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JN$PEC'IOB.Pew TD A"PERMIT BENR GRANTED
CITY OF_SALEM
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Permit to: BWLDN FOP.
PERMIT APPLICATION FO
(Circle whichever apply) Remof, Indall Sidlnp, Corntruct Deck, Shad, Pool,
dReplaa, Other:
PLEASE FILL OBIT LEGIBLY i COMPLETELY TO AVOID DELAYS N PROCEBOM
TO THE INSPECTOR OF BUILDINGS: '
The urKkn'g or' hereby applies for a permit to build aocordGip.to ft following,
Owner's Name r iKict /116AW<
Address a Phone 42 .S Aio44 26 07A 19qN-A✓W)
Arohiteot's Name
Address 6 Phone ( 1
Mechanics Name �A)M PIZ.V 141%&A--felM
Address & Phone 6�2-1 �46ergta)n sT �k►r .,ham a_ p 7P.) -"31-ggg
What b the Pspow at WWW lK{:J"A9/AL
mftw of b~ a dw.1Yq.for how in"ownft?
wN bulldrq aorram to law? Asbasros4
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e
a m Is*ra 7
of t
THE PENALTY'
OF PERWRY
DESCRIPTION OF WORK TO BE DONE °
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MAIL PERMIT TO: %� ,51,W Al k C4,,SAG-0- hiO, � f
APPLICAUM FOR
PE l TO
LOCATION
PERMIT GRANTED -
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INSPECTOR OF BUILDINGS
C
CITY OF SALEM9 MASSACHUSETTS
y� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM, MA O1970
TEL. (978)748-9595 ExT. 380
0 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 Ia S 150A.
The debris will be disposed of at: Y1 WAS—it
Location of Facility
M MVZMAi.
Si tune of P t licant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
NAIEQ (��t�/ �.,c+.ir,�peraef
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
G Department of Industrial Accidents
600 Washington Street, 7"Floor
Boston,Mass 02111
Workers'Com efisatiofi Ifisurouce Affidavit: Buildin lumbifi lectrical Contractors
name: tcla n/aivfJp
address: 41n111L& Q d
city S'AuWI state, //i'1 zip. 61276 phone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
[�1 am a soolleraoerietor and have no one working in any capacity. Building Addition
LZ 1 am an employer providing workers compensation for my employees workmton this ob
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
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as
et
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commmv"am
Failure to secore coverage as required under Section 25A of MGL 152 can lead to the ImpoYgoa of criminal
one yeah'Ins rlmnmeot ns well u civil peoohles of a Ilse rap to SI,500.00 and/or
p penalties in the form of a STOP WORK ORDER and o fins of$100.00 a day oplost me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certi under th!tL
nalties of perjury that the information provided above is true and correct
Signature p� /7��j�-z/
Print name Phone#f/G"' ,3JZL
official use only do not write in this area to be completed by city or tows official
city or town: peemil/licem a
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ent
rd
❑check if immediate response is required etcontact person: phone n;
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