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TO THE INSPECTOR Cr BLKDM&
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Ownara Name W i
IWdaaaaPhona 0:5 Rd . RD6 -0001
Amhkmft Name
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waanla Name
Addw A Phone
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CommantueutLUt of�'Jf2dJQLsd
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Workers' Compensati= Insurance Affidayit
. . with-a principal place of business a>w
ttape..r./iy,
do
btrelry'certify under the pains and penohfes of per;orya tin= '
E� 1 am an employer providing workers' compensation covera=e for my emplopees working a '
this job.
Insurance Company Policy Humber
I am a sole proprietor and have no one working for me Ina ca
�' paw.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' comperuiadon po8eienR
Contractor Insurance Company/Policy Humber
Contractor Insurance Com parry/Poliicy Humber
Contractor Insurance Com pasty/Policy Humber
0 1 am a homeowner performing all the work myself.
i��.ntane ow a co.r of 0b sumve.va be foe.woed o tax Ofree el I v know of ow oix for ca..ratt "M oiw ane an taws 0 rv.
(~Off a rraure.vmw Secioa 25w e(HGL 15 2 can km to taw:rweriw.f erivy n oenain ewwint of a Im taf"aai I.S00.0o rWer twe
resit "'wwrrnrN a va a chi oenafin in the ferrn of a STOP WORK ORDER an.a tore of S I00.o0 a an ap6m ON.
Signed this . 18 +h day of C)c 4,Z• 4xLc
accnsc ell Fermiuee Ice i Gepartri,ent
ceruing Eoar6
Seieamens Office
^calth Gepsrzmcr;
PUBLIC PROPERTY DEPARTMENT
�. �. 120 WAENINOTON STRM, aRO FLOOR
SALEM,MA 01970
TEL (276)7434595 EXT.390
FAX (070) 740-9046
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRLS AFFIDAVIT
la accordance with the provisicw Of MGL c 40,SA I aclmowledge that as a condition
of Building Permit 0_ all debris resulting from the consbuctien activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility.as defined by MCB,a ID.S150A.
The debris will be disposed of at R _ (�O
Location of Facility
�il�t nn l�fL AM , I O -is-014
Signature of Pemut Applicant Date
FULLY complete the following fiam>atim.
(PLEASE PRINT CLEARLY)
N'Pit'Cr. dRuAr t�IJ� '
Name of ifemit App
Firm Nana,if
PMA . 0196c)
Address,City&State
The above statute requires that debris from the demolition,renovation,rehab or otha
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MM CIQ,S 150A,and the building pamits or licenses are to
indicate the location of the facility.