94 OCEAN AVE - BUILDING INSPECTION It
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Workers'
kej- Compensation Insurance Ada*
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. . witha principal place of business at:
do he certify under the pains and penalties of perjury. thm
1 am an employer providing workers' compensation 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 any capacicy.
() 1 am a sole proprietor, general comraetor or homeowner (circle one) and have..hired the
contractors listed below who-have the following workers' compensation policles:
Contractor Irsurancle Company/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I um,,woo an a coot of"sucmwr.wo be ion.umd w rM Ofree ei krVaknow of Ow DIA ka corerne Wic" n a"Ulan{ire b.ae.re
cor.rara u rrou►ee aura Sw"m 2SA of HGL 15 I can kad m ow ino.wioe of erWilm 9e11.8e2 corJ.wat d a fra.f oo I"I.50=saN.r oft
rcan'inxoerr ,a no a exi ocaskin w vw Ions eta STOP WORK ORDER sin a S.w of S 100.00 a 9" arrw aat.
Signed this , l day of L)/V,-P� �
:ices i Ftnniuec euiidinE Deparin+ent
Licensing Ecarf
SeittSmeni Office
e:lth Deparmer-.
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 9RD FLOOR
SALEM,MA 01970
• TEL (978)745-9595 EXT. 360
? 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
The debris will be disposed of at: �ctA�111 5W3—/ d , fdL,!!4� _
cation of Facility
Agnatum of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
&Ak
Name ofPermit Applicant
//
Firm Name,if any
0Z
Address,City&State
t 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 cIll, S150A, and the building permits or licenses are to
indicate the location of the facility.