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APPLICATION F
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LOCATION
33
PEMAT GRANTER
� Cm
OF NP N08
CITY OF SALEM9 MASSACHUSETTS 1'
.� PUBLIC PROPERTY DEPARTMENT
IZO WASH INGTON STREET, 3RD FLOOR
SALEM, MA O1 970
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 a S 150A.
The debris will be disposed of at: /I�oyt�j t>ol� Cd/1T lr S�i✓i!i/��rcti��p�
Location of Facility
/I:ii" �J
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
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 c1lL S 150A, and the building permits or licenses are to
indicate the location of the facility.
— _\ The Commonwealth of Massachusetts
Department of Industrial Accidents
600 Washington Street,/°Floor
Boston,Mast 02111
Workers'Compensation Insurance Affidavit: Buildiu lumbin lectrical Contractors
name; /IIG1mez, .e,�,///fljj(/lf��
address: �3-7 2�r- yqv�/
city 0/ d seate• � An. Zyy 7d phone# ///
work site location(fult address)• 3J X 4.11—//Y//11P -'-
1 am a homeowner performing all work myself. Project Type: ❑New Construction;Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
I am an employer providing workers compensation for my employees workm on thisob
me
, �001fta{4 a.....ti: .. A01 �' �°
NO
iluuraoa m .• rRiwMx..R.„?:.. :"a?;E
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices: _
comas"naex:
Address' .
city.
t �r
i - �:;{, to.hr..�7Srt`xt,��✓ijda-tc rr.. .
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- t 3i 1 4 C { P'14N" 'ia:'t � 7T' 4 Yew
addrem
Failure to man avenge a required under Section 25A of MGL 152 as lad to the Imposition of criminal pmftks of a Dee up to S1,5a0.00 and/or
one years'ireprisoomeot as wen a civil penalties in the form ofs STOP-WORK ORDER and a Due of S100.00 a dry against mr. 1 understand ibst a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains a d penalty per)ury t information provided above b true and tarred
Signature Da
Print name �t�,si 'h%� /
�..! vl/fG-r✓ Phone# -��.�
official au only do not write in this area to be completed by city or town official
city or Iowa: permiUncense a ❑Building Department
❑check if immediate response is required ❑Cleansing Board Ottke❑SeketmaY
contact perroo: phone a: ❑NWth Department
contact
rto ❑Other