25A MARION RD - BUILDING INSPECTION fL4vVS 1W*EP»irD APPROVED BY Tw
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CITY OF SALEM
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Permit to: NO BUILDIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof Instal Siding, Con Deck, brad, Pool,
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS N PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned herby applies for a permit to build accor&q.to the following,
specifications.
Owner's Name
Address d Phane
Archkect's Name
Address A Phone
Mechanics Name `JG�4 tie e—
Address 6 Phone 1 f4S j e�� Sf M 14 7P I (�S I - r�c)-W
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Sigrtadtre of Applicant
SIGNED UNDER THE PENALTY'
OP PERJURY
DESCRIPTION OF WORK TO BEI DONE r°
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MAIL PERMIT TO: C o I ��� -r ll v e" ��
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The Commonwealth of Massachusetts
— Department of Industrial Accidents
F O1BgN�
600 Washington Street, 7°Floor
} Boston,Mass 02111
Workers'Compensation Insurance Affidavit: Buildih lumbip lectrical Contractors
name:
address:
city state' up• phone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
1 sole ro rietor and have no one workin in an i Building:Addition
I am an employer providing workers compensation for my emTl�.vecs workm on this'ob
�a " s
Comm"nallinst
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ci
❑ I am a sole proprietor,general contractor,or bomeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comnanv namr.
address:
city:
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. r,..r.nS+.LeSta .F�YMYA.3 `v3ksi"w'n? 143j*Z^'� r::;a +#gyrt,p,,z..rla' ,N,,. �jx
company c"�, r
,
namc
INN a
Failure to scan coverage ss required under Section 25A of MCL 152 an lead to the Imposition of criminal penalties of a floe up to SI,S00.00 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 aplmt me. I understand that■
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verpkanom
l do hereby cer/ un er a pdnr and a altly p a nJperjary that the information provided above is tree aid correct.
Signature Date
Print name t-�l �'e— Phone
L
d ute poly do opt write m Ibk area m be compkttd by city or Iowa ofl1t61
town: permithkeme# ❑BulWing Department
eek if homediate respooae n regalred ❑t.kemiog Boas❑Sekesmea'a Onke
❑Health Department
t person: - phone#: ❑Other
Sept ]x�31
1
1 ' CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (976)745-9595 ExT. 380
100 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, S 150A.
The debris will be disposed of at: A.,H--t -- (�L
Location of Facility/ f
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
-D er AIL'L-C�
Name of Permit Applicant/
Firm Name,if any
41
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.