143 1-2 NORTH ST - BUILDING INSPECTION f 1MtlST-1111EflLWD4ID APPROVED 8Y TW
JNSPZC=PWR W A PM WT BEING GRAW kD
v
CITY OF SALEM
No. V� � _
Dsls
\ ` Ward
Zol"Oftm
1s PMP"Lost 'in Loeatioa of /ft FNModc Dbtdcl? YN No� aaildiaa / y?J '/Z AJd 2 Ftf
Is Pto"my LocMcd In }� S T
tits Catsuva lon Ana? YN No\
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reoo n Iding, Co ,Dk Shed, Po ,
.RepeirR
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS N PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accorc6ig.to the folbwirtg
specifleatkrns:
Owner's Name
Addresa & Phone / W z5 �/Z /U.,(Z rH S i (9).f 1 lv0 , ,9 Sa
Arohitect's Name
Address & Phorm [ )
Mechanics Named N f f HCJ li y
yCo'3u2lk2j '
Address 6 Phone 244 r, - -�A,6feQ f-51*4
wto is st•pgmm at bu~ f 5 r n f A j=A C.
i mem or buldln0? U/iy y L Gt�i ti.) w n a dwnrq,for now m m andwy _
wa htM"ca ntt to law? Ambofts?
EsNtatad cost —!� Cay Uk tt sraM UMMa N
ftm
a Signadtre of Applicant
SONED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Gt /�Vi)aras -/Vn ��nc, n,�Zt �i y9�
MAIL PERMIT TO: BUNROEUN CHHOUY
HOME DEPOT
4 COBURN RD.
T)-'NGSBORO.MA.01879
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41 V Depgrffnent of Irlduses-in!ACciienrs
600 Iflashiniffton Street
Boston, Mass. 02111
Workers'gCom ensation insurance Affidavit; Ruildin lumbin Electrical Contractors
ffffrM fi
name: 6w,j Q H Ho L,%�A
address: 14CO&,A+—'N&J
city , 14QC:;rS9:>0R0 state: M A zip:
0210� T)bone# 7�
location(full address): LxZ & T7-,F
❑work
i —I M0 a homeowner performing all work myself. Project Type: LI New Construction L&Remodel
in an c�aa c, . El Buildin Addition
am a solcMeor and have no one w�orlddn ' a ff
have
no on c MAMMOMWAMMOV,
in compensation y employees
n employer providing workers' for employees working on this job.
OWIaln an employer providing workers'compensation fbr my
0 A uw
address'
one
A4_
>
Mas
M
I am a sole proprietor, general contractor{or homeowner(circle one)and have hired the contractors n a
clots listed below who
have the following workers'compensationp6lices:
1O pimyiturnse:
eitV:
Anne#.
ctimmfiv.na'
add
el t#• phone N:
re e eo*
Ira he
Fog=to secure coverage as required under Section 25A of MGL 152 can lead so the imposition of criminal Penalties of a time up to 31 500.00 and/or
one Yuri'imprisonment as well III civil Penalties to the form of a STOP WORK ORDER and a fine or si oo.00 a day against me. I understand that a
copy of this statement may be forwvrded to the Office of Investigations of the DIA for coverage verification.
I do hereby cerfoy under thepalus andpentaffies of perjury that the information provided above is true and correct
Sipature, Date
Print narne LAK( Ci,_1 �4(%AW —Phone#
official we only do nor write in this area to be completed by city or to"official
city or to": permit/licem.M --E]Bui]dWg Department
EILIcensing Board
[I check if 7immediste,response h required Elsetectmews onit,
E) -a c
�4 EIH"Itb Delmrtwea(
contectperson: phone#; ElOther
(m,.bd FSWL�)
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT -
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 ExT. 380
so 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 111,
,S 150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�C•Iti � H f4 oK.y
Name of Permit Applicant
l-112 wow
Firm Name,if any 1
S (f;v-z E tilYv00 t' '�:i l/L/cYGC i`S 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 01, S 150A, and the building permits or licenses are to
indicate the location of the facility.
Rpr 06 05 07: 14p Michael Bedard 1 -401 -246-28GO p. 5
TO:1BId09E363615 P:5'S
NNR-UO-c O5 I1:23B FRO11:
NOME,IMPROVEMENT CONTTtA('1'
Sul THT) Med 1.11m d ias ]cdws,by,
` T}lD A4}lDtre 9erVicts,In<.
f-d rJ Dota 3,..LQ-� d/bt, T -Vnme DCR`t At-`N mcAr' !'
