensation policies n OM �aWl�•/d -�T.irr�I�M�V} .LS��X��6 Contractor Irtsuranie Company/Policy Number Contractor Insurance Comparry/Policy Number Contractor insurance Company/Policy Number () I am a homeowner performing all the work myself. I onearaund wt a coal of dr6 auewnrm We be fon.aroea ice ON Office 9-1 Mrro$aoom of ow DIA for coeerare eael kwo am as bl re re aware ce.aarr a reoue,o sneer Secakm 25A of MGL 15 2 can kid to oar inomrrbn of c.ilirw densda corsatirar of a rear Of as eel I,SMM bower one rcaw kwroommm a.,ae a cirA owuia in the form of a STOP WORK ORDER wa a (ow of S 100A0 a an milt aae. Si feed this • 9 _ day of r . ictrocti'Ferrniuet ouiltiing Geparcr>,ens ucensing Eearc Seieamens Office r,e:lth Deparmer* ttF - S U I, �� : CONSTRUCIfN 0g3039 NumW BMdste 11/030961 ` ' = 4 Tr.no-. b � `, .8 3039 �, THQMASA BOUENARd t 24 MANOMET RD; �r , AdmimsftW MABODY, MA 019091, �, _t " .