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Workers' Compensation Insurance AffIdapit
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. . with.a principal place of business at:
Z/Z �9/vn ern r SIJYnn�s�ff// �1�
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do hereby certify under the pairs and pena1tim of perjury, chm
(� I am an employer providing workers' compensation coverage for my einAvy*es working 62
this job.
5r �l Ff;-e+ AorO Zns 0go13396o
Insurance Company Policy number
I am a sole proprietor and have no one working for me in any capacity.
() i am a sole proprietor, general comracsor or homeowner (circle one) and have hired the
pp contractors listed below who-have the following workers' compensadon pane=
11�.VMDh� I�010/VG �'Ch�rse,('D r' �C 916� �S• (�A.IW L-(J Z-'�Z�7/�`c1O
Contractor I ramie Com try/Polity Number
i21kn,14J 2�s ea 1wc5M707 oz
Contractor Ins ante Comps /Poky Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unerryand mat a cevf d Oil tuvrom•a br ien.aroed m rw Office of Wn *Mwe of the VIA br co.erare•"heads"am cur HLee r woon
co.erarr as rrwarro under Sw*m 2SA of MGL 152 can kad to Ow:rwowen of cminm eeerdaa coramdrtr of a fir el w w4I.500AO NWOr eee
rrxs':naroonrrwnt u ve u efri eaulrin:+ 6+e lone of a STOP WORK ORDER arse+fne e! S 100.00 a cal apart ere.
Signed this • 3 day of
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nsct/Fcrrrittet ouilcing Gepa ent
ucensinf Eoare
Scieamens Office
=�Ith Geparmer-'
PUBLIC PROPERTY DEPARTMENT
120 WAaNINaT0N ST11Esr, !RD FLOOR
6ALEM,MA 01670
TEL. (976)745-D696 EXT.360
FAX (076) 740.6846
STANLEY J. USOVIC7, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that e.a condition
of Binding Permit 0 ,all debris resulting from the coasuuctkm activity
governed by this Building Permit sbafl be disposed of in a properly licensed solid-
waste
dial ficrlity,as defined by MOL c III,SIMA.
The debris will be disposed of at _L Pp AN f rrus 'E yirnng ( Ae1601',t
L&idoiYof Facility
.y
=Ycomplete
of Permit Applicant Dais
in the following khm adon:
MZASE PRW CLEARLY)
Ak Jo h n k�4 ne.
Name ofPe kAppliant
Firm Name,if any
S— 07
Address,City&State S� c rp c.7 /� v 9
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of bmldmg or sh ucdue be disposed in a properly-licensed solid-waste disposal
filciW as defined by MM cA S 150A, and the building permits or licenses are to
indicate the location of the facility.