60 MOFFATT RD - BUILDING INSPECTION S
13 �
-Pt*NS 11AUST-GE fJL404AD A?PROVED BY T44E
MPEU11fil PFlM Tp.A PERMIT B.EINIG GRANTED
CITY OF_SALEM
No. 'U� '�\ Date
Is Property Located in Location of
the HWIcric District? Yes No Building
ty Located Is Proper In G Q t"1I oFfi� T fe6
the Caneervetlon Ares? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace th r. w I n�a aw
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 �af-£CAJ Af l' So"
Address & Phone G d "oFF,a-r7_ E6 If 4 -7y5-- 05W'
Architect's Name
Address & Phone
Mechanics Name �, o✓ C.H i °k�!
Address & Phone
Whet Is the purpose d building? 2 f f i0 f 2,77,-+ L
(/ iti� �
Metodal of buYdbrg? u_ i,ti ox3 5 n a dweYNtg, for how many famines?
WIN bundrq cordorm to law? Asbestos?
Ea*Msd cost 7 �!y City Umme• N ' State License K
Now Inpsoeesent
Lic. III el
O G d 4 3 Signature of Appli
SIGNED UNDER T E PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
2C PC'4 0C /L/ /-U lAjh ej�S
MAIL PERMIT TO: BUROEUN CHHOlyf
HOME DEPOT
COBURN RD.LT'j_N4
GSBORO,NIA.C;879
APPLICATION FOR
PERMIT TO
Al
LOCATION
to o ��-11-
PERMIT GRANTED
�2
APPR D
INSPECTOR O BUILDINGS
t
Thc Copy?
3
Depgrfmcne of Industrial A ccidents
M/ T AMC I-41�17
600 Washirifflon Street
Boston, Mass. 02111
Workers' Com ensationInsurance Affidavit:Dal Uln Mumb: al Contractors
OElectric
name: LJIiIN H Ho L,%y
address: 4 C06�' ,,j (2,b
city �IQGFS bog state7 MA zip:_0)&11phone# q (09 —5�
work site location(full address)? 7-1 / .P'
❑ I am a homeowner performing all work myself. Project Type: LJ New Construction ®,Remodel
ID I am a sole prop—nietor and have no one workin in an c act&jMVff El BuildizANdigon
Ii , 11 M 11 i!I�iii Oc MOMMAWAN
I am an employer providing workers' compensation for my employees working on this job.
A4 5 4
y' OA-A
L5
ao,
.am
totemic c NMI
I am a sole proprietor, general contractor{or homeowner(eircle one)and have hired the contractors listed below who
have the following workers'compensation polices:
oo,
comn name:
addren:
city., .. ....
sursuive ca.: olio N
7,
address:
: 1 1 11111101 1:11 1 11 1 11 i M:
FAHM to secure coverage 95 required under Section 25A ufMGL 152 can lead to the imposition ofcriminal penalties are fine tip to s1o500.08 andler
one years'imprisonment as well as civil penalties to the form of STOP WORK ORDER and a fine of$100.00 a day against mi. I understand that
COPY of this statement may be forwarded to the Met eflovestigstions of the DIA for coverage verification.
I do hereby eenify under thepalus and penalties ofperjury that the information provided above is true and correct
signature Date
Print name 11�LA I cwlqoA� t� Phone#
omcid me only do not write in this area to be completed by city or to"official
city or town pernalt/ficeme 9 EllBuilding;Department
LJLicewiug Beard
[I check If humediste response is required Oselectmen's Office
ElHeallhDapartwecit
contact person: phone#;
(.vt..d Sot 203)
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
). J' SALEM, MA O 1970
*' TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I aclmowledge 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 ` -5— 6z t0u w00-6
Location of Facility
Signature of Permit Applic Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
C4/hi (f " A/ °1.Ir
Name of Permit Applicant
/l
/ —Tor-jC � � �O �
Finn Name, if any
�� �� Cr2'iVwooD �� � lj(>4�zCfS7i;/i
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.