51 VALLEY ST - BUILDING INSPECTION f
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-SECT 41�, E"INFORMATION ,,'�. ,,
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ECINSTRUCIZON COSTS
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Item :> Estimated Costs OfHUaI Use Only ,:
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0,Total lirojcctlt6s0,'(I& )-x tnultipller
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--Workers
Compensottarrinsumnceaffidavtt must be completed and submitted wnh.this apphcu_hun. 'Pollute to prttt Ida;:
tans"uffduvn will resiltm
e'acnial
Affdavvi Atfurfied7j
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-SECTION;,7if-,'OWNER,-ALI.MORITA-TlolqTOBE7COMPLETED yfqnw
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(()f 4�,.7 OWNER ORAUTttORIZE[i'4iGE14t�6ECttkk.,
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that,the-smiements and-W&I mm on m;the foregoing.application.are'true.'and accurate to the bestof my knowledge
1.
SIjdft6&of'Ownevor'AuthdHzc Ag
I An Ov/"nes who obtains a building pemut to do h td -U-nm' glst-c-r'e-.d-c-o'nt'rL'wtnr,.
er own work,-or�anqwncr,7%v w Tures
pr
the arbniaimn
Program' }` pragmtn a guarbnry fund bade M O L c:147A Other important Irtfoimation tin the
MA
Hid _U
n -)can be feGd 4'
below ... ...
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IVumfier
Type OP tiepting systemNudibd
Enclosed.,
CITY OF S.AL&%l, %LAsS.ACHusETTS
BL imm,G DEPARTMENT
N
130 WASHLNGTON STREET, 3'FLOG&
TEL (978) 745-9595
FAX(978) 740-9846
KmBERLEY DRISCOLL
MAYOR TT o%w ST.PmRRa
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from.
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by
-DWi' VAr1XX,46 LLG
(name of hauler)
The debris will be disposed of in
LL+S mc—
(name
rtc.(name of facility)
S'7 Lou'xtu R-,,' SAI rv, N 14 a3o7°I
(address of facility)
i
signature of permit applicant
date
.lcbriutt'Ja:
1H n
CITY OF SSU EL I, INLkSSACHLSETTS
BI:HMLNG DEPAR'i-NEINT
.• 120 WASHINGTDN.STREET,3w FLOOR
TEL (978)745-9595
FA.e(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMASST.PrERR6
DIRECTOR OF PUBLIC PROPERTY/BUBD0IG CONJIMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �/ n }Please JPrint Legibly
dame lBusinass:OrganizatioNlndividuall: �Aui1 12o&gY /w/�Fl� COrTStC'V C/{-tU�
Address: -P,O• max O,S3
City/State/Zip:.6',/—,•2w)�^ MA 0 1887 Phone#:
Are ou an employer?Check the appropriate boa: Type of project(required):
1.
Are
am a=player with--- 4. ❑ 1 am a,gencrrl contractor and 1 6. ❑.New construction
employees(full and/or part-time).' have hired the subcontractors tot
2.❑ i am a sole proprietor or partner- listed on the attached sheet:: 7. 15 Remodeling
ship and have no employees Time sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance.. 9. ❑Building addition
[No workers comp.insurance 5. ❑ We area corporation and its ID ❑Electrical repairs or additions
required.] officers have exercised their
3.❑1 am a homeowner doing.all work .right of exemption per MGL I LCI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§IM,and we have no 12.❑Roof repairs
insurance required-1 t employees.LNo workers' 13.❑Other
comp:insurance required.]
'AaY oppliram dot arxks box di musralso ell out the section below stowing their worker'camisasauon policy information.
t I inmeownna who submit this affidavit indirazing Ihry are doing all work and than hire outside cant mcbm most submit arms affidavit indicating such
:Cuntmaers that chick Ibis box mut adached an additioral.sheet showing iI,nonce of thesubavntn Curs and their worker'camp,policy infonmtion.
I am as employer that is providing workers'compensation iasaraaee Jor my employees. Below Is the policy andJob site
injormariaa.
Insurance Company Name: A a.Z. M O.q
Policy N.or-Self-ins.Lie.M I/�l/�6 00 6 893 012 aagi Expiration Date: 7-/44- Z,0.40 F
Job Site Address: 5 ) VA L, e+.. S--- $3-1 t e yve City/staw/Zip: S-nLtM, lr t^
Attach.a copy of the workers'compensation policy declaration page(showing the policy number,and-expiration date).
Failure to sec:ure.covemge as required..under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the formofa.STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under thepaints aannd+penalties ojperJery that the b0formadat provided above its true and correct
. �i ire• E
Phenol.
OJjcial use only. Oa not write in this area,to be cwapletedby city or town afilcial
City or Town: T PcrmitILIcense q_ _
Issuing Authority(circle one):
1. Board of health r 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector,
6.Other
Contact Person: _ _ Phone il: