72-74 BUTLER ST - BPA-05-566 fLwftw4EAf1N4m APPROVED By we
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CITY OF SALEM
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PUMU PILL OUr LMLY i COMPL,IMY TO AVM D"VS iN PRO�
TO THE INSPECTOR OF BOIL MM, '
The i I J—aiprnd hereby @VON for a pafmk to build a000rftto the moNowkp
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The Commonwealth of Massachusetts
Department ofIndustrihlAccidenti
Office of invastlyations
600 Washington Street, 7'Floor
Workers' C n InsuranceAffidavit:Buildin'lPlumbin lectrical Contractors J L.'
11
name:
address, r4 lla._ ",I
city f Jar state., zip: phone#
work site location!full ad
LJ I am a homeowner performing all work myself Project Type: 0 New Construction EfR—emodel
I am a sole go%etor and have no one workin I any Building Addition
c'a iacity,
tB4,N%
am an employer providing.,workers',compensation for,my'employeesworking.on this job.
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address: ':,:
city: V Rhone 4�; 9 l 3
insurbInce.co
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LJ I am a sole proprietor,general
contractor, or homeowner(circle one)and have hired the contractors listed below who have
the following workqjt'compensation polices: l_ vd , I
company-name:
ij 1� ell. _717-7,
address: Z. k), h_
city: thOne'
:7
insurance
V
comRanyha me,
address: 1(.P,,Ww-1 i'.'
Ct�I
city:
insurance.co.
v
Failure to secure.coverage as required undirSecdon 25A Of MGL 352 eon lead to the Impositimanf.criminal penalties of a fine upJo Slv5,00.00 and/or
one Years'imprisonment as well as civil pinaltics in the form ofa STOP WORN ORDER and a fine of S160.6d dday against me. l understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby ceitify:zurdWi6epoins andpenalties'Ofjo ry that the information provided aboye is true and correct.
Signature L;�;
Print name 2e, -'PhoniI#
official use only do not write In this area to be completed by city or,town official l,
city or town:
Re cense# ElBuilding Department
t DUcensingBoard
0 check If immediate response Is required ElSelectmen's Office
contact person: o#; v I'! ❑Dicalth Department
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(. d Sep,.2003) []Other—
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SD6.7-I5=9595 Est, 38D
DI5PO5,!L OF DEBRIS AFFIDAVIT
In accordance with the provisions of MCL c 4,0 , 554 , I acknovledge ttuc as a
conaition of Building Permit p , all debris resulting from the
corecruetion activity governed by this Building Permit 5ha11 be disposed of
a properly licensed solid vaste disposal facility, as defined by t1GL c
5 150A, ^ /
The debris vi11 be disposed of at ; !1 Lam.•-r I V D� I�1 S t .�o Cp ; I�y�
location of frdlity
Signature oe p icanz Date '
Fully complete the folloving informations
(Please print clearly)
-40
Name 01 Perr= App/l�icant
_ _ L Firm .a�an
Name, i
► �1 9 �'1 a � � S z- Re boflv 0 1
nddress ; City i State
The above 'statute requires chat debris from the demolition, renovation , re_at
or ocher altcration, of building or structure be disposed of .in a properly
licensed solid vaste. disp,osdl facili-ty as defined 'by. tI.GL cIII ,' 5150A sad traL
building permits or license's are to indicate the location of the facility aL
DESCRIP nm rw wnov TrN ac nnnic