5 MOFFATT RD - BUILDING INSPECTION s
4:
i L*M*rdST-OE f-E-G JO;APMOVED By T44E
IN3PF�XTJ?R .PFJJJDR Tp A.PEI3MIT.BFMG GRANTED
CITY OF SALEM
No.2 2 O0 c,y ; may' VN '' �. Date
Sl^ _ �r �.
s a
\ rmNit
Is Property Located In Location of
the Historic District? Yes_No_ Building
Is Property Located in KID
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) (L;)Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:fT 5'A w? u le -Qoa m Gs
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:
Owner's Name Alay-k ard
ri SW r ✓i is k
Address & Phone 5 Nj?a
Architect's Name
Address & Phone
Mechanics Name �� ��r./3m5- La✓2� S E
Address & Phone 12 4ML AL lgr�ffa.
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Esbmat cD City License # N A State License q
nn xx Home Improvement
'V V Lic. I fss X �
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPT OF WORK TO BE DONE
/veW 06 jtjo�P rr( ( .
f�ev�wiv v Io 0 7�r%ce .� sG�tiv (ems o'P ) �v�a
rs
�I ✓l � i n Il iYIA� neW cca a2.
MAIL PERMIT TO: 1&r 4n W,14 i 61 )4
.t.
No.`
APPLICATION FOR
PERMIT TO
LOCATION.: n
PERMIT GRANTED
i -GL 2.003
APPROVFD
INSPECTOR OF BUILDINGS
I
fornmanwr:a(thnof/�/�/�r 1'11aFs6¢clzub¢fb
S �eparGa+sn1 ar.Jadria(scciasnb
boo Wask,11m.SWel
James J.Camwes (�oflen, Illaaae 02111
carmrssrow
Workers' Compensation Insurance Affidavit
la _ ��rNe,✓� vV1 �,� ;I I��S
laa..r.v�.rrere)
wither principal place of business at:
2 mler &e7 Lyro 1/1/lci -
iu.s.,e.na)
do hcreby'certify under the pains and penalties of perjury. that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
�C I am a sole proprietor and have no one working for me in any opacity.
»> circle one) and have hired the
O I am a sole proprietor, general contnctor or homeowner
contractors listed below who have the following workers' compensation policies:
Contractor insurance Company/Polity Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I onoeruanc Out a covy of the wtemmt rw be ion aroed m the Orrrce of ln.<stravons of the DIA for corceate•eAficalioet VW enal facture to feevre
cosrarr m reoarta Yncer Section I SA of MGL 15 2 on lead to the ineotaticn of criminto oenattan coratstint of a fine of in ttti I.5=400 antVor one
rtan'ir..Yuonmtnl at.cro u eiea o<naluo in the form of a STOP WORK ORDER ano a fine of S 100.00 a Gay atirast me.
Signed this /Off day of �e �3
:_i crscc/ erm tttt'� iiullding Deparcn ent
Licensing board
Seiectmens Office
He.aith Department
{ ' 7c
�o , . -' OF SALEM. MASSACHUSETTS
3 .L PUBLIC PROPERTY DEPARTMENT
120.WASHINGTON STREET, 3RD FLOOR
gp SALEM, MA01 970
TEL. (978)745-9595 EXT.380
' ar 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 Pe
rmit#
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, S150A.
The debris will be disposed of at: 5 /1�dTT SG eM
Location of F10
acility
9 dG3
igna o it Applicant ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
l�rridn� S �17Cvtada �� S
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, S 150A, and the building permits or licenses are to
indicate the location of the facility.
I = q ✓7Le
lop. BoardoB Iw'dfng Reg�i�andHOME IMPROVEMENT CONTRACTORRegistration: 139663
Expiration: 8/27,2005
Type: DBA
WILLIAMS RENOVATIONS
STEVEN WILLIAMS -
12 ALLEN AVE.
LYNN,MA 01902
Adminf� str