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APPLIQATION FOR
PERMIro
LOCATION
PEF*AT GRANTED
R OF OPLORM
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RD FLOOR
SALEM,MA 01970
TEL (976)745-9593 EXT. 360
40 FAX (976) 740.9646
STANLEY J. USOVICZ. AL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge that as a condition
of Building Permit ti .all debris resulting from the construction activity
m, governed by this Building Permit sha8 be disposed of in a properly licensed solid-wasps
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at A6, 5a/w,.
Location of Facility
Signature of Permit cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
8 R eT & jL, e-sr- .
Name of Permit Applicant
�liV) e �- 4 ed5 ✓ Cor �
Firm Nam6,if any
4 .
Address,City do 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 licensm are to
indicate the location of the facility.
• - `' _ The Commonwealth of Massachusetts
Department of Industrial Accidents
�r� OfllNIfl9Yet�tll
4 600 Washington Street, f*Floor
Boston,Mass. 02111
Workers'Com ensation lasurance Affidavit: Buildiu lumbia lectrical Contractors
name:
q �15 CrrvS r� r_�aN or� �« � h x
address: I /e /J t /!r Y )I J,
city Sa le state: 1 4tY r19:01 y76 phone# 97r- G 7
work site location I full address): WC44r56N .57R SW/,"
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
1 am a sole ro rietor and have no one workin i I Building Addition
P�rarn an employer providing workers'compensation for my employees working on this job.
address: ��
���� F �Y
5 5 3, ts' t v a :
4 v n,- ;:, y ;a
i oce 1�4NL�-�/D .L. NS � mNevAL
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comnanv name:
address;
city: phone ff: .�
V abl 21m1Y.MtW09@t!'F Sara � � 421.211Mrowr¢.�sv lYAii1Y1 SLI i�WWLs<:L'WI{GQ z _.�"a�-�
. .. -. ,. ,. 'v�}"c:" '� ,.rl?:.:.:«c ^-sr�` .#¢R•z§+.�SVIN�'i %wYY*. ��:t�*,r+sh`%' ' +Fin
com a
address• ;9
:.
city:
j.
1 E
Attgfsiuml
Failure to secure coverage as required under Section 25A of NGL 152 can lead to the Imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a flue of$100.00 a day against mt. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
i do hereby certify ur ,�'he aim and pen •of perjury that the information provided above is true and correct
Signature , _ Date
Print name /?fCo,— Phone# J�4D ^ 036
official use only do not write in this area to be completed by city or town omelal
city or town: permiolcense a ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑selectmen's Office
❑Healtb Department
contact person: phone N; ❑Other
OauW Sept lunl