35 RAVENNA - BUILDING INSPECTION R
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APPLICATION FOR
PMIII TO
LOCATION
PEF T GRANTED
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OF 9UILDPM
-, The Commonwealth of Massachusetts
QaV, 7 Department of Industrial Accidents
mceallmrostlgetlons
600 Washington Street, rh Floor
' Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin lumbin lectrical Contractors
ad ess:
city .�� /�/� state ` !� zips phone#
work site location(full address)'
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. Buildin Addition
am an employer providing
workers' compensation for my employees_working on this job..
address:
c l
❑ I am a sole proprietor,general contractor,or homeow (circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
ci •
Y7
insurance ea�i®e policvM - c
Company name: -
address; -
City.
Failure to secure coverage w required under Sectloo Mot MGL 153 coo lead to the Impositlon of criminal penalties of a fine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of S]00.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Omce of Investigations of ibe DIA for coverage verification.
l do hereby certify under e p 'ns an en ties of perjury that the information provided above is true and c rrect.
Signature - Date J'- G
Print name /�C Ice+ Phone#
official use only do not write in this area to be completed by city or town official
city or tow n: rmit/license a
M1 Pe ❑Building Department
❑Licensing Board
❑check if immediate response isrequired []Selectmen's Office
contact person: phone ❑Health Department
i 1o..N saps asu� P ❑Other
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
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, S 150A. / Q
The debris will be disposed of at: 7-5
Location of Faci
J �
Signature of P t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)`
Name of Permit Applicant
�
i ,` le-1
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.