30 OUTLOOK AVE - BUILDING INSPECTION i
-FLO ISiM T-DEfIbE ND APPROVED BY T44E
Jd: .R=DA PRIOR TOA.PERW SF1NG GRANTED
CITY OF SALEM
No.
s:
W Property Located in Location of /)
to Historic Mild? Yam _ '� ) q No• Dui]din6 3a a� z e
k Pmpwty Loceled In
em C dervae9n Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
RepaidReplace, 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:
Owner's Name '
Address & Phone 30 0
Architect's Name
Address & Phone (
Mechanics Name
Address & Phone I G "i r _ (`f 7k) 7 Ys - s 8' Z
WIW Is ew prapose c1 braktW if'b
MAW W 01 IMesrq? ,tir e a dwe",for flow many lambes? /
wo bo mdlrq cordomr to law? *L2 _Asbestos? —
EsW WW cost t 0 06, 96 CRY ucerua a N A sWe uoanse a
Bawa Lprovoant
Signature'of Applicant
SIGNED UNDER THE PENALTY.
OF PERJURY
DESCRIPTION
-O^_F_ yWORK TO BE DONE
"V r
MAIL PERMIT TO: 7 0
No.
APPLICATION FOR
PERWr TO
LOCATION
PERMIT GRANTED
2.0
APPAOVFD
i
INSPECTOR OF BUILDINGS
The Co mmxwedth ojM4zwhpsd/i
DepartneW ofIndkiNd A&Wa is
OBE 9fw
6M Wa kinge nMred
Boston,MA 02111
wwttfasatt�pa�eaYi
Workers'Compenadon hwamee Affidavit BoitdaWContradonMedridsnOlambera
ApipMewd haMatka P1
Name /
Addeess: 0 -
City/SUWJ7* `)Y� oG v PSooe 0.- g ? - 7 Y� s"s. 2
A,re,? ao e"ed Cleelr ttE ipproOriau boss' Type of Project 00111111reft
i.lY] I am a employs with : t. Q I m a 3maal contractor and I
��m(hR and/orp�� d di
l' bwa ae solkn nctots 6 New
1❑ 1 aaa a sole l opcieer or paatsa- listed oe dw attached sheet t 7. ❑ Remodeffing
ship and Lave m employees These sdK=tracl=km S. ❑Demolition
(Nwe >i1ti waftn'cow* S.
s. O w $ PQ '' i' . 9 Cl 'ddm°°
o>1lcol>s)isye '" their
10.0 FJxtrialrepai s cur additions
3.❑ I am a homeowner doing ap,wo>} rigbtofeaegiptiga hR($,' I I.[J Plumbing repsks or additions
�ok�� gyp, ex 1s2,41( aai(i�TeLsve ao 12.Q Rooftepaira
iasaraaoaregaire"t: <. , ...r 13.00 der
•
Any oppso.d,e.cbKbboneflmudWwfieogsagactin•bebwao wtof&*,.*jx m�q.tloasWjrymbn=dM.
tHaeroruasp1MomitdtY�dOvitudkrisR�Y �a�Awtaams3 odiiaau�oetitoabdkamwfdait war
aCamadea tbd eDoeltfaYbos'�mt dhrLd�od�i000l�bst ihovioa ftr mntKtelrabcau6Kbn edswiwhod'sae¢poky i�on�fotloe,
l sat a#"saepleyea•rAar bprot�ing+ '��btranxearjer aeyarr/pfjirfat actor.b tMpe:ltgy arol,/oi slat
ulardraa
honwance Companyxama
Policy 0 or Self=ins.Lin if t / C-�9# I-`!.i- 3 3 / Exphadon Date: 3 7
Job sits Addre= 3Q 0 (� r CIIY 1p: :4 �a" 0/ 'i 7 0
Attack a espy e(the workers'eompessatloa poBey dedarattoa page Ole w6ag the policy lumber and asplrstdon date}
Fat7me to secure coverage as requhad under Section 25A of MGL c. 152 can lad to Me imposition ofaimind penalties of s
tine up to S1,500.0D and/or ono-yesr roses bmmaat,s wrJ at civil penalties in the form of a STOP WORK ORDER and a tine
ofup so$250.00 a dry agaims tha violaim Be advised dos copy of dth statement maybe forwarded a the OtBce of
Inventions of the DIA for insurmce coverage verifiadon
I M Amby"no www do P"M wdPeRddw of 4*7 tAw Ae WO provided above to trw arl correct
lima= Date, y l l l 0 6
Phone N q 7 K �7 SAS — 3 SB 2
O,ofeW nrt ow/X. De sd rvrht In rAb inry b bI eowp�fets/bp db'aarnw o,Qldid
City w Tows: Pernbucease 0
Issaing Authority(cirde one):
1.Board of lieskk 2.BuBdtag Department 3.C7ty/rown Clerk 4.Electrical Inspector &Plumbing Inspector
6.Other
/ 'ontad Person: Phone 0:
Information and Instructions
152 Ta*a an emplaw 1p FW4*-° contract of hies,
is defied a"...every OUMAor
is ma savke agotba trader sap
>AnmW*oV assocb*16 oaporwm tir aher legal
mar,m U7 two or more
to defused as"as isdivi wg im adbf a 9f a daccad °r t t
m®ped is i joieta�se+R •sad mch O&W o c .
