18 VARNEY ST - BUILDING INSPECTION TM
AMO GRANTED
CITY OF SA�EM
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BUIUM PERMIT APPLICATION FOR: '
Park la
(CkoM whWWW AW ZLa(�I SWN, CMlbW.Daok. Shad, Paul,
PLEASE FB.L OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROGNIO N
TO THE INSPECTOR OF BUILDINGS;
The UMWSIWW hNSW apples. for a Pernik to WN a000rdYq to the folSwlrq
speomadom
ommes Name h s r /4/4
AftM & PtWW /A Lkzrhey 5�, HM -W 8/S--z3LC36
Arofrkao B Name
QAeOMIft Name A-1-1.-
A*h= & Ptwo _-rN %C(cc �i sT J �Le�S (97$1 9GZ-826 .5
Vlllld N ho popoM q buldrgt � ;f1es �cr�c�2 'ire
www a buMUgt- r�a!i Sk nc�c S r e dw.rrq,for now hmao9
aNWA.d ooa.6'7 i� . G U qy ub • N A ebb uO N 076 13 3 k.
Y.la. i i33o35
S' ` ipnature of Appkww
SIGNgD UNDER THE
DESCRIPTION OF WORK TO BE DONE OF PERJURY
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Coccymmonw+:a k 01 1lla_�6ackeft6
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,' 1Jtpnrlaaatnf o/, �fcciet�
600 w.sk-jl a 31,ed
�atate:l f aarmoa �Osl.,. ///.antkawal 021 It
comirsstaw
Workers' Compensation Insurance Affildr4t
la /�_(o4ri J(� � y�SlLci�I2 ✓7
. . w'rch a principal place of business at:
. . Itan�Ma+wysl
do hereby•certify under the pains and penaltim of perymys thm
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy number
1 am a sole proprietor and have no one working for me in any capacky.
() 1 am a ole propneto general contractor or homeowner (circle one) and have hired the
contraetort ' e •b:low who have the following workers' compensation policies:
Contractor Insurance Company/Policy Plumber
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I unoeraune gnat a cony of two gawne w wa be is r 4roeo to " 01rct el imesdtawm of the D1A for coverate.erSreadoe ar4 twat lalwe b atetrt
co.erare as eeovreo anew Stcton 25A of MGL 1 5 2 can kao w we:rwow-on of en+r"oenWM cerjsd#n of a rtwe e"M aai 1.500:00 wWw one
rears' r•,orwnnrnt as%,a as cwi "nak" in the form via STOP WORK ORDER ane a frr of S 100.00 a ran agairot wa.
a2PiG �(
Signed this , day ofa —
i
._iccnsee Fermittee Euilding Gepartrmcnt
�jcen..1 $ Ecare
seiectmens Office
�,�Ith Gep:�mer:'
-- - - 7 - - - - - - 7 4 r- Y - ena roc, _Cc 771
PUBLIC PROPERTY DEPARTMENT
J ' 120 WAsHIN .TON STREET, 9RD FLOOR
SALEM,MA 01970
TEL (976)745-9595 E%T.360
FAX (976) 740-9646
STANLEY J. USOVIC2, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge tint as a condition
of Building Permit 0 .all debris resulting from the conshuction activity
govened by this Building Permit shaft be disposed of in a properly licensed solid-wmts
disposal facility,as defined by MGL c III,SIMA.
The debris wi71 be disposed Of at: /l�o ih s c fe (mot' .ra 2 � �e PA
Location of Facift
7-7
Signatam of Permit Applicant Date
FULLY complete the following mbmm m
(PLEASE PRINT /CLEARLY)
A 6�✓'r k' . h+v v S 4 o w.e. 4
Name o Pe®itApplicant
r
Firm Name,if any
f2,G. r3ox S(3�3 1 eve ✓tom'/ OI g7 l
Address,City&State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or strucnm be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 1 SOA, and the building permits or licenses are to
indicate the location of the facility.