22 LORING AVE - BUILDING INSPECTION V•
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The Commonwealth of Massachusetts
Department of Industrial Accidents
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600 Washington Street, 7°Roor
Boston,Ma►x 02111
Workers' Com ensatioh Insurance Affidavit: Building/Plumbing/Electrical Contractors
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name
address,
cy
city �e o--G T/ state: �+—r' ao: L �/phone 0 � 2 ZS D r' 3 s�;L scl/I
work site location I full addrcssl,
❑ am a homeowner performing all work myself. Project Type: ❑New Construction emodel��.
am a sole proprietor and have no one working man capacity. ❑Building Addition
❑ I am an employer providing workers'compensation for my employees working on thisjob
company
add
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city: ,
❑ 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:
co_mnanv
address:
city: ohms k
USA
company name: -
Address:
city.
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A
Failure to won eorenae an required under Section 25A of MGL 152 an Ind to the Imporltios of criminal penalties of a fine up to 51,500.00 and/or
one yesn'impriwoment as well as civil penalties In the form of a STOP WORK ORDER and a fine ofS100.00 s day opium me. f understand that s
copy of this statement may be forwarded to the Office of lovestiplbm of the DU for coverage verification.
I do hereby certify under the pains and pen Itl ojpe�Ju m the inj lore provided above is true artd ewr
Signature .�}"�i � Date 4� 7 QS
Print name��f G/! �c+-1 �� Phone 0
o
fficial use only do not write is this area to be completed by city or town official
or tows: permiolceme a ❑Building Department
❑Liaasina Board
immediate response is required ❑selectma's Office
❑Hullh Department
tact prson: phone a: ❑Other
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CITY OF SALEMjo MASSACHUSETTS
060. PUBLIC PROPERTY DEPARTMENT
120 WASH INGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 360
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acimowledge 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:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Ua.a-rG %/ -J c«
Name of Permit Applicant
/
/�4.5/ C.—OCeS�C�OriS/FU��Oh
Firm Name, if any
mom _65HREMOk
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 ca S150A, and the building permits or licenses are to
indicate the location of the facility.
✓!re 'fOa�xmt07z4/eIL�.UL o�•/4[a°°aC�#tJB� �,
Board of Building Rrgolations and Standards
HOME IMPROVEMENT CONTACTOR
Regis{ration 131683
Expiration„ 8124I2006
Type. ParNershlp
EAST COAST PLASTERING
DARRELL SANDERS
25 DON AV E
DANVERS,MA 01923 Administrator
�/�e iponvnzoruo� o�✓�.aaeuc/u�eella
I 'BOARD 00 BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR LJ
Number CS 068153
i Birthdate 10/07/1971
4 , Expires 10/07/2006 Tr.no: 11286
tit i
Restricted 00 ,
DARRELLJ SANDERS
a DANV RS,VMA 01923 commissioner
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