HERITAGE DR - BUILDING INSPECTION 4
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fL*N61AlR6t�EfKA194ND APPROVED BY T44E
J UPECSOB.PWR W A PERMIT BEING GRANTED
CITY OF_SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) RM) Install Siding. Conebw Deck, Shed, Paolo
NReplsae. Other z b a c u:A l � -�
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS N PROCESSNG
TO THE INSPECTOR OF BUILDINGS:
The undprsigrisd herby applies for a permit to build accordaig.to the followirp
speoNicatiam:
Owner's Name _Pc.YnCe�Qr\ ?171 Q �\�S
Address A Phase Nenn,� �r �K. m (q7�1 U�� ?0 O
Architect's Name �—
Addreaa a Phone ( 1
Mechanics Name
Address & Phase ( I
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® � Sip re of Applicant
SKiNED UNDER THE PENALTY,
OF PERJURY
DESCRIPI OF WORK.TO BE DONE
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The Commonwealth of Massachusetts
Department of Industrial Accidents
ut M000IIRMSOMORS
600 Washington Street, 7t#Floor
Boston,Mass. 02111
Workers'Co easation Insurance Affidavit: Buildin Plumbin lectrical Contractors
name: — n 1^ R G-t y 1C/�A 4 r
address, t .I g v-�\r � < • t�§�, G
city Tt'AITPiI.W 1 state: Y A F' zip: r,)1 Bdphone#
work site location(full address), 1beiLf a p �2:Ve Q�s�a i�S 3 �" 4
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole roQnetor and have no one working in any capacity. ❑Buildin Addition
1 am an employer providing workers'compensation for my employees working on this jonxyb. _
NO
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city
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❑ 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:
eomoanv name:
address:
city: nhon¢S '
:t
i Wiliam
Company names
addressr.
IT
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t
Failure to secure coverage u required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a nne up to SI,500.00 and/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 Invesligatiom of the DIA for coverage veri0ntion.
l do hereby certify under the pains and penakies o he information provided above is true and correct"
Signature_ Date
Print name -)r<P lJ 1wY) Tea n/ 1 C Phone# Q 7 2_Y U'a
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑check if immediate response is required ❑L lectat g Board
❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
Ircris[A Sep).Pxnl
CITY OF SALEM9 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 Permit 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 y{ e c,5t 021"q 11
Location of Facility
� 2 s I
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�j
Name of Permit Applicant
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 properly-licensed solid-waste disposal
facility as defined by MGL cHL S 150A, and the building permits or licenses are to
indicate the location of the facility.
l
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Board of Building Regulations and Standards-
HOME INIRR�OVEMENT CONTRACTOR
Registretlo`n _08503
rAW2006
SUPPlement Card - -
J N R GUTTERgg,�,,INrC.
KEVIN FRANCiag� _ r '
114 Hale St
Haverhill,MA 01830 Adminis[rator
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