312 1-2 LAFAYETTE ST - BUILDING INSPECTION M ♦
A:
CITY OF STEM
LowAd
w. a to..tloa ofb Pow"Lamm I \
�.urs.a
awwit L41
TA I
BIRDBKi PN APPLICATION POR:
' P�nnit loc
PLMM P"OUT L MLY•COWUM LY TO AVOW DBLAYs N PROCB1B�Ir
M THE INSPECTOR OF BL4LDMB;
�om ��'!► �ppM�� �a pannR b build a000�ellnp to Iha IBMawiry
Ownws Name
Ad*m a Phon.
ArohW* Nw w \��0
Afton A Phom I
QMolw mal NWm n
"WYbP P=it- -- @I r
1d WW d oul�q► • q.for Aow wrhr IMi�t=_, .�.�►v
Wo kap asraw a Irw1
tdw*d ooM.���1_ay uoww r N A �r uo.■.• :.G .
us,
X EWIc- c4"��)
. � SlpntlY of AppNo�111 �^
saw�O P�RIU "N �.
we 611 CW TO U ohs
RJ I i
! I
�7a
3
� '
w f
s
' td
4 r J
11 `
•k
e
JUN-09-2004 WED 12:31 PM PROF BUSINESS SVCS 9785326352 P. 01
!
I
! iuewM3 09991d D dnV 4*d ❑ AGMw J"M 9 Pewn Cl :$MWN3a
II
panxissPnMJl Z ►0J9*UnN
� -� _ -�Y��� 3a
euogd"d
$096 LLL BL6 auogd X44 euogd
"M ILL 226 suald /
Aw9fiy aauwnsul Woo
j :f'y0ad
MtO SIG `s.muna)
ice almg
auv7 U0.14M..WWO SS
�ttl �uaB�a�uucnsul
710(T $f yo f
i
' I
t 'd OOZE 13rM38Hl dH Wtl42 : TT ipon so un r
.7 y. 1Jo�r�"malwwel "Welj
~ AUTO HOME • BUSINESS • LIFE
DOYLEAGENCY
June 9, 2004
To Whom It May Concern:
Mr. Henrique Godinho, S Margin St. Ct. Peabody, MA o1g6o
has applied for Workers Compensation through the
Massachusetts Workers' Compensation Assigned Rish Pool,
Sin 4Cetti
Sharo
Office Manager
i
i
LIBERTY TREE OFFICE PARK 85 CONSTITUTION LANE, RM.2-H DANVERS, MASSACHUSETTS 01923
OFFICE, (978) 777-6344 • FAX (978) 777-9804
.Pahinrl hhn MarrinH(lnurhrarrf of L ihnrW T.. M.H.
K 'd Z9£9Z£SM SOAS S008 KNd Wd TC21 48N VOU-60-NAf
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 9RD FLOOR
SALEM, MA O 1970
TEL (976)745-9595 Err.360
FAX (979) 740-9846 _
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MOL 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: 1
Location of Facility \
Signature 6f Permit Applicant ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY) \
Vx �' � V �� �\y
Name of Permit Applicant
Firm Name,if any
Address,City&
The above statute requires that debris from the demolition, renovation,rebab or odor
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL clll, S 150A, and the building permits or licenses are to
indicate the location of the facility.
COmmOI1fL1:QWa01 e-,64LCLaedd
' � JJtP..tat..le/.).diialdafl?«r.'..t,•
600 w.1.11.Stred
James J.aoaoea Aid., /I/..a.J .11/ 02111
caftussaw
Workers' Compensation Insurranere Affidapit
. . with.a principal plane of business at»
. . Icav/arr./a1N .
do hereby'certify under the pairs and penalties of perjoryo shush
() i am an employer providing workers' compensation coverage for my employees working an
tbb job.
Insurance Campaal Policy Number
1 am a sole proprietor and have no one working for me In any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and haw hired do
contractors listed below who-have the following workers' compensation poticim
Contractor Irourande Company/Polley Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I undewne gut a covy of did a,aMMM Wit be jox arced m ow Office i1 Mmycuawa of dw DIA for for erM+wf ksd*R see 00 Mile t.teeer.
co.erare st reoorra under Section 2SA of MGL 15 2 can kid co ow ir,ocaebn of cmi6w Veered"coraaiw,s of a hot of ere W4I.500A0 aver.ut
Team iaorwronrm s yr as c)4 dedwio in the town of a STOP WORK ORDER one a W of S 100.00 a an artist not.
Sirrled this . !- t A day ofzi
r
. iccrocti'Fermittee Building Department
ucensinf Eeare
Seieczmens Office
ne:lth Gepar'mer'
„cless. 'G-Roofin <
Wes. 03F g,,,,
L Expires 1?!31103-- �Y. .
Board of Building Regulatie BOARD OF EXAMINERS
CITY OF PEABOOV-pyILDING DEPT.
One Ashburton Place J LICENCE FOR CONTROL OF BUILDING OPERATION
This is to certify that: Henrique W Godinho
Boston. Massachus
Home Improvement Con is duly licensed to take personal charge of work under the
provisions of the Building ordinances of the city of Peabody
Board of i e —
Chairman.�
ERIC'S ROOFING
HENRIGUE GODINHO
5 MARGIN STREET COURT
PEABODY, MA 01960 _
Update Address and return card.Mark reason for change.
Address Renewal ❑ Employment El Lost Card
i