or other legal eatay,employist H0w 'q..,
noeiva a trmtet sins sad wfio resides thachk or the ooaptm°f�sF
owner of a dwreltlotbouse bttvfat not mme the three aptatmem Comtncdoa or rep =we*on sorb dwelling bome
dwelling bouse of saothar who cmploytt Palm a do mamteoaoce, f sari ceepq°ymembe damed a be an amploYm"
or m the grounds owboRding tbado d aS notbeaase
MQ.dtapter 1ST 425C(�WO shta "�'�stags or toad Sensing ate"Y shad wlthb"the Wmm"or
regewat Of a Seeass or pama t0°pme a busfaeas or to eosdrad batW"Is the eommogwettffh for aq
wlth the lamrsaoa ewa2p n9i1r "
appS,.&vrhs loss got prodood aoeeptabts aldnca o[tompltn0e ttae of iM mbdi4WM shag
Addiyonslly,MO[.cbspw 15Z 125M)states"Neidw the �of atmptiance w6 the imaranee
Cum into any non fi>S the pa> ofpnbtie wo>k ttsttl aocePtabls
Of this chaptw bave bem pmeded a to COMMcft MOMW '
ApplIcaaft �ebo>ars that appb�a Your stttsatiaa agd,tf
please ffq out the workers'conpawdoa l d dra �r)��their ems)of
neaxsly,e40Y s)namc(s),address( )sq¢PtaaO other thn the
fnsura" � (LI.C,�or Limaed I.iabaitY ParloasbfPs(LL=with r U d ea
am 10 regoad � tmonaoe If an I1.0 a I�.P does have
meatbas or partners, to bc submitted to the 1 gwOncd
Be advised etatths affidsyi[msY d Igdosfrfat
�,pby ,a policy is rogaftcd Also tns pre to sip and date the amdavit. The afSdgva sboaW
be r d� M �far t6et>amR > 0 o rho Dot of
Cityhove any pad a obtain s wordless'
IndusIM ref' DOBU �e Dep> st rho mmtber*W below. Self-ianaed �e their
poticyC Pt bne.
self-ittsttraoce lianas ttttmbd°O�°
C"or Tows OfSdm at the bottom
>s lets and printed k&ly. The Department has provided a space licant
of to be we dut you
SO fin of oampyou
of the affidavit tat you to fat out is the weal the ,,bi wills be igd w has to emtact ber addict M ding an��
please be sure to fill in the permW keme uag,ba wbiin wad given
ye err .n reference camber• afiSdavit current
le p�/ti�se applications is any rives►Yam:need ooly °IICisdicatinB (caY
submit m(if " wrM'all °r
p°�. � Hadar"IOb Sr00 Addrea th0 apphcant should
� Wrolnof(if necas k and. a town may be provided a the
uy")."A 660 of the sff5dsys rasa has low o o ix a rtttm er 4L ormarkad�OM. A new afffdavB mottbe fiw out eseh
��as peon{that s valid affidavit is oil 51s far Enlace patttm or conm=VW vensore
Of atism is obWnbg s Brame a panda trot rdatod.a nay husiom
year.wbm a borne owner a bum laves eon)said patron is NOT required to complete this afddsvit:
(ia a dog license or P�
ould Iaco tb thank you in advance few your coopaation and should you have a>ry questions,
The Office of Ivestisswo wus a call
pkasedo>nt hesba give
The Dcpa=nuts address.telephone and fa Member
The Commonwealth of Massachusetts
Departmaat of Indtstt W Accidenb
ova of faveattpdons
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET. 3*0 FLOOR
SALEM. MASSACNUSETTa 01970
STANLEY J. USOYICZ. J11. TELEPHONE: 979.743-9593 EXT. 380
MAYOR FAX: 978-740•Y64a
Salem Buildina PfMrtmana
Debris Dkpoa t F0
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in: _
' (Location of Facili -
--e-
Signa4tunf Applicant
WILL6
Date