2 WILLOW AVE - BUILDING INSPECTION Is NfiMWIDEfRl94019 ANIROVED BY UK
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Clyde whichever apply) Roof, Reroof. Instill Sidfnp, ConOW Deck, Shed, Pool,
RepaidReplace, OMer
PLEASE FILL OUr LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCEMO
TO THE INSPECTOR OF BUILDINGS:The ur4ws*W '•
hereby applies for a permit to build accortLig.to the.folbwktq
Owners Name 111a do w� Vrlsc /►
Address& Phone 7 u )
Architect's Name
Address d Phone
Mechanics Name awl�.s
Address A Phone 97Y
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re of Applicilitt
UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE `
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MAIL PERMIT TO: 1 '
APPLICATION FOR
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LOCATION III
PERMIT GRANTED
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INSPECTOR OF BUILDINGS
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The Commonwealth of Massachusetts
Department of Industrial Accidents
0/flCeellurreftlpstla�
600 Washington Street, f"Floor
Boston,Mass. 02111
v Workers'Com ensation Insurance Affidavit: Buildingffliumbin lectrical Contractors
name: L--�R/' &-]2
addre/ss�,�y ` Ar�ro /� C �+ j
city ` ✓A) kMO state• J� ao:6 �7/',� Monet /o p�g715
work site location(full address)-
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❑ 1 am a homeowner performing all work myself. 'Project Type: ❑New Construction Remodel
❑ 1 am a sole Proprietor and have no one worki capacity. ❑Building Addition
❑ I am an employer rovidin worke s co pensauon for my employees working on this job
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1 am a sole proprietor, ever contra_ or or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation po ices:
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comoanv name.
address:
city:
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company name: s,
address:
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Failure to secure coverage as required under Section 25A of MCL 152 can lead to the Imposition of criminal penalties of a fine up to s1,5oo.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 understand that a
copy of this statement maybe forwarded to the Once of Investigations of the DIA for coverage verification.
l do hereby certi y under the pai nd p allies ajpery'pry that the information provided above is true and correct
Signature �� O Date ) —3 `,�ry 'S/+ /�
Print n ---��{ P4 E'.S ' 19,4N6 / Phone H 7'�b �76 % 2�d
rOch,,ck
e only do not write in this area to be completed by city or town official
wn: permiUlicense a
❑Building Department
ifimmediate response is required ❑Sete tine Board
❑Selectmen's 011lee
❑Health Department
erson: phone N; ❑Other
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CITY OF SALEM9 MASSACHUSETTS
't' PUBLIC PROPERTY DEPARTMENT
/ 120 WASH INGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 ExT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,
��SI50/A
The debris will be disposed of at: /UO✓��I 'S C4 r`—iN 9
Location of Facility �—
Signature of Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Ram e of Permit Applicant
Firm Name,if any
Address, City& 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 licenses are to
indicate the location of the facility.