24 HAZEL ST - BUILDING INSPECTION f AMIANWmtE#MdNP# B A/PR0VGD BY IM
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CITY OF SALEM
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BULDM PEIBMT APP=TION P01t
PMmk to:
(Ckola whioh~apply) InsWl SMft CanajM Doak, Shed, Pool,
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PUUM PN.L Wf UUNKY a COMPLEMY TO AVOW D"VB IN PIIoOEBEINO
TO TIC INSPECTOR OF RA DIM&
hweby ap0w for a pannk to build aoowditto dn.Inln ,-*
Owns Imams VCt,//,o (A//(,) hur c_
Address a Phone D Vc,,%/�
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Address a Phone f )
Madams Nam.
Ad*m a Phone ( 1
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EIM�THE PENALTY'
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DEECCiNPTT10N OP WOiN(TO BE{DONE 'O `. Q 'L
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s # i8 ARD• BUILDINAtLEtilON3
k-License; CONSTRUCTION SUPERVISOR
Num�. C$, 089027
I07 Tr.no: 89027
"BILLY-KARAM
20 VALLEY ST _
SALEM; MA 019 �..
Commissioner
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coo w.s�ira.�..t
/I/.ua.I.A 02111
conmosokw
f Workers' Ccmpen advis tasoirasitx AlfWWk
. . W10-a prisdpd place at , ac
de hereby'cerdfy under tjn paius and penihdas of par*y, date
() 1 sin as employer previdtng workers' compessadon covapts for my employ** working on
tIi jer.
Insurance Company Po NwnbM
1 scot a sole proprieser and haw no ens working fdr an in say opackv.
() I am a sole proprteter, general contractor,or homeowner (drds one) sod hove hied tM
contractors lined bilow who-ha" the following workers' eompesutatlem Powell
Comrsaw Insuranu CompanylPoky.Nuadmir
Contractor insurance Company/Pe NuenbM
Contactor insurance Company/Policy Number
`v I am a homeowner performing all the work myself.
•1 rnaeraawa out a Nal a(tldr weasew on at G+r.arer a ere C+ilee i1 ir.edtatesr of.r PIA tw ce.wsft.wMradw sn,con liw a store
ep wap a►r.wrr,s cos fad"SSA r MGl 15 2 can t,aa r dr iisrie d obr:nar sem"eartradrrt of a aaa of aw W4 1302 0 crier am
teach'iyrwAmrat a s Orl ssrld.a the iorm a a STOP W ORK ORDER sir a bw of s 100.00 a an apiv,ar.
CJ L
Signed this
./` �(�L/ day o/ �C _
:iccnacci1crmiteet iutldimg Deparsnrent
LJctnsing Ecare
Seiectmens Office
=calth Derm.ment
tii f
Pusuc PROPEM D<PARTMKN T
120 WASHINGTON aY ZK% SRD FLOOD
SJUXN,MA 01970
Tat,.(979)745-MOO UT.380
FAX (V74) 7404141441
STANLKY-J. ---- ----- - -- --
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DISIMAL OF DEBRIS AFFIDAVIT
In aoeo:daDoe with the pa mmwmr of mm c 4%SK I wtwwb dv dw as a conmom
of Bmift Permit S .aD debris reaoltio3 Som the comskocbon a dVW
povemed by this Bm'Idin3 Permit"be disposed of in a properly licensed solid-wssts
disposal Lc'my,as dedm d by MM c A SIX&
The debdo w M be disposed of at
Locadm offacft
SAPAtfireofPermitApplicaat Dab
FULLY compleoe me foanvwS mh msb m;
(PLEASE PRINT CLEARLID
A,& ��ixxn rtvr��0s
Name ofPenalt App icimt
Firm Nsmek if say
Add1w.City dt State -- — ---
The above ststme regwms that debris fiom the demolition.rmovadon,rehab or odw
altendion of bull ft or stmcMm be disposed in a propaly-licensed DON"aste Sposd
facility as defined by MCM cjM S130A,and the bWldiq pumb or Ikenses ale to
iadwte the locedon of do hcUk.
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