Braneh NRme:
t , 345A rV,,Cf90j Skaa42 FIA<'9• fV
31v12• Tollvfc)WfilM6L,I 62; Fax'Cl Let1647
lnb*: [".�— ^ F•Ptrs lrx lSAn9AYAU MELT:YL iufl9 Fl Cmr.L'xd 16A17
� r.11IW u . N.'.Stimw lmnmuvmv:+c'anuwmr Fes'6'r)6NT
loslnllatien Addrexn:
ef9
w'nr4 PMnn �R�+a�,mr Pp•
U.p.r'a Lw AS eDrrn 1 ) `r 2�/�-d• 95�
� ` �5BeI4o�(Rlyx
l �Ita—
Ilnme Address: 5e1!'��-^
Sta[c 21P
city
(fidiRAml firm Inatdlrtian AJdresa)
IOCnWd at the above Inslallnticn in AlIJress,offer In
Irm.Depot")to fonnsh,d6w,-,Ie`r119'fur the mstolialioVi fnadc aP hereof
P oimt 1nt�IMmtlon: 1lWe/Yon('Purdua.cr^),the owntts aftM 9toP Y -enw xn'
Lortract wnh:WmC MW't U.5-rheef hS1L3 N q `f ,in9..norated herelr.b, r
Jtnenbed Vn sha M3hLd S9iC 5
M Tight to tronCel tbt+runtact if,upon ro-insperttan or the Job,Home Uepm detl.�m:nes tknt R
iu oEL trui,,Tal mM1lem Wilk dlehome nr Inman.wurk,oQuiredto rumpi9te the}ub
11ome Depot catNHt g
tenons pe[form li atltmr due ton 9 P
waa not Ineidded in the rnarncL. DL+1'OSII P AYMENT OP•PIUNV
jSublr'n In AId vnrtxvuu•,u�dlar eCrlh'M'Pmstl)
1 LleaA,Cnea'irn('her}nr U1 I'mbl9efri:e MamY rAA.r
CONTDACT AMOUNT S � - itd:6lY.IuryMkvl'u ilou,<DcpR)
I. Crula ffM•ned'A idler VtY'+unt aplu++f rlerk tine lkWw
CLFFSDEPOSfI S y�y Mvrten:uv: Uluowx 6"'Nean Pxmrrl
BALANCE[)if LI�i T]n Han Cant uartuhnPlw•+'ner¢In"" ThC Hamv DCwICWUCma
ON COMPLLITON 3 u 1-f I crmV: nn.a HUcc ONLY1
n•nnnA. y
traet Amonnf due open erncelam 4�saol�r<a UL ,, Er1V WM��
•Mltimum 25 k of C'on
I'thb Vommct NvmvnP gyms vr,mra_fi'1 sC'�a-"{ 4v0.! • —'
•ny mylou"Bmlun av IPax npm.A eltu^Itpmm D,T.m envL'c Wt'W'o
Indirala Pay-tooM-fbnd For 4rl
rekrtxxJcmin<vd:n the dcVuvt•^du'+'nA
BALANCP DUE ON COMPLETION:
' ram
fv dhal r s 5ignvlwr
HIL orRDC__..CA Niii11Fin Ilp+Moment -
v`S TA Deposit 1r �
A J
mmrd)Mely Ty'm gaisfamly tomple'.iun of the wnr':r.turchus«'will cxa:V,a CDmpletian Cnlirc'ure
0 leIANdr PRttts that,l rcesto bcl�'ntY'md sev«dlly OhhgldeJ ald liable h«ttmdcr.
sd Pq Any baLwcr Jne. Ptlrchlu«ahw ag fIT AROIA9 oATeemenL,rwnttin the C9rnp atc uRmemmtt
CnU WS ow"mml=1 its a whor mV,Incle. any
F.Ruru m b l IT xmdi:led en'C"III wrnnR m a Acpnrule aRfcement Algned by ooth paislee.
•em a pfones and rHn not be nm
NU•OCE Tel PURCIJASER t the dmt+,Cu irgu. RtVP
ud k.You A«endtted iV n rompletrly Mkd-m to Vy efth9 tcul+art s
by po nm eidn lo,iComps'"n CenlRnm t.anrce OCR rtaunit that you r,e nadARcd wllh lEe entire Vrvjcre
lift not shb pnwtl be&.S'an rc at A IreantmorodOn rmm rv�ettlto%yructnnnn�x C"mVleelon hrtiGnnrrgnta
6 m proteel yqur riR ertnrmed dfilk Ille rnnrnd.
been m1^vrel N,110 tl o0..,l tamoietianlof 0twork to 6u V
by Lb..ol. Pn r¢� a RertM dote of tbls Co.kPrt. Steh.j ut
Ynu maY CnlMet tall 1 d axs.,no
Rthelbh'd bamues>dvy.
Ry By My,IOF AICO"Y ION TF?a5Cr NIf1tACT AND 1W1mMPLDLO(DV IOPES OF TILL N0T10E OF RCI!LLA1 ONNO1Vi IID:iE
r• W, I/WL UNDERNI AND THAT Lwv AO[tEEMGNI IA 1URi6CT TO It P,VIRW OF MY"'lR
HOME Dltl'V'I ALTHOKIJLU C0N7?,AC l0%,TO VEP.B'Y Arlp REVfEa+ '"'I Ix
BY MYIUt1R SI08Al'llltl.BE M PROM .ALL LiP1JII,11V
CR::BIt'H7470RY A-ND I/WE AIM IOW LE
CRypCI RECORD
aN 1NDePltNDENT CRPDR 1ttPORT;Nr; AGENCY ANO RELEASE THEM
pdCpRHl10 fRGM INAOVFRYEN:ILINDR1ON3 OR ItIiRU:tS. DO NOT SIGN'TULS',.ON IF I'HFRR ARE ANY 4L.1NR
SPACES
SLfBMIT1ED UV' su �nauwrr=:a��
_
AfCEPTEU Its: yl e:mlmr Date:
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