79 SUMMER ST - BUILDING INSPECTION r
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AM GRANTED
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Pa toc OI LOM PERIAIT APPLJCATM FOR:
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PLEASE FILL OLtfr LROMLY A COMPLETELY TO AVOID DELAYS W PIIOO�
TO THE INSPECTOR OF WJ LDINQ&
The i hordW appon. for a permit to build a000rdkq to the toNaspedbeftm
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Owrwrs Name A WA DE L A C R U Z
AddnadPhone 79 SU/WM � ST (474 376 z9SH.
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MaoharAw Name
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PUBUC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01 S70
TEL (978)74S-S595 EXT. 360
FAX (976) 740•9646
STANL EY J. USOVICE. JIL
MAYOR
DISPOSAL OF DEBRE AFFIDAVIT
In accordance with the provision of M(R,c 40,S34,I w3mowledge Tint as a camditim
of BwldinS Permit g , all debris rmdting from the cmu mction activity
sovaned by this Build m Perm$abaci be disposed of in a propedy licensed solid-waft
disposal facility,as defined by MUL c IM SIX&
The debris wr71 be disposed of at: 7"m/. 247 A nMH,ER/.;AL Sr L y, I,y
Location of Faa'litf
t; - 1- 09
Si&abm OfPe®itApp Date
FULLY complete the following mfomlaum
(PLEASE PRINT CLEAny)
f'A -r i ti.c) ME,Cy
Name ofPasmftA"Hcaet
Firm Name,if any
Addmm,City-&Star
The above statmte requires that debris from the demolition,renovation,rehab or other
alteration of bml&S or structim be disposed in a Properly-licensed solid-waste disposal
facility as defned by M(X CM S150A,and the building pamits or licenses are to
indicate the location of the facility.
Cominanwaalllteofr 1.//o`-46nckatb
11e riawaal • .ladra4iol�eeisraL• .
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Commoaaw
Workers' Compensation Insurance Affidawk
4- 13
. . wrch.a principal place of business at:
. . ica.,iatwday
do hereby'certify under the pains and penalties of perjury, sloe
() I am an employer providing workers' compensation coverate for my employees working on
this job.
• � t G5, S 620 l3
Insurance Coanpsrry f Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers,' compensation potidea
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
1 vrowuane mat a coot of tic ataw„w,e wa be is r aroee m ow Office of Wvvsknom of Ott 01,k la co. vvg'"Ificadw aea out N4at a ware
co,erair a, rrourro unow Sieben IIA d MGL 1 S I can kaa a Ow i,mawien of poniD,owtadea cormadm of air of so wi 1—MI 0 muar oft
scarf iaorta,.nent a to a,ci i oeukie,it the ,omt of a STOP WORK ORDER arse a bw of S 100.00 a an!plat aK
Signed this • day of —
:ice rocci'Fenniuee ouilding Department
:�celtsing Eeard
Seiectmens Office
tit:hh Deparmcr: