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CITY OF SALEM, MASSACNUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3010 FLOOR
SALEM.MA 01970 ,
TEL (976)745-9395 EXT. 360
FAX (976) 740.9846
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aolmowledge that as a condition
of Building Permit g .all debris moilting from the cmarucdon activity
govemed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S1S"
The debris will be disposed of ato��
Location of Facility
SiPaUi of Permit cant Date
FULLY complete the following information:
(PLEASE PRWr CLEARLY)
S f��hf�✓. e v� b.<—vy�
Name of Permit Applicant
Firm Name,if any
� .
� Fes,
S c� 1�cs,vG�) S'.�C
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 cM S 150A, and the building permits or licenses are to
indicate the location of the facility.
i-
.s:
---~ The Commonwealth of Massachusetts
T' Department of Industrial Accidents
IRMS dlmrosuffaum
l 600 Washington Street, f'Floor
t Boston,Mass. 01111
4,. Workers'Com ensation Ipsuropce Affidavit: Buildio Iumbin lectrical Contractors
name,
addrecr
city state: zip: phone#
work site local on I full address)'
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole ro rietor and have no one worki El Building Addition
1 am an employer providing workers' compensation for my employees working on this job.
COMDAltvn*mc Cox,.
'Ic k S "' r 'Y-J-�` tai x. ad bl j� -� •• 3 y.
address: ���. l�C'ZiLr9l� r/�r Efit "h�.r , ` v rr:.• n l_'>e• ie "�
Y
rite:
❑ 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.
company name:
address
city' obonef r. 1
1 n; , +.s.s i3t c•,,y.: .!� ".Yi.,- �,� �4w- �+,r^fF3r�.��k,.Y'%'� s.,"'�
`Y4i'k,'v �i"f i§' )l•+k'k ..atlS��Yt4�.y1�'�+';�'!q^"� �;�V",�'i YS 91:
Company namc
address
Apalt�
Failure Insecure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penattin of a Bat up to$1,500.00 and/or
one years'imprisonment n well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day agaiost me. 1 understand that■
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification.!do hereby certify under th pains and pens stttof perjury that the information provided above is free and correct.
Signature Date .0—S _d 5—
Print name Phone# 272 '1; /
I
l use only do not write in this area to be completed by city or town official
town: permit license# ❑Building Department
❑Licensing Board
ck if immediate response is required ❑selectmen's Omce
❑Hnllh Department
t person: phone#; ❑Other
Sep,2,01