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PUBLIC PROPERTY DEPARTMENT
120 WASHINOTON STREET, 3RDFLOOR
' 6ALaM,MA 01670
TM (676)745-9595 E)rr.360
FAX (&76) 740-9646
STANLEY J. U60VICZ, JIL
MAYOR
DISPOSAL OF DEEM AFFIDAVIT
In accordance with the provision of MGL c 40,S34,I aclmowledge that as a condition
of Building Permit d .all debris resulting from the contrnction activity
governed by Ibis Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by M(R,c a S1SQA.
The debris will be disposed of at; Q& y f6*1bis A 1 n/�//c�/� !'270f&
Location of Facrgky
ignture Of Pemrit Applicant Dde
FURY complete the followmS mfien aam
(PLEASE PRINT CLEARLY)
Name of amit Applicant
Firm Name,if my
�• .✓'
City ds Siste
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 Mfs'I,CUL S1S0A,and the building permits or liceoaes are to
indicate the location of the facility.
Mani COM=A"111abi 0/MaMAL1,044
'—� 1Jep.rleae.i e�.7adrf4iel J�eeie�a
600 ryU .L.1le..Slreel
a Bern lQnsicx /!/&.6, .salt& 02111
Workers' Compensation Insurance Ada*
I, GJ (/
. . with.a principal plate of business at: ,p
ltaor
do hereby-certify under the pairs and peniWas of perjury, that:
() I am an employer providing workers' compensation coverage for rrry employees working on
this job.
ins tent Company Policy Number
1 am a sole proprietor and have no one working for me in arty capaeicy.
()/ 1 am a sole proprietor, general conaacsor or homeowner (circle one) and have hind the
{/ contractors listed below who-have the following workers' compensadou policies:
L✓ �% Se,04 of r0-f ZL d-as/
Contractor Insurance Compatry/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
(} I am a homeowner performing all the work myself.
I ano"Wee W."a cast of No wanton wo be fon.arwe m Aw Of Ka ei kMc*swro of Ow OIA for eererare earWabe lee aac Moore 0 rare
co.erarc as remorto snow Secian 2SA of MGL 15 2 can kae ore ow wwoolkm of c6minw oseaoia coraa6m of a ewe of s M4I.Soom sewer eee
rears•:naroen e x as ter eiri mwiaw in the torn+of a STO P W ORK ORD ER ante a bw of S 10oAo a ear aa"tot.
SiEned this • 5rO A)£. / S �4 day of
rscci FcrmnEtt iiuilding Departr•stnt
''icercinf Eoare
Seitamens Office
=eutth Deprt-.mer.c