34 OUTLOOK RD - BUILDING INSPECTION • .,dl >
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 3q OUTLLne KA0
Building Permit Applicatioo For:
'(Circle whichever applies) Roof, &roof. nstall Sidin onstruct Deck, Shed, Pool
Addition, Alteration,Repair/Replace,Foundation Only, Wrecking
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:
Ownerd Name: (_LI(( )-6ait< Contractor. rAN/AI" r2/�1 S
Street_ /StSTLUSIC2,0 Cit Street�SSiPGyI�Gn/UT��/ City PA/
State, 1� Phone (g 2yb� State IL PhonePle) S3/�/629
Architect: City of Salem Licit
Street City State Lic# HIP# lj o l y
State Phone ( ) _ Homeowners Exempt Formes ono
Structure: (please circle) Ingle Famil • Multi Family# Other
Estimated Cost of job S 000.
WiU building confirm to Jaw? vies no
Asbestos?_yes /_/ no
Description of work to be done: //J IAZY4 it/64J UtWYL 570 iN M o Ji�il(3
IWO a6V5 %Zfv_/C Der'/ ant,5jQVa1A-11s
Dral Su matte Yes no Mail Permit to: OUTL�CYZ��
MAP A,X
Signs re of Applica ' n,TGNED UNDER THE PENALTY OF PERJURY
;x
CONSTRUCTION TO BHjCOMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
t.
Department use only: Petmli# .� \ Zoning Map/Lot
Permit fee$ , •a T—
COMMMS:
" 1
CITY OF SALEm. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
0(b FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge 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: ��
Location of Facility
S
Si lure of P licant D
FULLY complete the fo owing information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
link Cl�
Firm Name, if any
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.
--�` The Commonwealth of Massachusetts
.' Department of Industrial Accidents
t 600 Washington Street, f Floor
Boston,Mass. 02111
}Workers'Compensation Insurance Affidavit: Buildip lumbin lectrical Contractors
name: '1/ /�/� �.S 40
city v 'r7C/m slow; MA nD: Q19/U phone 0 9V- —d90P.
work site location(frill address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction RRemodel
[� 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
1 am an employer providing workers'compensation for my employees working on thisjob
compamy now
i t^tM' t 7' 1J$•b:..� . 'S .�rry,&}7 ?y� '7T
add
w t + a moil
,k
irraursea ea f../ i�'� /{�I�/�i�L eafin i
❑ 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:
eomoaey name:
address:
city: Anne III:
i
. - .. _ ,. .•,�- .• ^,,;::• �cta4}¢gd4 t.�s' Ayo+ ei4@`".?P4#+4�krsv..e, rrwa:�+:µ
Company name:
addrew
city. r f y
t suffm
i
Failure ta secure coverage as required under Section 25A of MGL 152 can lead to the Impoaitloa of criminal penalties of a Rae up to S1,51M.00 and/or
one years'imprisonment a well as civil penalties in the form of a STOP WORK ORDER and a Rae of$100.00 a day opium me. 1 understand that a
copy of this statement may be forwarded to the Olfke of lavestiptbos of the DIA for coverage verification.
l da hereby crr/ under the pain nd penalJler a per stry that the information provided above is true and corn cl
Signature � Date
D�
Print name Phone q
umcial use only do not write in this area to be completed by city or town official
city or town: permittliceam o ❑Building Department(
❑Wceming Board
❑check if immediate response is required ❑selectmes's Office
❑Health Department
contact person: phone o; ❑Other
�iaW SeW !lull