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Permit to: BUILDWO PERMIT APPLICATION FOR:
(Circle whichever app"�Asroof, Install Siding, Constnrct Dads, Shred, Pool,
RepaidRepgae, Other
PLEASE FILL OILY LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undweipnsd hereby smiles for a permit to bulid accordwip,to the mowing
specifications.
Owner's Name � ��
Address A Phone9 Ll
Arch tecrs Name
Address a Phone
Machenics Name
Address 6 Phone a Z `a2 l f - i/ 4!202�2- �S
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Signature of App t
SKWD UND E PENALTY,
Olt PERJURY
DESCRIPTION OF WORK TO BE DONE `
MAIL PERMIT TO:—T . " ' /7ZF���iliL
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The Commonwealth of Massachusetts
rs = Department of Industrial Accidents
Offies olimosesum
600 Washington Street, 70 Floor
}a Boston,Mass 02111
Workers'Compensation Insurance Affidavit: BuildiaztPlumbinzfElectrical Contractors
n
address:
city state: vo� phone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 'I ales an employer providing work rs' compensation for my employees workinggn this job
. .�_ ^/ .�/ �yLf.a�-,�I a.�',�„1
add
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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:
cortmarry name
city: .. ,.
'ITT•T�, ;s-� `°
.xF' ;
�
cornompi
address:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Once of Investigations o e DIA for coverage verification.
I do hereby certify der the ins and penald jp ly I he nj motion provided above is true and corre
Signatu Date yn'��,
Print name PhonF' g 9
official use only do not write in this area t be completed by city or town oincial
city or Iowa: permit/license a ❑Building Department
❑check if immediate response b required ❑Lkeming Board
❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
IrtvisN SePI_axnl
r
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 ExT. 380
04& 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 III,�S1150A.
The debris will be disposed of at:
on of Facility
Signature of Permit licant Date
FULLY complete th following information:
(PLEASE PRINT CLEARLY)
�1 // / AJ
Name of Permit Applicant
�'I'1 r o�✓C,
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 CM S150A, and the building permits or licenses are to
indicate the location of the facility.