10 VARNEY ST - BUILDING INSPECTION f
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Tw$Y T44E ,
P J=Q GRANTED M.
CITY OF SA�EM
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BURDING PERW APPLICATION FOR: '
P«mk to:
(Ckob whiohewr apply Roof. Reroof, Deck Shad, Pak
RspaldReplaoe,ih�w�-ln
PLEASE I "WT LEGIBLY&COMPLEMY TO AVOID DELAYS IN PRoaLLI1SII0
TO THE INSPECTOR OF BUILDINGS:
The undersood hereby applies for a permit to WW aa:om tp to the tokswMto
apeoMloationa: 1 /`�/.
Ownses Name �u f Sf c.2/(o
Address APhone /dam S �; eAA, f9)h 2-V//17(//
Arohl wft Name
Address& Phone ( 1
Medtsnlcs Now
Address a Phone /(!T3 c a *2 (LZo,6
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SWAJA of Avowt
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SKw D UNDER THE
OF PERJURY
DESCRIPTION OF WORK TO BE DCHE
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'4 MAIL PERMIT TO: C
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PUBLIC PROPERTY DEPARTMENT
r ¢ 120 WASHINGTON STREET, a11D FLOOIr '
6AI M,MA 01970
TEL. (976)743-9595 EXT.960
FAX (676) 740-9646
STANLEY J. USOVICZ, JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(X c 40,SX I acknowledge that m a condition
of Bm1ding Permit g .all debris resulting from the constructim actift
governed by this Building Permit shall be disposed of in a Fopa*licensed aokid-waft
disposal hciW,as defined by MCM c 1%SIX&
The debris will be disposed of a /�o rfiii E/0 J -C C-g r j A TJ i 9 at lF rt r� �UP�
Location of Facility T—
Sipat&e Of Applicant Date
FULLY complete the following in*MSUM
(PLEASE PRIM'CLEARLY)
(rco � 4 -- - �-rc,t9✓l
Name o0eimit Applicant
Firm Name,if any
/u C-�- /YIQ/CJ/e/l C��l /X of cv ?yf
Ad&wk City dt State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of bmldkg or structure be disposed in a properly-licemw solid-waste disposal
facility as deliaed by MU clX S 150A,and the building pamits or license:are to
indicate the lotion of the facility.
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CammonSue alth o 111a�ncaf�
?dim
600 ryw��.L-1be.�beal
camas a f anaeaat &A. , .aa.tl.6 021 l 1
Cwaanaaioiw
Workers' Compensation Insurance AffidaYk
t
. . wgh.a principal place of business at:
. . icbaaw.�s+N
do hereby'cersify under the pains and peniltks of perjury, thm
() I am an employer providing workers' compensation coverage for my sinployees working on
this job.
Insurance Company Policy Humber
1 am a sole proprietor and have no one working for me in any cspadq.
() I am a sole proprietor, general contracsor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compelasaseon poliicles:
Cantr r insurance company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
i unorncanc wt a coo,of ofo atasenwm aim be is +woet to ow Once of Inredtasaam .f tax DIA 1W ce+srste.s.Sicadm ana.Nt MAT m MCWN
co.e m at ,revue uneer Section 2SA of MGL 15 2 can kao to ow Orwoudea{of cPo,vta venal"coriadn/ of a hne eaf w W41.500 O wWor use
lean• inortamwn{a.,a/L ci.i xmlo"in the iorm of a STOP WORK ORDER ane a fne of S 100=a an atd,w aces.
Sinned this • day of —� r
:ictnstci Fcrrmitttt cuilcing Deparm-rnt
'icemsing Eearc
Seiemmens Office