2 CHESTNUT ST - BUILDING INSPECTION (2) M
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CITY OF SA.EM
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR_
IVumber:�CS 085356:-,
Birthdats:_0 4/3 011 95 9
Expnea:`04/30l2007 Tr.no:. 85356
DOUGLAS M BROUGHTON.' -'
49 SEWALL ST
MARBLEHEAD, MA 01945.;
Administrator-
.'.
COrnrIWALVtiahk 01 O-469Lt"tt.4
lip �Jepn+lOauel of JadWfrial./fttiaswla
600 ryw�q-1-ILm 31,,J
James 1 camood �wleti //lasaaoM.A 021 l l
Conrasnow
1 Workers' Compensation insurance Affidr*
. . with.a principal place of business at:
. . -T ltkraae.r✓alr)
do hereby certify under she pains and penalties of perjury, thm
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Humber
1 am a sole proprietor and have no one working for me in any capaehy.
() 1 am a sole propriewr general comnewr or homeowner (circle one) and have hired the
contractor sited be ow who-have the following workers' compensation polio,":
Contractor T Insurance Comparry/Polity Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Poliicy Number
() I am a homeowner performing all the work myself.
I unoenuna om a cosy of thin wa m nt wO be icr arced to the Offce el ky knorw of the DM la coearart TrAlcadan awe Our laarae m"cure
co.ecate at reou'ea under Section 25A of HOL 152 can kad to dne inoea'ron of crtn'nal cenaoes eorwdnr of a fm of as 041300"MWW one
yesn'inor'onnmt x KA at er i d.npwo in the loan at a STOP WORK ORDER ana a fine of S 1OOAO a aar ap:ut am.
Signed this f day of Sutle r .r�00Y
GL
.ic -neei'Fenriu a iiuild g Gepart tint
scenting 5ear�
SeiectmenS OfflCe
,e.lth Gepat-men-.
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON 6MM, 3RD FLOOR
SALaw,MA 01670
TRL (978)745-6665 EXT.360
FAX (676) 740-6646
STANLEY J. UGOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(X c 40,M I aclmowledge that as a condition
of MdiDS Permit S ,all debris resulting from the c mat<mctk m activity
governed by this Building Permit sba9 be disposed of in a properly liceaaed sDlid-wasbs
disposal facility,as defned by MUL c IIL S1NA.
The debris WM be disposed of at:
Location of Facility
/-�Z/
.Si ofPermitAnlie t Date
FULLY complete the following mk m um
(PLEASE PRINT CLEARLY)
`-i c)Jq1AzS ?�.nokj!4k• ov
Name of P-06ait Applieaot 1-3
Firm Name,if any
Addew,City tit State S
The above statute mp ma that debris from the demolitiON renovation,mbab or other
alteration of bmldmg or ah mum be disposed m a properly-licensed solid-waste disposal
facility as defined by MQ,cM S I50A,and the building permits or licenses are to
indicate the location of the facility.