55 ORD ST - BUILDING INSPECTION k
i
iL-aNSiMWT19E fIL-E� AP. MOVED BY 774E
JWZ=DB PRIDR Tp A PEI7W AMG GRANTED
CITY OF_SALEM
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No.
Date
s:
IS Property Located in Location of
fM �< /i
Historic District? Yee No WldinH S G Gy
Is Property Wcabd in
the CormarvaWn Area? Yee No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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: /1//w `/
Owner's Name �C i // 66g /U, A
Address & Phone h
Architect's Name
Address & Phone '� It 1
Mechanics Name
Address & Phone -e
What Is the purpose of btd kV?
Matelot of twlldirg? If a dweling,for how many famoss?
WM bWldirg conform to law? Asbestos?
El" Wed coat Gay ucwm a N 0- state Uoarrea
Haws I"roveaeat X
1�L� ' Y sa
lipwure o App► t
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ZC'
MAIL PERMIT TO: e)
w
No
APPLICATION FOR
PERM T TO
LOCAT10NF
PERMIT GRANTED
A=D
VSPFCTOR OF BUILDI S
The Commonwealth ofMassaehusetts
s
Department oj Industrial Accidents
all - omesollarrostlsadeas
y 600 Washington Street, 7 h Floor
Boston, Mass. 01111
Workers' Compensation Insurance Affidavit: BuildinglPlumbin lectrical Contractors
narnz
addri: GC�CQ /9 L
c1tv staW zip' C( ;(,)Cphoneq l� J
ork site location(full address)�
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction model
❑ I am a sole proprietor and have no one working in any capacity. 0 Building Addition
dl-atii an employer providing workers' ccompensati it for m_ y employees working on this job.
address, C/
7�15 ;:
, �_.� �M•
�ti� r�5, suet,v �>-<— 7 S l' �S'7 G <
❑ 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:
commurt
address:
D
city: 4
insuranceco. _ : MileyN
coma e•
address; -----
city,
i 9Wiry
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 fine of 5100.U0 a day against me. I understand that a
copy of this statement may be forwarded to the Omce of InIpmfigaflons of the DIA for coverage verification.
I do hereby certify under the pains a d p !ties of r) that the information provided above is true and correct, {
Signature Date
Print name Phone N 7
Lomn,ci,ulse only do not write in this area to be completed by city or town omcial
owq: permittlicensea ❑Building Department
❑Licensing Board
k if immediate response is required ❑Selectmen's OMce
❑Health Department
person: phone#; ❑Olber
ri :, W)