11 SUTTON AVE - BUILDING INSPECTION (2) fL*1IS YlE fALA1B414D AfWROYED BY 744E
J UPJ=0ff.PM0R W A'PEAIUT•=M GRANTED
CITY OF SALEM
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BUILDM PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) ImsWI Si , Construct Deck, Shtad, Pool.
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PLEASE FILL Otrr LEta11BLY A COMPLETELY TO AVOID DELAYS IN PROCMM
TO THE INSPECTOR OF BUILDINGS: '
The undersip W hereby applies for a permit to build aocorc ft to ft t kwinq'
speawkwAlona:
Owners Name
Address a Phone 11
A►chkftfs Name
Address A Phone ( 1
Mechanics Name /�iG1x��//�t�c✓�r���vs��^
Address a Phone ( 1
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Sig"m4f Applibant
SIMM UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DONE OF PE'RJURY
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MAIL PERMIT TO: s
APPLICATION FOR
PE l TO
LOCATION
PERMIT GRANTED
APPROVED
I OR OF BUI S
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
GO) FAX (978) 740-9846
STANLEY J. UBOvICZ, 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 III, S 1550A. /
The debris will be disposed of at: At u'1 / z��S
Location of Facility l
Sigfiaturjy6ffrermi Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY) /
Name
of Permit A
//
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
I
The Commonwealth of Massachusetts
r - Department of Industrial Accidents
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600 Washington Street, 1"Floor
psi Boston,Mass 02111
Workers'Compensation Insurance Affidavit: Buildin lumbio Iectrical Contractors
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address: z _ ,(� �y-7
city �Qf2�� crate• /-tom ao f)/'92l rah n #
work site location(full addressl: J l..C7-7o-i-7 C j,&_
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction EIR6mtodel
am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers comPertj .
sauon for mf emQloyets workln on thisob
empany
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I am a sole proprietor, eneral contractis r homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
eomoarty Dame: -
address: -
city:
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Failure Iowan avenge as required under Section 25A of MGL 152 an lad to the Imposition of criminal pemoldes of a Me up ta 51,500.00 and/or
one years'Imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that■
copy of this statement may be forwarded to the Offlee of Investigations of the DU for coverage verification.
I do hereby certify ander the pairs and pen ahi r of perlt ry that the information provided above is true and correct
Signature //� // Datey�LC��U-s —
Print name /T/L e/ D �`'c'� Phone# 9 _ 37S—Z2S"-9-
official use only do not write in this area to be completed by city or town official
city or Iowa: permithieeme a
❑Building Department
❑check if immediate response it required ❑ ide gogine Board
❑seketma's Owe
❑Health Department
contact person: phone#; ❑Other
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