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5 SALT WALL LN - BUILDING INSPECTION (3) WMCWX PW TO A'VMW=W QRAN*D •\ \��^� CITY OF SALEM No. 5 a. Wd mntiq n. 1 . rM 1 011E(�d01'�� YY No_ NNUAlft of 7 r SALT WALL LAVo M PlOW9 Loaded In M Cmew%Mon And YM NO BIAIim PfoVwMf APPLICAIm pm • Parmk to: (Cirob WhI W4W apply) Roof. R j IWA SWft CaMUM Do*. Shad, Pooh OUtar: PLEASE I "OW LEOMY A COMPLETELY TO AV=ON.AYE N PQOOfissfrl0 TO THE INSPECTOR OF WALDM8 The hmW appNn for a pwmk to bukd a000id%to to iokowlrq OwrNtr'a Name G ,4 L o C o L Adds A Pl ana ' 7 S A Lr W A LL L,g u, ( 1 '7 4 5 2 Z vc;, l4ohkact'a Noma Addmu A Phone ( 1 Maohan m Nam. G , h.o LY Addren A Phone _ J LI 9 MA(4) S T Pgn A ID y (9791 S 3\ g Z34 Whd Is b pOpm it UmW klo w d- - - my N a dwOanp,for how mar trh1OO7 WE bAdg anlam b W? a mm and-4•8. 5 5 0 plp Llouw a aw.LbdhM a O S ) Cl R ',- Sip WAn of AppY " ll�INfff1N1 no Ps"TT, fF PORAW DESCpIptIDN OF VM W TO OE om i rz ; l� �z �o2 F MAIL PERMIT To L P� G b�� v ��Ai�oa�, M�a ar96o -- - The COntino2wealth o Massachusetts ,�zl;'_=_, = Department of Industrial Accidents Office Oflnvestigations — 600 Washington Street, 7"Floor ` < Boston, Mass. 02111 . Workers' Com ensat)on Insurance Affidavit Bmldin /Plumbs Electrical Contractors Annhcay�lm'forma 'a1Jt'e� ytiyfYr'1,3i c ; ^v�3� se,P2dTe' b �t name: address: - ' city state: Zip. phoneN work site location(fu)l addressl: U 1 am a homeowner performing all work myself Project Type: ❑ New Construction ❑Remodel ❑ 1 am a sole proprietor and have no one working In an capacity. g Y ❑ Buildmu Addition i3 ri> A({!g"J'�.C]�4eSr,-17.�ccttil°0.v ;?. n. 1 w� (t ! ".„ t t ' r 'rt m .. ... .�. ,ti 1{3u1.f1 fu Xam an employer providing workers' compensation for my employees working on this job. company no a: L .t,v �t {, 9 LY address: I.Lt Q .,- L1 t,�✓ //9 insurance.co /'l. .L .: LT'IJ �.' ;y-�v ol(C M b 6 p 9-7 C) 1p O C.J ❑,1 or homeowner(circle one) and have hired the contractors listed below who have am a sole proprietor, general contractor, 1 the following workers' compensation polices: company name: address: - city: Phone�t' msurance,co. ' S ali no Iry coin ;m name. - _ . . ..comp;my address: . city: 'hone#: insurance.co. - olic. 3i Failure to secure coverage as required under Section 2sA of MUL 152 can lead to the imposition of criminal penalt' ,';l�k� ies of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORT(ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I elo hereby certify under the pains and penalties ofperjury that the information provided above is(ate mud correct. Signature .L_)--2ti7 ''� Date — Z` 0 L' Print name L .O,✓ (:s ( b,y L`/ Phone N t� 3 Z./ y�u0il-�"c3'rt3n2stL": 8}�"g'Stt�EL�1A�E4'�IfASYL'Wi'O:CnrL'�6'i.>.�rduSJ�^'vBt3t1ti.�'e7r3 ;i'aXQt;4aSd1t�'w'n>Hnvau_u,;t�.wexsm::SLtiYl�e �Gnn;..u,r.:(GcE,us�n i;jtyCi47iu�iYrlG.�,� .r official use only do not write in this area to be completed by city or town official r ,3 jqMa city or town: permfUllcense H ' L5 ❑Building Department []Licensing Board ❑ check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone III; ❑Other +� ( uds.v12cor) �'3i€ESL�:r^s7��RE'A',En ` a32`fc'8�1FnsS:,k7v:.E`�tifBg�ISii4lyS+ic'U'1�-76F 4vi'Y4:T"rSLfvllk""s, Yt•Sg7li'ai3`iSti%dCfiY4c&"vni�."ni'k2.SSi['(.SilF.4�kiiS�©3'151.`43�Cii�''k�s" :� ..� � v�s � •.r .-r �+....-.fir �.r�...r... ...�� �-.......��«- s l �ublit �raptzYq $tpnrimtitt �U11�Ulg �tpIIi'rtnrut i l0at v�l�m 6rmt 50a-7J9�9595 Est, 3aD DISPOSAL OF DEBRIS AFFIDAVIT in accordance vith the provisions of HOL c 4.01 554 , I acknoviedge that as e conoicion of Building Permit 0 , all debris resudti" from the construction activity governed by thi5 Building Perm' t 51a11 be disposed of a properly licensed solid vaste disposal facility, as defined by nc! c S 150A, The dehrisc'vill be disposed of at : L�rr ND ! P i �n CRtiC c location of facility 5i aa cure of Ye g Fm1t plicant Date Fully complete the following information: (Please print clearly) L' r Name o P�AppIicant Firm Nacre, it any P-0 A 1600 � hddress , City i State The above statute requires chat debris from the demol '_tion,. renovation , re not or other alteration; of building or structure be disposed of in a propexly licensed, solid vasty dis�,osal facility as defined by. hGL cI11 , 5150, and uuc building permits or license's are to 'indicate the location of the facility at DESCPIPTInN r1F Wncv rn Me: nnair