10 WOODSIDE ST - BUILDING INSPECTION (3) fbAMS~49EfI A"M APPROVED BY THE
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CITY OF_SALEM
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Permit to: ERMIT BUILDING P APPLICATION FOR:
(Circle whichever apply) Roof. Romof, Instal Sidktp, Construct Dads, Shed, Pool,
RepaidReplaoe.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The Wimailir" hereby appNes for a permit to build a=rdi;V.to the.folbwbV
Owner's Name /1 1. $E
Address A Phan
Architect's Name
Address a Phone f
Mechanics Name
Address dr Ph" ( 1
Wfw is sta p.pm a trtrmrrp? h-2�
maw of wow K a q,for how many fttman?
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WIN bAdM CU*M to law? AoONbs? rw� u ii�vy v,
Etamr d oo. /SOG. °O cay Lim"• awa r � 's
am 08 �C/ Lie. �'o•"
Siprta ure.of Applicant
SNOM UNDER THE PENALTY'
OF PERJURY
DESCRIP ION OF WORK TO BE DONE
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MAIL PERMIT TO:
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APPucATUM FOR
PERIOT TO
r
LOCATION
PERMIT GRANTED
19
APP,ROVFD _
INSPECTOR OF BUILDINGS
\—� The Commonwealth of Massachusetts
Department of Industrial Accidents
O/BaN
600 Washington Street, >h Floor
8 �
Boston,Mass 02111
Workers'Compensation Insurance Affidavit: Buildiu lumbin lectrical Contractors
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work sire location(full address]: U 'c"',(f p
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
[�1 am a sole proprietor and have no one working in any capacity. []Building Addition
I am an employer providing workers meensauon f m�employees workin on this}job
• -�' $
Mass-
itwrrsrmda. _,: a�ieek141C-" �'p.� it��� 4ti:'
❑ 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:
comoatw rams - - -
address,
a 9
city: ohdm
` VI
x!*"��.' ,i
address:
Follure to won coverage an required under section 23A of MGL I52 can lead to the imposition of criminal pen day of•file . mS1entand and/or
a
one years'imprisonment es well u civil peualtks in the form of a STOP WORK ORDER and a Ave of 5100.00 a day against me. I usdentaed shot■
copy of Ibis statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby c Yf der the ai an penalties of erjury that the information provided above is true and correct.
Signature (/��%` 7w .,1 � _ ,/ Date '7Z3�J�
Print name QY1Kt S tf/N1f;9ie %. J t d 5EI & S Phone A 7 (-/ S`J S y(o
official use only do not write In this area to be completed by city or Iowa official
city or town: permit/license a []Building Department
[]
❑check If immediate response it required ebart a Board
[]selestmea a Office
❑health Department
contact person: phone N; []Other
Imsed Sep, ax131
CITY OF SALEM,, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASH INGTON STREET, 3Ro FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
00 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_9 Ili, S 150A. CH Q7 iN 6
OATIf Sf pe„1
The debris will be disposed of at: Sa.Er.,y, .c� .
Location of Facility
- 3v
Signature of Permit Applicant 'Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Gh`2ISTo/f /<? % 615 ,4E'y
Name of Permit Applicant
Firm Name,if any
Addym,City& State
/ice
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 cM S I50A, and the building permits or licenses are to
indicate the location of the facility.
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