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Permit to:
BUILDING PERMIT APPLICATION FOR:
0019 whWWW apply) Roof. ROW, Instal Siding, Const m Deck. Shad, Pool,
Repair/Replace. Other
PLEASE FILL OIIT LEGIBLY a COMPLETELY TO AVOID DELAYS N PROCESSING
TO THE INSPECTOR OF BUILDINGS:The
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hereby applies for a permit to build aocordksig.to the.folbwfng-
specifica
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Owners Name i f&ef 111ye a), a N h e ti s e�
Address a Phone I• 3 �� p L ✓� (�r ) r,��-�yi�>
AmhkoWs Name
Address a Phone m ( )
l�Asche Ws Name ��,� U� ,
Address a Phone ( )
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SK NED UND1ElR THE PENALTY
OF PENIURY
DESCRIPTION OF WORK TO BE DONE '
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MAIL PERMIT TO: j ,,9Ati l o v cl\*-ti
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APPLICATION FOR
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LOCATION
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PERMIT GRANTED
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INSPECTOA OF BUILDINGS .
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
FAX (978) 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 resulting from the construction activity
governed by this Building Pemtit 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 G cq�h ✓4 C
Location of Facility
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Signature of Permit licant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
A
Address, City dt 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 cID, S 150A, and the building permits or licenses are to
indicate the location of the facility.
= =\ The Commonwealth of Massachusetts
_ Department of Industrial Accidents
weesl/nralfiNU es
600 Washington Street, 7*Floor
13 Boston,Mass. 02111
..... . /Workers'Com ensation Insurance Affidavit: BuildingTiumbin Electrical Contractors
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name: De-AN Thur-Lon—
address: 1 � J. vti ✓ 'Y .
city V 4 6e.- state• A.(.s rip:r)197_phone# 6
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole ro rietor and have no one workin in an capacity. ❑Buildin Addition
I am an employer providing workers compensation for my employees working on this job
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I am a sole proprietorCgenerii contractor or homeowner(circle one)and have hired the contractors listed below who have
e following workers'compen a ion po ices:
company name: rIlw
address (oA I ',
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city: /Vruu d pboo tl 1�3?f f�F �K a a
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company name: .: :.•s,.tr ,� .,�bt, .�_ �.- M�' -+ _ .,s�E . ;a z�i,�. j" Fis,¢
addrew.
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Failure to won coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a Doe up to S1,5W.00 aad/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do here r fy unde a pa nd a alties of perjury that the information provided above is true and correct
Signature .. .Q�h, L, '-� Date 44.00(
Print name b" !4 ` �JO ur-�dg, —Phone#
official use only do not write in this area to be completed by city or Iowa official
city or town: permit/license#
[]Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
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