38 WILLSON ST - BPA-05-920 fLwNi�T7E�11li�ND MPROVED 8Y TiiE
•PRJDR TO A:plEBWr BEM WANTkD
CITY OF SALEM
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PLEASE PILL OUT LEOWLY a COMPLETELY TO AVOID DELAYS N PROCESSM
TO THE INSPEUM OF M&DINOS.
The wdwsow hereby apples for a psrmk to build a000rWato the,bNwa g
Ownses Name /l/'.a_k4e4s
Address a Phorfe K
AmhkmWs Name
Address a Phone ( )
WManin Name
Addnee a Phone ( 1
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DESCRPTION OF"TO BE gDNE
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z CITY OF SALEM.9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MA O 1970
TEL. (976)745-9595 EXT. 380
Is FAx (976) 7409846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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,
S 150/A.
The debris will be disposed of at: I I/t�
on of Facility(/
Oil, iyp L GCS
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any j
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 cl1l, S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department of Industrial Accidents
` ,� 0/1laN/YYfIt�iWl/i
600 Washington Street, a Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit: Buildin lumbip leetrieal Contractors
name: -7-2/OCuet�S l Q✓fi 6R�
address, I5 // Slop.2t
city IT e/`ll 4
state f/LIG sf ap QI FIS phone# ¢J 7 Lcl
work site location(full address):
® I am a homeowner performing all work myself. Project Type: ❑New Construction®Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers compensation for my employees workin on this job
Is
P
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❑ 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:
company name.
address: - . ..
itvo
r A i1
ro reE is,'r Y `� ,.+ J7i' ry5 ` i: 'L.'zit`�5? �'i:+f
[ ,F3 ¢{3 pK'»!;
company nallm
Failure to won coveralls as required under Section 25A of MGL IS2 an lead to the Impositions*(criminal penalties of not up to s1,500.00 Tower
one years'imprisonment a well as civil penalties to the form of a STOP WORK ORDER and a fine of S1oo.00 a day oplost me. 1 understand that s
copy of this statement may be forwarded to the Omes of(nvestiptiom of The DU for covemp verification,
t do hereby certify u) r under the pains anndd penahin®of perjury that the information provided above is True and correct
Signature �Ov_4a /�U/�kA..� /� Date 6-Poi,/ l ZS- Z520S
Print name 7 J r k teJ hone o 92-) ZC
official ase only do not write in this arm to be completed by city or to"official
city or town:
PermitNkense a
❑Building Department
❑check if Immediate response To required ❑ eie Board
❑seketm a m's Otlke
contact person: phone a; ❑Beslth Department
liaisedS ,?x13i ❑Other
APPROVED
St"Liect to approval b tarry i,6r
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