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16 HAWTHORNE BLVD - BUILDING INSPECTION (3) { j , fL�l'M�7Ef�� �NIIOYf�i AY 7ME �t�l17DA�l��!!Mq �p ����_�� CITY OF SALEM , o.r 28 a� w �, VMiltl �..J ��11p OIw1o1.�� k�YrM Loerbd In in.►won°°wa� r.—"°— � '� (� l� l-�aw,�a,�ae ��w�i�7 B '� Y�l� Ik.� P�nnk�a �'�p �r�w710N POIk (GraM wlMolMwr�ppy) q�IdR�pl�i�j�'. CanMn�ct�� g�Nd. p� �.�-'J PLEAiE lN.L OIR L��L.Y i COYRETlLY TO AMO�O�LA�i M/pOG�p TO 11�E N'�C'TOR OF BtJIL,DIWpg; + �.��ip!�d h��by appY�� b► a pMmit �o bultd �000ndHp,eo 1h�.foNow4q . / Owr�s N�nN ��.� �r� �/Q-✓ , . Aadn..aPl+ona /6 /,�,�w/-�oK,�,e. 6/��: c��g � 7�f(- �zq7 AiohiN�x's t�nN Add�w l Pho�M ( 1 �dMINQ� N�IIN !Mh t�k C/J-c,C o�x Addrw l PhaM _ (o�(e F—SSe,�,' � v 2 (v7 s f S q� — Z.Scr� ww�h.p.'o,.a e„a„ot�e5� �,e„�,F�,a-L �I�w a 11�101 w uocL N�d�q,b►ho111�1r�� 2 �.�� ��p��a�rf h �S �..,,.� ,v a E��eaor �pA►��r__�w, s o f `� Ce55 �It �� .- Pl�b..� � �.w.�.e �� Z��� tta. I I a S ��,�� .� � �°"'�'• a i ��� ��w� oe�rnoN oF w�o�c ro � qo� � , r R �.�k- d�� B,� �'`� 2 �C ��F�r �"�1� n�� a���,��oM�d /1�,, s 3R�F/2 /Ne...� .�,� 3 ,�.� �/� � p� � ` " ' � � i —��.,�_� I��� ��w��P-�:/ .�, Zn�-�!/� I .�.�.� � w� � . � - � .. ... � � I MN� PB�T ` � u' �: ,., , :� y , 1 H „ . �, .. � . � � � � � 0 o �� � � � � . � � M , �. � � � • , � � � } ��, _ .._«'"iYtw^«+�.a' -- y ""�e �iur�erilU'°���mru�u/uaelfv. ' : BOARD pF gUILDINGREG�ILqT10NS� License CONSTlFUCTiON SUPEI2VISOR!` �� "'' ' Numbe(C$` � 049399�f ., .. tt' Blrt�tQ� 05/2q%1957 � Y:y r IPi-" � tP�k= 3{ i.17 �.� . .. �!C����,� rs� E�F!��5�24%3006 . ....Ti.no: 24t0a� .-, .."�,� Rp.s�rlcU�d OQ„�� , � � � � �MARKR LACROIX��'�.� . , �, r^• .. - ��.+�BY6ES3EXAVE �a:, ., �. };•, '° �..� �,.. �,• � �. ... .��GLOUCESTER Mq ��g3p.s?` G`�� ` _�.. � �* ., '-.::��:.Nii1�;�,� �` 5+`,.;.:.*Sv Commisetone� s� :,}--�'� Y� Y��#y;;-_ar. '� �..�:.iga, . -.��.--"�C`""�..A-"�v..�.,.`�'.-�.r: . e� �: . ._. _—_`�=-".��i� , , CITY OF SALEM� MASSACHUSETTS PUBLIG PROPERTY DEPARTMENT i 120 WASMINGTON STREET, 3RD FIOOR ' SAl6M, MA 01970 TEI. (978)745-9393 ExT. 3B0 FAX (�70) 7409846 STANLEY J. U�30VIGZ. JR. MArae DISPOSAL OF DEBRIS AFFIDAVIT In accordaace with the provisiona of MGL c 40,534,I aclmowledge that as a condition of Building Pamit# .all debris nwlting from tha constructiaa adiviry gov�ad by thia Building Pecmit al�all be dispoeed of in a propesly licenaed solid-waste diapoat facility.�de5ned by MGL c III.S150A. The debri�will be diepoeed of� nl u/� S��,e �A'✓�I w� �5���, Locaaon of Facility /,l�v(� �� $ o Si�at�ue of Pamit Applicant Da FULLY complde the following info:mation: (PLEASE PRINT CLEARL� yv1,��1-� L�- ��LaiX Name of Pe�mi't Applicaat � Cn-� � r���rc B�, (��,-s Fum Name,if any �PI�P �7SQX f�U2 �P/b�ct.es�✓ /Y/!1. Addrest,Ciry� State The above statute requires thst debria fi+om the demolition, rmovation,rehab or othet alteration of building or structun be disposed in a pmperly-licenaed solid-waste disposal faciliry as de5ned by MGL cIII, S 150A, and the building permiU or licensea are to indicate the location of the faciliry. :� a��� � \>- The Commonwealth of Massachusetts � __ DepartmentoflndustrialAccidents �±� OIfl60 B/I tl00t ���= ' -- 600 Washington�St��, 7`"Flaor a Boston,Mass. 02117 u���Workers' Com ensation Insuraoce Affidavit• Buildin lumbin�/Electrical Coetractors ..