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LOCATION
PERMIT ORANM
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OF
-= The Commonwealth of Massachusetts
Department of Industrial Accidents
k 600 Washington Street, 7d'Floor
Boston,Mass 01111 alfiAfQ
¢}Workers'Compensation insurance Affidavit: Building/PlumbluittElectrical Contractors
AZ IN"
name- . J ` L. (mot A&0 CCL)N 5rleULt rr_ci/`l ..F•�aG
address, SG de&,- 57e-
city state, //r/ rio• 04/S phone#
work site location Ifull address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
I am a sole ro 3rietor and have no one working in any capacity. Building Addition
am an employer providing workers'compensation for my employees working on this job
Company
L• y
city:
imnrsera eo. - 009"E`
❑ 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:
comnanv name:
address,
eirv: alwae�
. .. -., ^.'. Yi`+�. \ i ..,e:c':. .r.<6` -" Fi'A.i�'•�H.�,',6g?'�"i''�,- '�C56'4 A�4+Ri'1d6
comoaov name:
address:
cily, t rr ,i in>ests e^a. ai ..
i +
A
Fallon a secore coverage ss required under Section 25A of MGL 152 can lead to the Imposition of criminal penahles of s fina op to S1,500.00 and/or
one years'imprisonment u well as civil penalties in the form of a STOP WORK ORDER and a Rae of f100.00 a day opium me. I understand that■
copy of this statement may be forwarded to the Office of Investigations of the DIA for covenge verification.
l do hereby certih under the pains and penalties of pmilary that the information provided above is true and correct.
Signature — Date f 05,
Print name -C 4. Phone#
official use only do not write in this area to be completed by city or town ollicial
city or town: permit/lictase a ❑guildiog Department
❑Lice sing Board
❑check if immediate response is required ❑Selectmen's Office
❑Hcaltb Department
contact person: phone a; ❑Other
ue.:.w kD A•nl
CITY OF SALEM., MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
so FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, SA I aclmowledge 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, S 150A.
The debris will be disposed of at: Al,wfh S;olL SG oe•-r /YW
Location of FacilitydmtI
'
Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
e /
Name of Permit Applicant
L. L_j tgo GCvIJtf%lGcc 73' -�G
Firm Name, if any
�c.� Q•l:G�G�e�. rJYr` /S2�rCr !y � a!�i/S
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 cID, S 150A, and the building permits or licenses are to
indicate the location of the facility.