61 VALIANT WAY - BUILDING INSPECTION z
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CITY OF S�LEM
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PUBLIC PROPERTY DEPARTMENT
' 120 WASHINGTON STREW, 3010 FLOOR
6ALZM,MA 01670
TEL. (676)740-Y396 EXT.380
FAX (976) 740-9646
STANLEY J. USOVWZ, JR.
MAYOR
DISPOSAL OF DE M AFFIDAVIT
In accordance with the pmvisiona Of MCL c 409 SK I acbWwle*t W as a camdidon
Of Bwd n Pamit# .all debris resulting from the consmiedm activity
pvaned by this BT I&S Pemit ahali be disposed of in a propaiy Hcenad soH&wasoa
dulposd facilityo as da$oad by M($,c Iq S110A.
The debds wlll be disposed of at: �,��,�} S_�
Lbcadm of Fw ity
Vo7 04——
S' Peemit Date
FULLY complde the following ui m ahm
(PLEASE mm CLEaLT)
6 N
Name Of Peomrit AppWnot
Film Name,if=W
11 UAJIP
�k State
The above statute regaims fiat debris frm the demolition. renovation.rehab or other
altaudon of buOdmg or strut um be disposed in a properly-licensed solid-wma digmal
facility as deft W by MM cM S15K and the building permits or liceoap—to
iadTeate the location of the h ality.
• COrnmonWloQ� 0 j�CWnCi�a� •
6 1Japa.loMal a j�.�rriaf./rcoie r�• .
nMi 600 WJ6616Silas1
JameaJ.Camaod �,1.� /I/a.a.sLrMw 02111
Commanarr
Workers' Compensation Insurance Ada*
. . with.a principal place of business as»
n�,7o al l • l6
rca,,...oialq
do hereby'certify under the pains and penalties of perjury, thm
() i am an employer providing workers' compensation coverage for my employees working e101
thb job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensaiwn po0dew
. �i�ilUC IBIS. '��P�I�23ZS
Contractor Insurance Comparry/Polley Number
Contractor ura� nce Comparry/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I urraayana tot a cc"of 0i aawmmr vM ere iern.arwa wow Of&e o1 LT ek oom of Ore M far co. a"'"Wadm and tot fat m eo Mon
comae as rea wro amw Stc6m 25A of HGL 152 can kw M Ore irwowba of a:rira oerunka Cor-away d a rest d M earl 1.500:00 Older one
•can•wwoorrnmr as vo as cm oedua in O+r gam of a STOP WORK ORDE ano a raw of $100.00 a an aim aat.
Signed this , day of ((f -
LAJL
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:iccrs ei F iatee ouilciny Gepartn+ent
uccnsin€ Ecare
Seiectmens Office
se:ith Geparmen,
BOARD OF BUILDING REGULATIONS
Lii:erm: CONSTRUCTION SUPERVISOR
Numbw:.CS, 034839
Birtlickim 10125/1955
1 Expiro= 10/25/2005 Tr.no: 8224.0
ResVte
{ JOSEPH F MAL0— k`
17 JUNIPER RD "
NORTON, MA 02788 `— Administrator
✓� >°ioaur�ur�uiiax�c o�✓�.aaaaP.2uJ8�Q
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration i-f,1156
Ezpiratton 21912004
IiMWidual
JOSEPH MALONEY -
JOSEPH MALONEYd`�ET�
17 JUNIPER RD
NORTON. MA 02766 ictra,or