93 MASON ST - BUILDING INSPECTION AN
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED ,_ 6�A f�
Location of Building IU
Building Permit:Application For:
'(Circle whichever applies) Roof, Reroof, install Siding,Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace,Foundation Only, Wrecking
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 specifications:
OwnerdName: P,I/Nec LferexeH r Contractor. agpvf /r,
Street LN &Ii-SUN S rf Ci1v L!54e/0'x Street e// erbAn S'T city S�
State. /YI if Phone (q Ib)_7 t/S— qG4f3 State Phone#,?k ) yet'" 70
Architect: City of Salem Licli_
Street City State Lic# DL�t: 3 SHIP# / y6/, 7�-
State Phone ( ) Homeowners Exempt Form
_yes no
Structure: (please circle) S' a Famii , Multi Family# Other
Estimated Cost of job S
Will building confirm to law? 9/yes no
Asbestos?_yes V no
Description of work to be done:
fiteXIWA.i LcQ JA/ aWS
Drawings Submitted: yes ✓ no Mail Permit to:
x 7,// CP-Q S
X
Si lure of Application,SIGNED UNDER THE PENALTY OF PERJURY
X
CONSTRUCTION TO B 'aCOMPLETED WITHIN SIX 6)MONTHS OF PERMIT ISSUED DATE
Department use only: Pen #\ Zoning Mapvut_r_
Permit fee
COMMENTS:
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11
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t` CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (976)743-9595 EXT. 380
40 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: 5 A L eh�' T AN5Feit STftg ,tv
Location of Facility
ignature of Permit Applicant —� Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
(?G r EMT Y• 4-a,- tydu4
Name of Permit Applicant
A-Rselu -ur l $ Scan,5 Z-4 A.-- stir
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
O/ ce911sYdsayffi►sOs
600 Washington Street, 7h Floor
-� Boston,Mass. 011ll
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name' —
address:
city state: ziw phone#
work site location(full address)
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole ro rietor and have no one working in any capacity. ❑Building Addition
IP11 am an employer providing workers compensation for my employees working on thisjob
company • {J�.S e/wl 0".p S'ON�'+:. O A%T,4°,�. G' . '�.� f
name
address:
e
city:
'�8:.° �i•._...r ,x �s �3 .it•.r rE abu+.n�/q' G p V �T^"�� �*3,
z a�
�❑ 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:
com an name:
address: y
city: phone k: f
insurance1
company name: - ft�
7
Sa'Iv ....�.(.s 4'`i" �'.i;.
address• o' k
F
city: nhone�Y6^
Al4
�ck:P46_
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 51,500.00 and/or
one years'imprisonment as Well as civil penalties in the form of a STOP WORK ORDER and a Bne of 5100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and pen lies of perjury 11 at the information provided above is true and tarred..
Signaturey/, � Date G/e3/67
Print name 64 aw Phone N 9ZJ(7-- 7Y Y— 3 k 7.2
L
use only do not write in this area to be completed by city or town official
town: permit/license fl ❑Building Department
❑Licensing Board
k if immediate response is required ❑Selectmen's Office❑Health Department person: phone a; ❑Otherp 3u)1)