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CITY OF_SALEM
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Permit to: BUILDING PERIIIT APPLICATION FOR:
(Circle whichever apply) R Ira l SWing, Construct Deck, Shed, Pool,
PLEASE RLL OIJT LEGIBLY A COMPLETELY TO AVOID DELAYS N PROCESSNG
TO THE INSPECTOR OF BUILDINGS: '
The undws0ml hereby applies for a permit to build aocortLiq.to the following
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Owners Name /�/' 4t
Address d Phone ��°i?� 5� av✓P� ( )
Archksct's Name
Address d Phone ( )
Mechanics Name
Address 6 Phone 7 L 4.� 4-e ( )
whO Is the p.po cf ,,. /X e 1/ 2
AJMI"of buldep? ti0 a M a dvraarq,for hour m"Mmlhs4 02
we b Aft=ft.. to law?
fErilrlsMd cm J m 0am qly tJCMIMI R 8MM LIOMIM►M °7 ��—
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Signature of Applicant
SIONED UNDER THE PENALTY,
OR PERJURY
DESCRIPTION OF":TO BE DOME
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MAIL PERMIT
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No. ���
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
19
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INSPECTOR OF BUILDINGS
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The Commonwealth of Massachusetts
Department of Industrial Accidents
wesonfiWashington
dftlQ8U0a
600 Washington Street, 7i6 Floor
,3 Boston,Mass. 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name: .^�Cv(// i/
address. / L�`y CK,, q 9y
city W7 I State- Ax. in.0/ phone#
work site l0 1 ad ress
❑- I am a homeowner performing all work myself. Project Type: ❑New Construction Remodel
❑ 1 am a soleproprietor and have no one working in any capacity. ❑Building Addition
�7 I am an employer rovidm1g w kers' compensation for my employees working on this Job
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add
city' "%�""^!`L/'�;`-�#r/ +' f-:�S'''.� `a 'fi1' g ,`�R mte' '�" Sfeet � xy � Vt
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
a
comoanv name
address:•
city: N ohms*
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4 s{u ...�y��..4#t'&tR
Da, y
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comoadv name.
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
copy orthis statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify unde to pains and penal ' of ppeer/* that the information provided above is true andforre
ft
Signature �'/ rtt Date
Print name r 1 ( O /' h V t�i� Phone#
official use only do not write in this area to be completed by city or town official
city or town: permittlicense a ❑BuiJDepartment❑check ifimmediate respogx i4 required ❑Lic❑Selcogmet persoq: hone#; ❑Bacomatprop ❑Otb
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON 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, S150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
s; 7�
Name of Permit Applicant
Aye I
rllvv4��
ry,--
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.
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