69-71 HATHORNE STREET - BUILDING INSPECTION (002) FROM 5 5 • 510:37AM PI
u� sa
CITY
OF
h }rcw 0
s r 7M�
... ,.. .. PmoA Ikow
sift canow •n
KUM w a-
I
To THE l
Rs � ,
• s ftft
./&k"
.. l�. ,. •r 1. ��� ♦1
..O..... I�.� - �� 0 IN raw wx
..d.
—=I
...a. ii...:-0,7■6-
_ - —
OF PTA=
/
Pa Cam,:
i
r'
e.,
�,Ccf/ Ke��r,P�
�9- Z� /��
M,� � � �y '
� �.-
FROM :HUILDINGDEPARTMENT FAX NO. :9787409846 Apr. 29 2005 10:37AM P2
CITY OF SALCM9 MABOACNU/IETTlll
PUBLIC PROPERTY DEPARTMENT
120 WA/NINOTON STREET.3RD FLOOR
eALEM.MA OI 070
TEL. (978)748-9898 EAT. 360
FAx (9741 740.084E
STANLEY J. UOOVICZ, Je.
MAVCW
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with tba provisions of MC L c 40,S34,I wUmladga that u a condition
of Building Permit III .all debris resulting from due conowAion activity
governed by this Building Pannit shall be disposed of in a properly Have ed eoH&maate
diapaal heility,ss degnad by MOL c lA,S150A.
1%dabria will be disposed of at:
Location of Facility
D '
o P t Applicant Nate
FULLY complete the fouawing WmInsdam.
(PLEASE PRINT CLEARLY)
Nuns of Psm9t Apples
Fizm Name,if any
Addroaa,City& Stete
?he above statute requifeo that debris 6om the demolition, rmovation,rehab or other
alteration of building or sttuctum be disposed in a properly-licensed solid-waate disposal
fscihty a ddued by MGL cm.S130A, and the bWWing partniu or licenses are to
indicate the lacadon of the facility.
FROM :BUILDINGDEPARTMENT FAX NO. :9787409846 Apr. 29 2005 10:37AM P3
The Commonwealth of Massachusetts
d t = Department of Industrial Accidents
600 Washington Street, Ira Floor
Boston Mass. 02111
WW/o�rkers'Com ensation Insurance Affidavit: Buildlagilumbla Blaetrlegl Contracture
o. box q86 }`56 r �
city fi -,/�tujtg Y Yj^'1' zill,O1 ZO Ahone#! �z•66 3
A site location Laddress), may—
1 am a homeowner performing all work myself. Prgject Tf pe: L New Construction 21fimodel
[a 1wo a sole proprietor and have no one workin in an ca aclt . Building Addition
�e
1 am an am ycr providing workers'compensation for my employees working on this)ob.
v
iti ( .`'s: tilti u 3 y jai
I am u sale proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices.
addrufle
t . i.• � ':�,cak��JD��7'°1Y�Fi{+nm'tN' °8N'�^IvN;`ylZ ",',w y4�f
atimart
CILVA
.. ,,,y., ,, ;,,I,.•,� ,n aw1rRJ�.u�q`G ,' "�'4d(en
r
IInt�.. ....
Failure to ounce coverage u required under Section 29A ofMGL I53 no Ind to the Impulnus of crimind pexunes of fine up to 111,5011.00 and/or
ens ynn'imprisonment xs well as civil penxlllea In Ike lorin of STOP WORK ORDER and a line 01`5100.00 a day against no. 1 nmkntnnd that a
COPY of this obltmenl may be forwarded to I Oake of Invea11gat1anO of the DIA for roversp verification.
I do barely Ili coder/he pains an pen des of perJxry thin the Information provided above is true cod eef en.
Sipnatur —�
Data
Print name .Phone 0
unklal are only do not write In Ohio ern le be completed by city or Iowa omelal
city Or Iowa: permllbkemea ❑Buiteing Deparuneat
❑cheek IflmmvAlne reepenae Li required Board
d I]Seknmva's Omer
ronlxCt person: ❑Health Department
cartel gap,.rout phone e; ❑Other
�1�\v - 05