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12 AMERICA WAY - BPA-05-937 CLOSET '*�*�+�+IISM�wD AP�wovfao er TIE mpsaw-pWIN Tp A:/!fdQI ET SOM GRANTED CITY OF SALEM NOA w N►nd 7 lipsdO y = aMAa 3 �° � Vat fia ii Loatim of aiai,a z Ain ra tJ� w A'oP«b loowd In In CogorMaftn oiw . YN__mo BU LUMKi Mmm APPLICATION FOR. f armk t0: Alolo mftwwr apply) Roof, Paw, Imm sift Conwuct . ppapww OR rc -P `r V'f�sTt Shed, Pool, � W. Sheet PLEAM FNL OUT UMMY i CCYPt.ITILY TO AVOID DlLAYs Mi PROfX@. TO THE INSPBCTOR OF BUILDINGS—. �undMaipnad hanby 800m for a PWit to build a000rft to ft foNpap Ow wa Name �e� b�rgyo Ada i Phom �Jc�r 1701 Amhltoces Name Ad*uo i Pffofn ( f MNhanla Nano �w�� Le©vct✓ Ad*m i ✓off e- CS 5 scfi I� I 5 5�-6 75 Mmwm d q'_Lg)t)ocQ a doe ft for how m"�niaN? YM bAdkq to"I ` ZZ A�ea.r .s edf�wd NM �� uoaw. CRY r --�--- ua.w r ;)--? —O ab � \ r D\\ Lie. It of App�arlt tN IIN THE PBNALTY' OF W-mm, To K Rm or r P` 4 MAIL PERMIT 1,4 No, �=� � APPLICATION FOR PIMA I TO �,d,6F.s�Qou�. .saa Gca�Er , LOCATION i 2 A-mee��a cJ�q PEFMT GRANTED y--'�- APPF!OVR i OR OF , —_— \- The Commonwealth of Massachusetts a - ^ Department of Industrial Accidents MraflovaWAUM 600 Washington Street, >f Floor Boston,Mass. 02111 Workers'Com eosatioa Insurance Affidavit: Building/PlumbinZfElectrical Contractors .�sxorY I narriz v addressC+�� PV o--.GQP.� city `J rStd'1 ✓ state: �/(/1�'� n p� -'1 o; !//RD / chime 7 g ,/�/ "6 L work site location(full addressl, ❑ am a homeowner performing all work myself. Project Type: ❑New Construction ORemodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer provtdmg workers compensation for my employees workmon this lob b. addteafP S ti S s, Sg L<� * 4a° e. elm ❑ 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: comnanv name. - - -s addrea• eltvousing.IF. i eeo� a P19t Wn cmoaov S , Z r hz T �,�;sa Failure to seven avenge as required under Section SSA of MGL 153 an lead to the imposition of criminal penalties of a line up to s1,500.00 and/or one yarn'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a One of S100.00 a day against me. 1 understand that■ copy of this statement may he forwarded to the Office of lavestigatleos of the DIA for coverage verification. t do hereby t Jy under th ins an nattier of perjury that the information provided above is true and correct Signature Date Print nam Phone A 7S official use only do not write in this ma to be completed by city or town of vial city or town: permit/liceme a []Building Department ❑check If immediate response isrequired ❑ Board ❑selatm g electmah Office contact person: phone a; ❑Naltb Department„..:<d s.p,.n.m ❑Other CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT IZO WASHINGTON STREET, 3RDFLOOR SALEM, MA 01970 TEL. (976)745-9595 EXT. 380 FAX.(976) 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 MGLc a S150A The debris will be disposed of at: Xlod4 Location of Facility Signatfire of P Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant 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 ca S150A, and the building permits or licenses are to indicate the location of the facility.