198 LAFAYETTE ST - BUILDING INSPECTION IF.
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CITY OF SA�EM
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TO THE INSPECTOR OF BLALDING&
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Owners Name . f /Zscrf
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M@dW*a Name
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J / Workers' Compensation Insurance MUM*1, ��l�l n LtJ! � S C4
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. . with.a principal place of business at:
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do hereby'cerzify under the pairs and penaull" of perimys tha1C
I am an employer providing workers' compensation coverage for my employees working on
this job.
3z1646 - a�
Insurance Co parry Policy I!Iumber
I am a sole proprietor and have no one working for me in any capadtyo.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hind the
contractors listed below who-have the following workers' compensation polities:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I uneencane Mt a cool of to ataewnenr WE be iorwaroee m the Office of Ineeri nmw of the DIA ler Ceerrata WwW48don Mai bane m ceps
eorware as reowro unew Section 25A of MGL 15 2 can leae w uw inoornion of erv*'n+r oenatn eor�tint rat a fh.e of eo 1.500A0 awler one
roan'j%wwhnrrhrnt a va at ewi oauhin in she Iorm of a STOP W ORK ORDER ano a fhne of 51OOAO a ON at ' ena.
SiErled this .
Z- day of
. iccra i F iuet cung Depa r> ent
stewing Eeare
Seieamens Office
-ic�lth Gepar-.mcr.:
- - - - - -- - - - - - -_ ` - _�< <0S, 4pc, 771
i
92.
Board of BuildingRe '7"
gul and Standards
HOME IMPROVEMENT
CONTRACTOR
Registration: 104546
Expiration: 7/14/2004
Type: Private Corporation
SHELDON FRISCH DEVELOPMEN
S�tieron Frisch
218 HUMPHREY STREET
Marblehead, MA 01945
Admfni—strat�—
✓�te �i�vramw-ea.�.0 a�i���itruaci�war./,f4
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 051135
Birthdate: 07/14/1955
Expires:07/14/2004 Tr-no: 26125
Restricted: 00
SHELDON W FRISCH
PO BOX811 - a"-e V
MARBLEHEAD,,MA 01945 AdminiStrata
PUBLIC PROPERTY DEPARTMENT
120 W"HINGTON 5TUST, 3NO FLOOR
SALEM.MA 01670
TEL (976)74"595 Err.360
FAX (976) 740.6646
STANLEY J. USCV1CZ, JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Bu lding Permit 0 .all debris resulting from the cansavctiom activity
governed by this Building Pemlit sW be disposed of is a properly licensed cord-washer
disposal faciyity,as defined by MGL c 14 S150A.
The debris will be drspoaed of at K', Z �/,PdF4
Lo mdom of Facility
Z� 6
=Ycompleft
ofPem itApp Dfft
it the followmg m&maum
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
2le llu , �,� sF,
Address,City&State
Mw above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or shucdue be disposed in a properly-licensed sokid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or licenser are to
indicate the location of the facility.