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' CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (978)745-9395 EXT. 380
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# .all debris making 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 Ili.S150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Too ed 13111,5�4e ff
Name of Permit Applicant
leek 4 SL r
Firm Name,if any
Address,city& State
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a property-licensed solid-waste disposal
facility as defined by MGL eM S 150A, and the building permits or licenses are to
indicate the location of the facility.
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
10
OflIBBB/hrtreStlgetlBOS
600 Washington Street, 7rh Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
address:city �(�F' state l 4 �AZio l2) Co phone# s R3 6 �J
workit location full J - -CAP YtrL/P H-t G
❑ 1 am a homeowner performing all 4rk myself. Project Type: ❑New Construction gRemodel
e® 1 am a sole_�ro r�ietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers'compensation-for—my employees working on this job
le So f S% "a �r Pifer x u p
Company name:
/� t p
..) KG_. PleA�'
address• b �,2vIOj y
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¢s.k,:. m atk. t' rr`:l /a *k /
Mabel
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insu n ppOcv# `'•'
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name: -
address: ,
city: phone#
i
m prance X•. " r ' $� •.a '�p.-4;Rr.f; piv+a:.i .w*+.`+"' ^y,."i . '+- #.• :7zg. 'd R,q#.,p
... .. .;r ,f .�.._ rn ,.°Pa?�,°ara" rx'W,'yr�i:�.'•"gf-, 6`�e n �;: � '�....t
cormumv name: "
address: t ..$ .;� ;.�. +v '-•���x. rx ,gw.is,. sk? Su" ,yvh kr,.y,,- x
city: n {�• (t ro'�y
Failure to secure coverage m required under Section 25A of MGL 152 can lead to the imposition or criminal penalties of a not up to s1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of S100.00 s day against me. l understand that s
copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification.
I do here rtify under t aai�itns an p_enaaltippes of perjury that the information provided above is true and correct.
Signature -L / /t�t-✓��^-'k-/�, Dale - Y Z p�/
Print name ��4 �..L/ '�(3//S' Phone# 7y �36
official use only do not write in this area to be completed by city or town official
city or town: permitnicense a []Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
hone#; ❑Health Department
contact person:
or„:m Sept._�xul P ❑Other
�Tk
Board O,BoMog Regolsdo sed Shedsrde
ROME IMPROVEMENT CONTRACTOR
Regisbik 136995
Exp"dWt9l2412006
BLAISDELL+SONS_CARP (Y�.'+MASONARY
�.�DANIEL BLAISDEIL��; - :: '
16 ARNOLD
PEABODY,MA 01960 " - AdmmMmtor
BOARD OF BUILDING REGULATIONS
ONSTRUCOTIO�N7SUPERVISOR
Nmtf a 1
�r008; Tr.no' 3637.0.1
� " DANIEL E BLAISS Y mil.. /y j
' pEARBOD D Commisslon" i