5D NIMITZ - BUILDING INSPECTION 35 ,
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J0PZC=2.PWH TO A !gMff BEING GRANTtD
CITY OF SALEM
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Perna to: BUILDING PERMIT APPLICATM FOR:
(Ckcie wifthever apply) �Inar oSkft Coast Wt� shed. Pool,
PLEASE PMLL OUT LJEGIBLY ti COMPI.lTELY TO AVOID DELAYS MN PROCESS m
TO THE INSPECTOR OF BUILDINGS.
hereby applies for a permit to build a000r&g.to the.toMw4*q
Ow Ws Name a L- h e w� e u ti
Address d Phone i_ agg'1 7 C/S
AmhkWo Name VIA
Address a Phan ( 1
Mechanics Name
Address A Phone 1- 8
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DESCI�TION OF t#IORK TO W DONE
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MAIL PERMIT TO: 1 c 4 a�c L ,(1 u .^eA. "
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' CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM, MA O 1970
TEL. (978)743-9595 EXT. 380
FAx (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I aelmowledge 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,ar defined by MGL c III,S150A.
The debris will be disposed of at: Sc/ate,.._,
Location of Facility
Signature of t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
_ Ro 6-e' J_ L. 'ti ,eu „ uIc
Name of Permit Applicant
Firm Name,if any
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 ca S150A, and the building permits or licenses are to
indicate the location of the facility.
A
—= \ The Commonwealth of Massachusetts
G - Department of Industrial Accidents
�� 'y -; � OIIIgN/Ywer�Win
600 Washington Street, 70 Floor
;} Boston,Mass, 01111
Workers'Com ensation insurance Affidavit: Building/Pi mbin lectrical Contractors
•fix-
name: IZoJ, 6 . )_ L'lj et�tr-e tyc
address w.
city state, m 1a zip- 620 20 phone ii "/7
w - D N t -. 4 z. W,- so(e„-,
❑ I am a homeowner performing all work myself. Project Type: New Constructioni;lRemodel
�1 am a sole proprietor and have no one working in any capacity.cowmam ❑Building Addition
❑ 1 am an employer providing workers compensation for my employT worlungon this job
,E'.:y'�"j"C y y�y $rC PE .•' `P✓ j1•A'�X� Y Y. a
Y w
K• $4K't�t AL, 'tT6iQC7' } 'T 4e .� zY1 4 i
S
t r �'`::; �'t3`fr�rg'4' �•�'$ d�tf �� Apr :'x +,F
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comoanv namr. -
address:
city:
Failure to men coverep as required under Section SSA of MGL 152 me tend to the imposition of criminal penalties of a flue up to s1,500.00 and/or
one years'imprisonment u wen"civil penalties In the form of s STOP WORK ORDER and a fine of S100.00 s day spiel mc l undentaud that■
copy of this sutement may be forwarded to the Office of Investiptiom of the DU for coverage verification.
1 do hereby cerd der the pains and penalties ojper)ury that the information provided above is true and correct.
signature (/(/' Date 2-
/ —O
Print name o -eiL J. L h eLEE e Lt Phone q cr7 F- 7,Y S-6 I,
omcial use only do not write In this arm to be completed by city or tows official
city or town: permit/license N ❑Building Department
❑Lleeeing Board
❑check if immediate response isrequired
❑Seketmen's Oflke
❑Ilmlth Department
contact per ma: phone a: ❑Other
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