21 1-2 BROAD ST - BUILDING INSPECTION wmn�in"m lW;W
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APPLICATION FOR
PEMWTo
LOCATION
\ � V OgLE' ✓ � Q� _
PERWr GRANTED
WBPBCTO OF BO LDOM
CITY OF SALEMv MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 ExT. 380
0 FAX (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, 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: /yo-iA -111,- r a >!, 5
Location of Facility
Signature of Permit An 'cant t)ate/
FULLY complete the fo/llowing information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
jJ
/'9.� �{�c7 B/f�TC-C'/ /%✓C ` /_/R`h VlrJ' 1A)
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department of Industrial Accidents
�' -=- OIAaNhn�tlMt
, 1 600 Washington Street, 7 Floor
Boston,Miss. 02111
Workers'Com ease tioo Insurance AlBdavit: Bufldid IumDinZfElectricall Contractors
AQ
city A vi VPA,-j state, zip: /qr7 3 phone# 0)' • -9 -7
work site location I full addressit 92 rY o a
❑ 1 am a homeowner performing all work myself Project Type: ❑New Construction emodel
v I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ tam an employer providing workers'compensation for my employees working on this job
casement NAME
qw.
city: Z;;n,t
film a
❑ I am a 1c proprie ,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the followi worAke�rs'compensation polices:
m
copnav name: /X 0Z i n 19l1 /i F'T✓i C'
address: —
c'
4
. ti t e•'{3: 41 .' .�'�, .�c"fi F.
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..:
OM
Como"v name. (� +r r-r✓ /� c—D.� P✓r � 'C4L 6f rn r/'b
address,•
t �
A
Failure to were coverage as required under Section 25A of VIGIL 152 can lead to the Imposition of criminal pewlaes ale flu op to S1.500.00 and/or*
one yesn'imprhooment as well as civil penalties in the form of s STOP WORK ORDER and a Me of$100.00 a day splsst me. I understand that s
copy of this statement may be forwarded to the Office of lavestiptioss of the DEA for mvemge veriikatios.
l do hereby certify under-the pains and penalties of perjury that the information provided above is true and correct
—
Signature Date //9 /O S
Print name .��r U - vi I S Phone p 2 7 7-7
omcial use only do not write in this area to be completed by city or town official
city or town: permit/Ilcense a ❑Building Department
❑Wcessing Board
❑check if immediale response is required ❑selectmen's Office
❑11ealth Department
contact person: phone a: ❑Other
e„ui sepi non
i
E15/20/2005 09:27 3787746850 ED BRUENJES PAGE 01
ED Bk LT MIXES
Residential Remodeling
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