20 PALMER ST - BUILDING INSPECTION »sTZ 7
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RRIORTAPT ED BY TIOIRRV &G (,'RANTED
Buildio Poatal Loeat un of Buildipe 2-0 PA-& vLfk
g t+,�pplicatioa For:
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w app es) Robf, oof I!4141 Siding;,Constntet l ",.Shed-Pool
Ad�iitiori Alteration, RePau/Repltide,Foundation Only Wt W.S
OtherI.
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508-7.15-J595 Fsi. 380
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 4a11Sdebrisaresultingefrom that
the a
condition of Building Permit p +
ned by this Building Permit shall be disposed of in
construction activity gover
a properly licensed solid waste disposal facility, as defined
defined by MGL c III,
S 150A. h+ �� Aj
The debris will be disposed of at: R=d -- —�-�
location of faeiiity
G ► A.( � l �Cl--two W„� � � �¢ --
Signature of Permit App hcant Date
Fully complete t e following
jinformation:
(please
int
l AV I D A,16fF l MA*J
Name of Permit �Applicant
V S/4— j I VIiI�L ptA l
Firm N me, if any
Address. Litt' 6 State
The above statute alteration ?flbuilding orbris from structurethe be disposed of in�avproperlyehab
licenser solidwste as
licensed permits license'slaretto1indicatefthed by r-GL locationcofithel50A and facilitytatt
building p
(p ( ommonwaalm 0// maJJaCLJet1J
1Jeparfmznfo���`ndu�tria[ 4cciae
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//�� 600 gVgl�/al�iirt9fort �freeE
James J.Camobell 4.Joefon, �r/auaacLeffe 02/ 1 1
Commissioner
Workers' Compensation Insurance Affidavit
I,
with.a principal place of business at:
(Ory/State/Z10)
do/hereby certify under the pains and penalties of perjury, that:
(y I am an employer providing workers' compensation coverage for my employees working on
this job.
I G CLn to R1 4a-M Q )
Insurance Company Policy Number
() 1 am a sole proprietor and have no one working for me in any capacity.
() 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:
kb�Sk 1 31AAE �NlpRd\/Z
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I understand that a COOP of this statement will be forwarded to the Office of Investigations of the DIA for coverage verification and that failure to secure
coverage as redutred under Section 25A of MGL 152 can lead to the imocsrtion of criminal oenanies cors¢tmg of a fine of uo so S I•S00.00 and/or one
Years' imorucinment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S 100.00 a day against me.
Signed this day of !' 19
Licensee/Permit tee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375