13 LINDEN ST - BUILDING INSPECTION (2) a Q}ff
vfao BY r44E
flow . . ALNo GRANTED lu'p'rr�r
L1^:.
CITY OF SALEM
Do
Y Pf"alr Laodod at L"atum of
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b POWNIV Loo.ra In
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tlUILDWO PMW APPLICATION FOR:
ftmk 0:
(Ckalo whbhewr apply) Roof Rmd, In" mine, Contact.DUK Shad, Poet.
PANWReplaoe. Other:•
PLEASE FILL OUT LENKY A COMPLETELY TO AVOID DELAYS N PROONIIIftIII
�- TO THE INSPECTOR OF BUILDINGS:
TIN umweow hw*W applies for a mmk to bukd aoo ft to fN Polo--* i
speauftm
Owners Name Le516'e / ,Qr
Address& Phom _�3 F n C12v. .57• (R7x 1 �c'- �/A_5 .
Amhksds Name
Address& Ph"
Maohanlp Name Z-en we..f Isere, .�
Address A Phone
Whd M b p111poN d Olrftilar ,��� •
MINN of bi/iligt ft a olwarilq,for hm WSW onion? i
wo kmft aaMoml WWI k
mv uo. r N A Sees Uo r L) QW-7k),._ . ,'
1os• a �/ �-
� Signature of ApploW
SIGNF,D UNDER THE P
OF PERJURY ;
DESCRIPTION OF wm TO BE ma
w
MAIL P8 0 IT Ta
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40
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PUBLIC PROPERTY DEPARTMENT
• `^`� 120 WASNINGTON STREET, 9RO FLOOR
SALEM.MA 01970
TEL (979)745-9395 EXT. 880
FAX (076) 740-9646
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 soh&waste
disposal facility,as defined by MQ,c III,S150A.
d�Ak hs(
The debris will be disposed of at: �
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following inforuntion
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
`� & �bV-,�r S) �da� A
Address,City&State
The above statute requires that debris from the demolition, renovation,rebab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
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ccmmoun:a e01/�/y�r 1.11afl6nAckwatid
6 JJaparteaaat a/.J.dr>leial Jtcc;e.a�s
600 eycW-sk-jbn-Stoat
Jams J Can=" 02111
COMM ssioaaa(
/ Workers' Compensation insurance Affidayit
I, I�G tom- I ll�n 1on11'nr¢
t
. . witha principal place
of business at: // c•
/K
do hereby'certffy under she pains and penalties of perjury, thm
() I am an cmployer providing workers' compensation coven`e for my employees working on
this job. /
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacky.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have Wired the
contractors listed below who-have the following workers' compensation policies:
Contractor Iruurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I rndergine we a coot of die aaamaa WE be is n areed w Ott Once e1 irrresdramna of the DIX for ceeerare eeRrcaim and ox lancer a°aettre
coeeearf as reou►ro anoer Secion ZSA of MCL 15 2 can kad go the irwtw60a of crw ina ornania coraaunt of a bee of as w-6I.500A0 andler doe
00 a an aaa+ut we
rears r ornom rnt y tN>r c ri ",mew in the ie r n of a STOP WORK ORDER lacer s for of $100
Signed this day of �rf C�1 - .-P
iccmtciFcrrnittlt Building Department
resin
'�cc € Ecarc
scieamens Office
^,e:lth Dep;nmcn-'
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