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�DlflO PERfiMT APPLICATION Pf�R
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TO THE INSPEMM OF SUWNM.
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Ow ees Name r(A. A r^r
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600 w.J.11.3W.1
une.d &4 , ..clNwa.lfr 02111
Commeaoer -
Workers' Compensation Insurance7:1
af< r4IK-C U IV,,, • .
. . wrch.a principal piece of business as:
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do hereby'cenify under the pains and pentihies of perprya shag '
i am an employer providing workers' compensation coverage for my einployea working on
this job.
Insurance Compsaq Policy Nu bet
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1 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 policies:
Contractor Insurance Company/PORGY Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing ale the work myself.
I wr4"wne mat a ceor of"w"m w wa be 1e wose m dr Olke of M•adraww of du DIA lei ce.erare.sAkaden am UM 4L.e r News
ce.erar, y ieevaw.no.r Sedan 2SA el MGL 152 on kae ae eA s 6r.I w0 wi 1.'; I WA1Gt ern
+wan'i+uroemm�t w ye w ci.i eauliia u+e loan e!a STOP WORK ORDER aiw a iir e! S t00 00 a dal ataiw rat
Silrned this • day of -
:;cersct/Ferrmitet iiuilaing Departrkent
ucensinf boare
Seieamens Office
ie:lt�� Geparmer.'
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 31110 FLOOR
SALEN.MA 01670
TEL (976)745-D696 Err.990
FAX (676) 740.9046
STANLEY J. UfOVICZ, JNL
MAYOR
D010SAL OF DEBRE AFFIDAVIT
In accordance with the provisim of MGL c 4%S34.I aclmowledga that as a condition
Of Bm'lding Permit g .all debris resulting from the conat cad m activity
governed by thin Building Pelmit dnH be disposed of in a pnValy licensed solid-waft
disposal facility,as def ned by M($,c ID.S150A.
The debris wi l be disposed of at: SA(" .
Location of Facility
ignatum Of Pact AFpltcmw Date
FULLY complete the following infoml sum
(PLEASE PRW CLEARLY)
P-?,t-�- B"4rtI4 -
Name of Pamit AppHcaot
Firm Name,if any
17— Sj -1 hV y
Address.City tit State
The above statute require that debris from the demolition,renovation,rehab or other
altastion of bmlding or smwtu a be disposed in a properly-licensed solid-wsste dispoul
facility as&Tined by M�,"I,cID. S 130A,and the building pamita or license:we to
indicate the location of the facility.