�m-.:-r vwar ee�ans�z . � ------ __. .- - �.r"���.a. .. 9.�; -.'�a�f narnz: /�/kvik �A-�Roix address: VJ( � �SS e7� /�-�Q citv (��a'4. C a-S � f state� /j2�' zip� D(I 3 0 ohone# �1 78 -$�(o - ZS� work sire location(PoII addressh ❑ I am a homeowner perfortning all work myself. Projec[Type: ❑New Construction�Remodel �,I am a sole ro rietor and have no one working in any capacity. ❑Building Addition �.e�, _ � — �❑ 1 am an employer providmg workers' compensation for my employees working on this job. � comoanv neme: . . �. z � „ > ' s , MN� ��z�t"'`�i� �"�y�° ��,�� ��r �-?n' Y� ..,� q k=,s.c v �s;�b p�'?gv�y p sa ��.°p�2 '�{�a�' �� � a " w °"�.}� eddfesa: r �;` �t i ,�e�'� 3v-v 3� v,� ��v a +�,r-� uu, r` � ' +*.<'�� y a t a'`h�i t'F. ��^ ��i,.#���14',r �d'` 2�?� o+v� �+b'k� +...�'�� citv: � �^ m e6eeelh t uvr.x�}�,,��: �*;�.zt'L -s..�"'�"".' „w"'� „�� � i�uranceco. - . : . ... . r;�,F. � 6�' +�, y��"Y:-r r :r„��>� g.ra . •'.� mliry Y + ❑ 1 am a sole propnetor,general contractoq or 6omeowner(ci�cle one)and have hired the conVactors listed below who have the following workers' compensation polices: � co�nv name: � � � . � � � eaa�3: eicv: - � . g�lqneq . ,. � ;. insurnn � ,.�droz-� �,� i.."" � 'SF. "'° `� '+�r*`� ,};�.#'��'� �a-.`��`�����e"`��,f�, .{��.�et�'�',�� rs N...w.�� � . .. .f ,.�� � w .r.,y� t xA.:. .'et�A 'q�$5'�`,a's,P�.,•M'�'�#'M� � ' d{$gJ, � u.., . ' ,���5+;a"v�a3.�'k� camnanv name: � � �� ` . 9QI�Ct39• � , . .. .. ;*:x'c" s�,. �..,roi: ,j„ay W�,y%tx:�,�fi.x t h a-,�.'?�'Y��s�,��kk�k:p G , -�S . .. . , . .;-+ citv: - � � _ ` = o6one��lh . " . ,. t .�rc � r'��e � � ,. W��.�, I 9 0 � ,F' � ?s '� r ' � ,Z; AfWC�!� . _ -'� � s "z" Failure[o secure conraee as requireA under Sectioo ISA af MGL 152 cao lead�to the imposilioo of crimioal peoaltln of a(ine up ta 51,500.00 and/or one years'imprisonmenl es well as civil penalties in IM1e form of e STOP WORK ORDER and a fine of SI00.00 a day egeinst me. 1 understand tha�e copy of this stalemeot may be forwerded to the ORce of Invesligetions of the DIA for coverage verificatiaa /do hereby cerdjy under�he pain�s)and penalties ojperjury fhaJ the injormafion p�ovided nbove is lrue and correct Signature�•'��"ti� f'2� Date �{'Z b'l O-� Printname �✓�'✓L� LRC(LJi�c � Phone#_ -�(78 -5 /"�' Z.�v� of(cial use only do nol write in this area to be wmplehd by ciry ar town omcial city or town: permit/license k ❑Building Depanment ❑check if immediale response ic required ❑Littming Board ❑Selectmen's Olflce contac�person: hone 1!; �Heallh Department or���.��srp�.axi�� P �Ot6er '� � a.^•� . _.. ___________._.�� _____v _-____ _ . _ _ �; ; w � � : c I '} ii_ 9R%..d'r 3`-e:�"°,"� - - ,! - - ' -- _ � � � i _. . �"� - & �. � _ � � t�N, --�_�-����y���'�'_���-�Ett � . _� � . { i . 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