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35 NORTHEND ST - BUILDING INSPECTION f1�11�111Mt�E#��f19 AFIylWltp aY 7b� •�lpll TD A 1!s�rOMq fMAN1'�p CITY OF SALEM or. o o s WIN DYMal7 of N°�Lamm 1�tLt�s 3 s 7✓orie�� i.n w in yak.me Pwmk Oft��M��Mp ANLJCA110N IOIk C �� OMIaP�ft Cwagm 0@0k pool PU'M A.L GW L MLY a OOIIPLEMY TO AMO DELAY•N PIIOfx� TO TW W0BOTM OF MAUD &- hIfty sppks for a PWW to bW aooadaip b Iha.lobwrq OWWO Nona E S4-ek 'Pecs✓c� ,to a Phon. (��c�� cam► �� 7 C- R � Aohbmes Nana l*hn a No IMa1wMa Nana Addra�a a Ph" � Mww a- � a!bddy so+..lo jWf tared eoa yS qr uow�a w� • @© -7 IM PUMA"' APPLICATION FOR poraffiro LOCATION PdrECTOR OF 89ALDMB '�ke o.�,vr�iorMuealdf`o�.i�aaaac%".°.l�, BOARD OF 9UIWVjG-RFG,4_1`iATIONS- 1 � License:_GpN$TRUGTIOt SUPBRVfSO t" _- r Number'- 080878: ' :Exptre� 09/03/2005-: Tr no. 8(IBZB d ` Ri! �� 9 7 DANIEL R FiARRIGAP , ' r 'PEABODY,MA 01960 �y : minisbatOr PEABOD F The Commonwealth of Massachusetts Department of Industrial Accidents - 600 , Washington Street >h Floor 8 Boston,Mass 02111 Workers'Corn ensation Insurance Affidavit Buildin /PlumbinztElectrical Contractors name, --../ y( t11� \ ",..G(f, �Ct YI address V` (-))-,f f Fr) ,n- cit,v G state: V'1\ zip:d(9 �O phone# 1 7e 5-3,> �6 work site location(full address): 1 am a homeowner performing all work myself. Project Type: ❑New Construction®Remodel 1 �m a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I+am an employer providing workers' compensation for my employees working{[on thisjob compaavesttte. �-14dr,'�Ar �r c�t�4� �.JS r-S�t.>.C,`1-"•^'�,'X7�,ru,,'' xt s. fi s." $ ' add GItY: / / nit 1 ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comonav name address' city: alone Ig: .. e in once 0 addresse. r s city. y i i 1 ApK Fallum to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of s floe up to SI,500.00 and/or one years'imprisonmeat ae well as civil penalties in the form of a STOP WORK ORDER and a flue of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i do hereby rlify r th p ns and ties of perjury that the information provided above is true and correct. Signature II Date � /� C) rr Print name an`4 � \�Gf � � SS`'1 Phone# g7� official use only do not write in this area to be completed by city or town omcial city or town: permit/llcense N ❑Building Department ❑Licensing Board ❑check if immediate response it required ❑seleclmea's Office []Health Department contact person: phone#; ❑Other Seri 2-W) CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 01a 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 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 c III,S150A. I The debris will be disposed of at�Gh4� �)i0)1 ✓� Location of Facility (�O�L) 'X�� s ) 41- Signature of Permit Applicant ate FULLY complete the following information: (PLEASE PRINT CLEARLY) �✓1� � l '��iY f �SCYh Name of Permit Applicant Firm Name,if any I n jS rrFv) �Y �� 1 Y '/� OI 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 cI ll, S 150A, and the building permits or licenses are to indicate the location of the facility.