011A FILLMORE ROAD - BPA-09-147 .. y � T?K Ctt11�iQIturG4lth rtf 1►1us:uchsurits •• '
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1 ltis Sevi=For Offid3l Use Only
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/.a Prn .rir Address' 11-A.Fillmore Rd L2 AnrxwvKop At P4mdNutwbm
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978-270-8770
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18386 11-02-2009Robert J. L'heureux u :rmeFuncer c=n1�uH+ �.
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Mwiij%icn
` 1-B art Way, Sale , MA 01970 U ILnrcstn�teuts ro�ettocit et•o '�,
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welrkers a otapertssuote Immes sffrbvit's,/tt bt evmVoltd and l++hmiunt with;hi!spphrvi+n. F'nilnm a rn:dc
Ihim afrtdavit will estuh in ilm dwat of the ludanet of the buildirgperah.
51srAsAffiidavitAllmhw? YCM..... ....d(. sw. ... ... G
ter..-.w... -+..�.
SECTION 7ac dW V F*AtJiH MZATL40 TUBS E:UMYLxrw wNCA
uWNER'SACEMOROONTPACT 01APA MSFORRUlfdllNGPRRMIT
itt9tasilut ._ tux!�rnty5elto.tin�) rrlten
ndaiiscw aurkaudnsriaetl by this wlhtln¢perin::appll:o lan
S_i IueufOwr�s Cde -..T»
0Cr10169bt OWNER°Olt AUVIIOP12$@AOENT DEVILA1tAU0.14
Robert eureux
2, w.CK*v Z or AuthakicaL A6cnt hcwhy d::.wc
d•.a:the ctcsemeiu cod rs!btrndan an dw"aint appllcatlatt a2:fw sns occutme,to dr.test ei my azwlnlbe J110
benutt. Robert J. L'heureux
kw.Nuf
t 8-05-08`.. ._
t StdtutaaetdOw.tuo t1uJAtlttl the:
15iuttd W dutlu ours p+0XN!?!!xrIXtlunrl
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ItC �t
(}f0)IOjiDatd intFs ffupta7mpn+v n1r tMyar(ffIG)TRVJtlte will is 11t7raiml Ia the attlwu*m
.ptmpair tsr eutr"rmW unew M.a.L L 242A.O0=ivV&wjnt inlbrmatinn:m Itt::RTC Rv"m and
Ccnstnnan StOersisvr Lit ensin(l iC$L1 canto tatlhd in Tip C:WI seg tidons 11ORG nd I lG.RS.:ea¢ulivdp.
2. WIlasubasnlltivtxklsplotrbd.prarldelhetntbrmsllatCil w:
Tc*d Optua- (5q.Ett (includins prop.reaishW bawmeatlallic►.ddAs✓:lAwlt
tittxsllvinRe.T!'.sp FLf $LAllwenwmcutue
Vundto tt(recowel tiLndtt:r.tf halnv" _..
Number of bilbroom) INumber c�hrltlbaths
:yppUrlplinS��oann_-,,,--,,,�„ +inmberafeo.•ksvrytn:hr! _ ._. �
rypeuteaol-resysle+q__ _._. L'u;hesed__ Uptn
]. 'Tt��Squtt=icalallt mtr btsuitcdtur_a.`or"Cnt.t PrAject Cvc.:' � _.._.. .... .,._._�
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i
s� CITY OF S.U.P.m3 1ANSSACI USET TS
}1unnnsiG DRPART'SILSi'r
120 WASHINGTON ST'.1t6.ETt Yn FLOOR
Trs.076)745-9595
F.ax(978)790-9&t6
KINMERI.EY DRISCOLL
tiiEAYt�R 11ttSala3s ST.PSEltali
1WliE.FATojL or PUBLIC PROPERTY,6i:I MMG CONDIISSIMER.
