15 MASON ST - BUILDING INSPECTION pL. MSIM;r gE f ND A.PPROVE-O BY 744E
' ASP ;=PWR TD A.PEAI�fI Bf.1Nt"s GRANTED
CITY OF,SALEM
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is Pmwty Loam in Location of
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do ConnrveY9n Ants? Yu No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo Reroof. Install Siding, Constnrct Deck, Shed. Pool.
dReplace. Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifloatiom
Owner's Name T/1/'1 S D
Address & Phone ^/ �/�S o/ 1
Architect's Name
Address & Phone / I
Mechanics Name 4>A , 1r
Address & Phone ,x. , e'l -fuC m
WhO is ffw purpose of WNW
mdwid d fxil WV? if a dMs&N,for how miry farm n?
wfr birldinp cadorm to law? Asbedos?
Es*mm cost 66). CRY Ucsrne M N 0. f3tate Ucwtse 0 g-7/6�,��
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Signature,of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
r
L PERMIT TO.
I
d
No.
APPLICATION FOR
PERT TO
LOCATION
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PERMITGRANTED
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APP VfD
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INSPECTOR 13FBUILDINGS
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- The Commonwealth of Massachusetts
Department of Industrial Accidents
>f offlco allnvesdgadoas
-- 600 Washington Street, 7h Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit, Buildin lumbin lectrical Contractors
A 11
name ,r/ 'n L L�
city .� �l/� state � zip: phone#
work site location(full address)
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole Eroprietor and have no one working in any ca acit . Building Addition
Lj�mm an employer providing workers' compensation for my employees workin on this job.
c
.. .
address..
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'
❑ I am a sole proprietor,general contractor,or homeow (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comoanv name:
address:
c'
insurance
company name:
address:
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the Imposition of crhninal penalties of a fine up to S1,5W.00 and/or
one years'imprisonment a,well as civil penalties in the form ors STOP WORK ORDER sad a fine of 5100.00 a day against me. I understand(bat s
copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby certify under l e Manen ies of perjury That the information provided above is true and correct.
Signature Date y G
Print name Phone#
official use only do not write In this area to be completed by city or town official
city or lawn: -
s M rmiulicense# ❑Building Department
❑Licensing Board
❑check if immediate response isrequired ❑selectmen's Office
[]Health Department
contact person: phone a; ❑Otber
ue,,w Sep, :wm