75 COLUMBUS AVE - BUILDING INSPECTION � � r
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bITY OF S1&'I.EM
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Workers' Compensailon Insurance Affidavis
. . with.a principal place of business as»
tovi+.„.nrs .
do hereby•ctnify under the pairs and peraihties of perjury, thatt
(� 1 am an employer providing workers' compensation coverage for my einployeea working ors
/V this job.
LI YV1v yC ills
Insurance Compasry Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policies:
Contractor Insurance Company/Poliq Number
Contractor Insurance Comparry/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I rnoenone eat a cay of die SOMYRN wo be fen.arw. 0 am Ogee of Wn kawm of dre CIA for co. are.erfksd.n WA am l,4re se seem
co.erare L reoWed anger Setaon 2SA e(MCL 15 S can lead,o v-TeOlelOn of RrngN 0eri00 cor."adm of a IM of n w4I.S00AC sower ere
rcan' 6%wwr.rent as.,a it d.i een*w in the icrt eta STOP WORK ORDER ant a are of S IOC.CO a clay ag•6lu on.
Sirned this . 6 day of �b\,A _ av"�
:ictnsttiFtrrniutt omta;in g Geparcrnent
'ictnSing Ecare
Seiectmens Office
�t:tth Geparzmerc
_ . PUBLIC PROPERTY DEPARTMENT
120 WAiNINQTON W mmm, $Ro FLOOR
DALEM.MA O t D70
TaL. (976)745-MDS FXT.M!O
U* FAX WG) 740-9545
STANLEY J. UDOVs= JR.
MAYOR
DISPOSAL OF DEB=AFFIDAVIT
In accordance with the proviaicm of MOi,c 40,SA I acimowledge that as a cm&dm
of Bu17db*Permit d .A debris resu*g from the constiucd m acdvity
pvaned by,bier B=WM Permit shaft be disposed of is a poperly lieeaaed soH&wmb
diepoaal hmlty,a defined by MOL a II;.six&
Tha debda wiU be disposed of at W)cS�e wkJ))9, s
Location ofFscBity
igoamm of Pew Applicant Dale
FULLY complete the fonowms mbmxb n:
(PLEASE PRM CLEARLY)
Qe�i r`f ?)erce
Name of Permit Applicant
Fnm Name,if any
The above statute mgmrw that debm from the demolition6 rmovadM reW or other
alteration of bu&lmg or stmam be disposed in a properly-lioeased soN&wste dispoul
fiaW as defined by MM cIM SIMA, sad the building permit,or licenser are to
indicate the location of the facility.
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