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77 LAFAYETTE ST - BUILDING INSPECTION 2 Ett R, ; a JONG GRANTED °�.. ud 6 -6q .CITY OF SA�EM k PIMUlf Looatad In ldmmmd a Of for titlorb Otr4im1? Yr1�No. 77 Ste. so Omm"MagnAndf Yak_/10 NULDING PEEMNT APPU ATION FOR: PMOIk ux (Ck*whbhsvw apply kWd Skft COMUM.De* Shad, P@K OV , PLEASE PILL WT L MMY a CMV%EMY TO AVOID DELAYS N PIgON10M TO THE INSPECTOR OF BIALOING& hereby rMW. for a pannk to bukd a000n" to go fokawirtE Ownn'a Nam Aeye2 lL �oarilyT7�P �4.,,� Ad*Ml a Phone 73 2-g,f4 yerl? ST, f??A 92- 2 3 9S� Ataltftft]Nama oAa Y %T-e ))e54 7 Atfdroa a Phone Ia 70aea ofF, e (Vt 1 h'32 - 2 V(o 7 MadWft Name MFM 39 S�/s�Kry STQc�i , Adddnp a Phone -Z 92 - 72�7 ; VYllal Y tira pnpoM p(ai�'IO} �!`'fi C P �,Gi?CP Idtarlat d tart�,�i�/� a dwr■rq,for hoar wAny taraaaa1 YM haft aotoaa a bw Ye S A/O ■aEagad eat./S aIle, cw umm r N A awe LbrrrN r CS�519�1 _.__ . r UNIM THE OF PERIURY DESCR IPTION OF WOIIK TO OE D91A MNL PERWT S ;� ' •, ,r• .. �• ' :� ti _ .. �� RF' r,�. r,;;•. ,��• ./ �,f. ,. t 4�;ei , ' , �. w �� '.ri � R o..rr �� r ..u,�. :� ,. • -� � �� . r.��+ �ri � � � ;�: i�. ,. :.. , �w . , �d. � 4 , `: J •� } �� ', ��., � � YCommonwr:ar'lh Of /Ila�aG�s� . 6 ..Uepa+leual Lfib I'600 W"Llbe,Simef Hemet a Camooel Qeelac /!/a.,esluu.111 02111 cce mssiorw Workers' Compensation Insurance Affidrdt I, lyery f�zq//M/ P,— r r7 • S7�' cam . . witha principal place of business at: 7� lonw.�.raq do hereby•cenify under the pains and penalties of perjury, that: () I am in employer providing workers' compensation coverage for my sinploytes working on this job. ©flip 4l-r�7YoS25o"��0 Insurance Company I Policy Number I am a sole proprietor and have no one working for me in any caPackY- () I am a sole proprietor general contractors homeowner (circle one) and have hired the contractors listed below w o-have t e following workers' compensation policies: IVL&7 Jkw S� aSlof�. Contractor Insurance Company/Polity Humber Contractor Insurance Company/Policy number Contractor Insurance Company/Policy Humber () I am a homeowner performing all the work myself. I unoencand wr i coos of dro waernsne r7�be iorr+arwa m O+e Offce et lnvodrivon+of Use OlA fer ceverate v�a�MW Out leave m wears coreurt as recwtc unew Swden ISA of MGL 15 2 can kid w Ow inoauMoe of crinlnar oenard'cor""S d a 6ec of oK I.SOOAO aoelec oft rcin'inwwnn.enr m w.0 as emi nr vWW in the loan of a STOP WORK ORDER am a tow of S 100.00 a On +bays wt. Signed this . iyc2l 20v`K day of c�yile �Oa :icer.s rules Building Departn+ent '�cerlsing Eear[ Seiearnens Office -e:ILh Depar•:men. . . r. - - - _ n__ . _ _ . . _ _ PUBUC PROPERTY DEPARTMENT • ` ,'. 120 WAsmma m STRacr, aRD FLOOR SALEN,MA O t S70 `+ TEL (276)745-0595 EXT.960 FAX (676) 740-YS46 STANLEY J. USOVIC7, JIL MAYOR DLSPOSAL OF DEBRL4 AFFIDAVIT rn accordance with the provisions of MGL c 40,SA I aclmowledge tint aS a condition of Bm'lding Permit d .all debris sesuh iog fom the consbuctinn activity govaned by this Building Permit shaH be disposed of in a properly licensed solid-waste disposal facility,as defi ned by M(iL c nL S130A. The debris wi)1 be disposed of st: �s�e- �1,ronLfe-AP�W (o. Location of Facility 200,E SigagwOWPemvtApplicant Dame FULLY eOmplde the following information; (PLEASE PRIM CLEARLY) Name ofPe®$Appliant Fi®Names 3e ..5Q�s 4Fz Sx ajdlcesTie ow. olio y Address,City dt Stite The above statute mgmrea that debris from the demolition,renovation,mhab or otber aheradon of bmldmg or smrcam be disposed m a properly-licensed solid-waste disposal haW as defined by MGL clM S130A, and the building permits or uceosa are to indicate the location of the f mHV.