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Permit to. NO SUILD POW APPLICATION FOR:
(Ckole whWWW aPOIY) Roof IndW Sksrrrp, Consb t
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PLEASE PILL OUT LNUBLY a COMPLETELY TO AVOID DELAYS N PROCESUM
TO THE INSPECTOR OF BUILDINGS:The Wdwsow '
herby appNes for a pemrR to build according,to the fmNowirp
Owners Name Mar_, ZQ.) 6 o
Ad&maPhone 3 -A 1=, II mom ( 2A 7iti - '3O3
Architect's Name
Address a Phone ( 1
Muhanics Name po'�,. d J. L 'ti w e u
Address a Phase /-b /-( oti Cy ( 974 'J w S'-
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■°'° I�to.�at swoon o plioant
aIONiD UNDER THE PENALTY,
OF PNUURY
DEscRIPnoN OF WOI!i TO w om
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MAIL PERMIT To Ma: Zc,c 6a 3/�= ) /Iy,wY.
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
j TEL. (976)743-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVTf
In accordance with the provisions of MGL c 40, S34,I acknowledge 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 , %,a,�R L,
Location of Facility
SipaturcrAf Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City tit 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
— \ The Commonwealth of Massachusetts
G - Department of Industrial Accidents
600 Washington Street, 1a Floor
Boston,Mas.L 02111
Workers'Compton icon Insurance Affidavit: Buildin lumbin lectrical Contractors
name' o b en D J Lt� u ne Lt-,c
address: o-r
city state, no DI S70 ohon # 7(kS 61 tit
work site location(full address), )=i /l " d� e 12. S s l et,
❑ I am a homeowner performing all work myself Project Type: ❑New Construction[]Remodel
[ 1 am a sale proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers compensation for my employees workinon this'ob _
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•,1. ,.. C T': t .kc.,�S i$yy'e>4tR���"AtiK` � ' a
3 a y'
in
1XII am a sole proprietor neral contractor homeowner(circle one)and have hired the contractors listed below who have
the following workers'co on po tces:
tntnaSny n nm N /A ;
address:
t'"''�, ri xIR r�x�
comnanv niter.
ell
insurance ess.
1 r P
;• % 4r.4�'.5 F 1 JAN{� \. m� t 4y rv1
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Failure Iowan coverage a required under Section 25A of MGL 152 no lead to the imposition of criminal penalties of a fine up to S14KOO and/or
one years'imprisonment a well as civil penalties in the roan of*STOP WORK ORDER and a not of SI00.00 a day■plart me. I understand that s
copy of this statement maybe forwarded to the Office of Investipttom of the DIA for coverage verification.
l do hereby ce nder the painsand penalties of perjury that the information provided above is true and correct.
Signature p�1 ( Date � - 2/_a 5-
Print name R 0 91LI J. IL 4 e Lt ti Phone# 4/
official use only do not write in this arce to be completed by city or town official
city or town; permiNicense# ❑Building Department
❑cheek if Immediate response is required _ ❑&-kct n{Board
❑Seketsen's ODke
❑11enith Department
contact person: phone a;ntact rs ❑Other