92 NORTH ST - BUILDING INSPECTION fLlWS1AttST13EfILf� APPROVED BY T+IE
MSPECJ.DF.t PAIOA TD A PERWT BFWG GRANTED
CITY OF SALEM
Date
Is Property Located in Location of /
Me HW"k District? Yak_No_ Banding f,',y G I+r/S11—
Is Properly Located In
die Goneervetion Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Laws Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
r
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name /ff C
1
Address & Phone %� ti� l s (p1 �y y L/3 �
Architect's Name
Address & Phone
Mechanics Name r��✓ o a
Address & Phone o S
Whet is it*p1apose of hWkllng7 �f�S�l G n c LO• /tl c �co / fy t//S/ �
mew"of txdw g? N a dwell tg,for tow many lamilies?
WIN building cordoen to law? Asbestos?
Estimated cost L,C752 N A State License 0
6>l 7�
Bose Improv®ent
: Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
S 13J c z✓-
5���
aM 1
N0. )))
APPLICATION FOR
/P_(7EFIMT TO
VIA
LOCATION,
PERMIT GRANTED-
20
AP RONFD
r✓J
IWSPECTOFMF BUILDINGS
i
The Commonwealth of Massachusetts
a�i T Department of Industrial Accidents
011lee ollnvestfoodons
_ 600 Washington Street, 7 h Floor
i` 3 Boston, Mass. 01111
t'L`Workers Compensation Insurance Affidavit; Building/PlumbingfElectrical Contractors
r
-e-A7 cvo �9
city /Z_G%J state / /X/"` zip: G/l,)Cphone# e� f
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction model
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
Z.Afi an employer providing workers'
/compensati n for my employees working on this lob.
Company name:
z—le / 'Ty S= 3 p
incnevnrwm_ /l//� wIS� nolicYAtb .�<—�L/]
YId �
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
cmanname:
address,
city:
insurance co. _. -_ oolicv k .;'. .a.
comoaav name:
address:
. __. _..c -•-°;c. ...._. .?... was_•,. ,_..v....
Failure to secure coverage as required under Section 35A of MCL 151 cau 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 ors STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of InIorstigations of the DIA for coverage verification.
l do hereby certify under the pains a kip tries of ry' that the information provided above is true and corre
Signature Date J- d S C —
Print name Phone N
official use only do not write in this area to be completed by city or town official
city or towli: per nullicense a ❑Building Department
[]Licensing Board
❑check if immediate response is required []Selectmen's Office
[]Health Deparimeot
contact person: phone a; —[]Other
um u�Scai Sxnl