Workers"Compensadon Ensurance AIndavit: Iiuiiderr/Contraeior11TE1tsctriciansfPlumLers
Applicant Information Pleast Print Legibly
Vii:flCSWninet>:t7rGanixwiDtilmGvidslal}: Robert eureUX
Address: 1-B Hart Way
CityiStaleizip: Salem, MA 01970 I,hooe _ 978-578-4162
..re rou on cemployer?Chcck.Mc appropriate has: i Type of pro§ere(r�eq,tlt'wi):
1.13 1 am s Lnptayer with 4. 111 am z gl;:lcrrl:omtroctor and 1 1 6. Q New umixtnrt nn
�)employees(full amdior part-lintel.` haw u hired the t'ctmtmchtts
2_LII T IJII,as old llriiiiiietur iR parlior, listed on the 21112clubd zhoet i E 7. ❑Remodeling -
.hip and love w employees Thwv sub-cD/ttructors 1•aw S. 0 Pernoutitm
wcrfing fornwinadycapuicy, workm,camp¢tnyurarige. q luiI
diag addition
Iota i d.] officers Lave�:.¢cl.ixrtl their ctemp. 'snsunoce 3. We are a cnlpnrdtian and
lits
r¢quiroll.] ir 10 0rrectro-_al.repairs or addi:ians
3,11 Iwo.a humeoiner doing all work right erc;mnption pa MOL I1.0 Plumbing mpuim etrmJdiiivas
:nyxrlf'[\u warkclx't�,:nP_ e. i.52,§1(4L an¢t wY hart w 110 R"J'?epairs
ivaulentertyt,ited.j 1 crnpluym, [No warkora'
comp.inaurrno:requirud_] ,3. Other,
nor.::.>lilvn nm c11VAk itWt X1 mlti alwtill out the wttim xlov>aawlne.ncir wulkuri oxr4ffn¢ronn]alley ilergr t:: n
'1r-, .mwnac•+hosubinil IhisaNdamir ied'i=hog IFAy xwiry,all-gill and dim hint+% hk autm,w,nA,¢mlhmit t+1ew e1G.hvit'rdi:aiiilt such
:.aarw6lx dial 4d kilia bo rnld Y¢1'4rie an rldoliumi tart shcwina the aY Reel theaGG¢Cna,tNo.lnd d>L4r W%kkoi n.RM.policy kvlorwce
.lane ant rarpfnyrr d ivi a prrryldlny.,sprkers'rompenmrlaer 1,e41Jrn900for my empfnysex. 1ysJowis a4epaUry uwdlDlbsib
'V—Wadi
Isiurancc Conn'-day Name: _._.�.._.__.v..
Policy 4 w Sdf-wE:Lie. ?:__ _ 'Expiration rra¢e:
Job.';ilb Addremo Cley,SGW,iZiP:
Art"h a copy of the workers'compemsallon Policy llechirstion papa{showing ilia policy number tail espirotim date}
Failure to saris ceveraga as m quired under Stccon 25A o£MfrL c.I S2c811,(east to the impnsilim arcriminat penalties a£a
re up to S t 500.00 aadtcr one-year:mpri:alnrt vit,as well as civil ptnaf kva is the form of a STOW WORK ORDER and a fine
of ui la.S2 WON)a day agilimi the violator. Tk adviil:il that a copy of thissoxemerll may be rorwwelixi In line MIX&-of
inr'estigmiom of die BIA for iazurtnce cov.mge verlfseation.
l do herefry cxrlr rr tJre PW' raed;uloldrs ufprr}ury r4al the fafarmatian propideat uTiuyeix drat nxd earrree
�aleAug. 05, 2008
J.
ynr.,c i:_ 978-578 62 -
OfffefalnseafiN Da,rar write firthfsarew,ro6ecampletrdbyrity tip mw,e,j)WaL
City or'rown: Pcrmilir.Feame a
lnauinq A u Mori.ly It:irt le o Ilc)t
t.Uvard ofIte'rlth 2,nuitdlet Deparemeat .3.(;ieyf70wn Clerlt 4.Efrctrical tn%ltcetor S.Plumbing fltlprdrer
b.01irm_
Cnntsrr Prr¢ri ___ Phone of
.' CITY OF SALENi, ANS4.q.-kCHGSE'TTS
' 120 WASHNGTON STREET. Y'r+1A0Bt
T123 ro 0) 745-9595
FAX(TIE) j 40-93"
MAYOR IHOM"STYMM
ICI�,�ERI.t=Y�lr35GL�lS,
L'MECYOR OF PI_:RT;IC PAQPFR gyf 8l'iLDRG l Ot IkiT5StC1ti�F_!t
C un%kruction Debris Disposal .affidavit
(rccuiacd for all deniodtion and rcnovatien work)
In accordance with chc sixth edilion of the Saes.Building Cock, 7.90 CMR sccticin 111.5
Debrs,and the provisions ofVQT.,a •10t S 54,
Building Pern-jit i is iSsuUd whit f is condition tilaE the debris resultirg frc n
:his Work shall be disposal of in a properly licensed w�vi1C d::sposal tacility as dcfinea by MGT c
III, S iSOA.
Thr c rhriti wi h hr transt.orred i+y:
Northside Carting
I FI$Ih1L GJ?I9a'LIt!i�
i11'debris will be disposed of in :
Northside Carting Transfer Station
Marlboro Rd, Salem, MA
fIddi x x x ot'rac'I IiCj,I
�r
_.• .^_eramre Ofirit apliunt
August 5, 2008
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i cr'arw9:t�n