14 SYMONDS - BUILDING INSPECTION t
*w+�+k��E�Er� APwrovEo sr�iiE
�P�caoo�.�m�►r!ae�raEwo c+I�ANr�
CITY OF SALEM
' wee
�__ �_
b M�Mmb omftn� Yr Ns of
tt. s„a f Sd wi co) S
a ftomv Latin to
• M caumftn AmW Yw ttr_
Pttmtk toe OULWO MMW APPUCATM POI
(C *whioharar GPM Roof, I o$Wft Conti W peat, &44 pool,
PLEAAE PR4OW LILY&COYPL MY TO AVM OELAVO M PROCUUp
TO THE POPECM OF flUILOIfVQ6:
Whu�Y # on for a Wink to buN a000 *ftto ".%ftwr'p
O~s wino d '�
Addmw A Rwo > S yINL o s
f A � �--
Amhhn s Noma
Addrw A Phone f
Maolnttioa Wattta �;// awes ��;I�,KS �- 2e�,o�zii.�
Aditn& Phona . 37&17v: eL;; ���� �;� � ,� If fi t 9Si-9S�q
No is or popm it tw-mv
MIN"a, bdoJ F�, � r.a iq,b►ea.mmw
w.kd"aoiaw a tW ..e...i,.�
�d00w ��ao' — t�►t►onwr_,_wr r CS' o �7136
sm �tune
INO�1 TM PENALTY
oEEtC:1RrIMOf/ WOOKm " m/m OF Pl�
41 V2eit4 ���L�✓IMC
MNL PENwNT
..i 1
•
SONKT IR AQ d0103dw
eA LY PI
CBLNVU /
NK)LLVWI
MLAg�
CITY OF SALE1019 MASSACHUSETTS
/ 9 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MA O1970
TEL (979)743-9595 EXT. 360
FAX (97e) 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 III .all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed soh&wasts
disposal facility,m defined by MGL c ID.8150A.
The debris will be disposed of at: T—, 2e I w
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
4A)i//07M DCZe✓X
Name of Permit Applicant
Firm Name,if any
53 /Jr�1a�-
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
a Department of Industrial Accidents
i Ofl16B B11mWimosunfis
600 Washington Street, 7`h Floor
Boston,Mass. 02111
4sy�lWorkers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
A Dlid�.)�9t10R �t ' i#.'£b`p(zs �:,r��.ldiiS"aPleaie.PRfNt esiblK ....s �
name: � Jej ..a:l .1 t'e ;/
��
address: `i 3 '/ J 4 r"/uiit-j A-I o e
cif ��� � 'LLL
r state / !' zip 'a ;ZYc1 ohnn #
work site location(full address)- IY sx&M e A k; S'T a SU, t ✓1'I A❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction
�I am a sole proprietor and have no one working in any capacity.. _ ❑Building Addition
❑ 1 am an employer providing workers'compensation for my employees working on thislob
k ti f—IN x
company name:
p
ti y yj
• - T k ! S•1, SN yXT'rv� 3e.F, i t
address:
city: m':*�•;
insurance co. ool�ev p
❑ I am a sole proprietor,general contractor,or homeowner(c/rc%one)and have hired the contractors listed below who have
the following workers' compensation polices:
comoanv name• -
address:
city: nhone a• `
•irk Y ! *I
insurari z .�- ,- r. ",•c,ix„ h �.'-0+,".,�;fI-+' . �i %`'^�• " .':: ' h
F
v� . - - _ ..
,
company name:
address: rt
city:— nhon -u. J
1411
a
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of s STOP WORK ORDER and a fine orsio0.00 a day against 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 certify under the pains andpenalties of perjury that the information provided above is true and correct.
Signature P:5-e tC <.:^G(,,.i, Date
Print name I->��� C)"e.-t —Phone#
o
fficial use only do not write in this area to be completed by city or town omelet
r town: permit/license# ❑Building Department
eck if immediate response is required ❑Licensing Board
❑Selectmen's Office
❑Health Department
ct person: phone#: ❑Other
d Sept '-001