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sCITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
IZO WASH INGTON STREET, 3RD FLOOR
SALEM, MAO1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVrr
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 III, SS/150A.
The debris will be disposed of at: IV
Location of Facility
114 (S411,1r
Si tune of t pplicant ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
,el e d&Re S
Name of Permit Applicant
,"�-N�7%
Firm Name, if any
2te* kw�
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 cR S150A, and the building permits or licenses are to
indicate the location of the facility.
-- ~ The Commonwealth of Massachusetts
Department of Industrial Accidents
j BH/taN�
600 Washington Street, 7o Floor
Boston,Mass. 02111
Workers'Com eus tiou lusuraoce Affidavit: BuildingtPlumbin lectrical Co_u_tfactors
. .�'K""vYfi •^}TY"'Rrh ler�3..lrrrs? •^�•�.•�+ '
address: L//uDEy sl
city ��006,6n stare: P7A{ zip:649C) phone# E?y5-- /Wes
work site location(full addressl:
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
❑ I am a sole ro rietor and have no one workin in any canacitv Building Addition
UJ_J I am an employer providing workers' compensation for my employees working on thisjob.
comoanv nanw.. g/y 6 / 1 Y
,�.r yyam�,�//�r.�1 / y4m h its, y�
eddresa: r�'I /Lf�7N� (Si .7 r s � t �ru ;a
9 � s
city: / t adlsana�i'' r r s
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❑ 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:
comoanv name:
address;
city obtain - .
Company name:
address:
,g+;c
}INS `1
i s
A
Failure to secure coverage a required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment es well as civil penalties In the form arm STOP WORK ORDER and a Rue ofS100.00 a day against me. f understand that a
copy of this statement maybe forwarded to the Office of lavesligatiunt of the DW for coverage verification.
!do hereby cert�y under the pall and penalder of perjury that the information provided above is true and co red
Signature Date 6
Print name Phone k
LE]checkifimmedisle
nly do not write in this area to be completed by city or town official
permit/license R ❑Building Department
(]Liceming Board
medisle response is required Qselectmen's Omce
❑lleallh Department
n: phone k; ClOtherr