11 SHILLABER ST - BUILDING INSPECTION (2) ql,
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PLEASE P"WH LMLY a OOMPUMY W AYO D O"Ys N PROONmn 1 •
TO-THE INSPECTOR OP TilAL "K.
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1Jep.aiee.al a/.7tdrdaiol./icci..ata
600 W. L.11.SLwl
James J Camtod •. /I/.aa.tM.a.11f 021/I
Cemmasaw
Workers' Compensation Insurance Afr'dWk
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. . wi .ba principal place of businessr.a 1'
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do�hcreby•cerdfy under the pains and penalties of perjury, that
q I am an employer prvAding workers' compensation coverajs for my employees working on
this job.
CA r8(L1nS .�Tocxya. 2C5 �17l4�80
Insurance Compiny Policy Numbw
i am a sole proprietor and have no one working for me in arty opatkr.
() 1 am a sole proprietor, general Cmractor or homeowner (circle one) and have hired do
contractors listed below who-have the following workers' compensation policies:
Contractor Insurance Company/Poft Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
I
0 1 am a homeowner performing all the work myself.
• I urWeratane tot a Corr d the wwr mM wa be tea wftd m aw ORce el M.saora M of the DIA ler Ce are.eAatarlm aed tat Kle e b wee
ctnararr ar rrouero center Sec6en 2SA ed MGL 152 can hen wow inotaW n of CAVWWM ocrwes eorw6M of a fwe el ao of I.SOOAO&Wer eves
Hari inxeannrtnt a to a efri eertal w in the lion el a STOP WORK ORDER and a few of S 1tf0A0 a tar atM.eat
SiEned this • ,�a"d day of 5L) _aO�AI
is rsce Ferrrmtee uilcin( Geparcn.ent
jc`cnsinf Eoare
Seiemmens Office
^e:ltlr Geparmer:;
1 PUBLIC PROPERTY DEPARTMENT
` h20 WASHINGTON STREET, 9RD FLOOR
SALEM,MA 01870
TEL (978)7434595 EXT.380
FAX (&78) 740.8846
STANLEY J. U80V=Z, JIL
MAYOR
I
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions Of MGL c 40,S34,I acknowl
edge that as a conditiast
of Building Permit 0 .all debris resulting fmom the conshuction activity
govemed by this Building Permit shall be disposed of in a properly licensed sor,&wasbe
disposal facility,as defined by MOL c Iq SISOA.
The debris will be disposed of at I as R .P)c.x n 54 . Pn a� "MA 019LoO
Laced=of Fectilldy
�-era-ay i
Si atrre of Permit Applicant - Date
FULLY complete the following mfi rmahm
(PLEASE PRINT CLEARLY)
LI-« Afll?gr( 114
Name ofPermitApplicant
Firm Name,if any
I
1aa- r , s i Reg . ma
Address,City&state
The above statute requires that debris fivm the demolition, renovation,rehab or other
alteration of bur'ldmg or structure be disposed is a Fopcly-licensed solid-waste disposal
facility as defined by MQ cl%SI50A, and the building permits or licenses are to
indicate the location of the facility.