9 PATRIOT LN - BUILDING INSPECTION SU NY µ k k 1
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M�t I„ II�ISFT If11,1A 7p;y# pL'! lrT BEING GRANTED
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CITY OF SALEM
is No. w y Date
Iri E,
9 " Is Property Located In Location of
t the Historic District? Yak__No _ Building
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Is Properly Located In
tl the ConeervaWn Ares? Yes_No_ q0 �r �
BUILDING PERMIT APPLICATION FOR:
p Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other,
!
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING L
TO THE INSPECTOR OF BUILDINGS: .
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name CZ�A f <L" °`S c
Address & Phone °r t �! sd�- ��/n/� i li,,, 1 j97k ) 3 1174
Architect's Name
Address & Phone A/ 0e4e,2,,jC C(y(, 7y1)
Mechanics Name WI cg yl 06in-ze < sC T� 2
Address & Phone di Lei-+6rao (/� r ��t ) ' `'�o'
What Is Bro purpose of building? , — l7s�,c�rt�i r1< r4
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Meterlel of building? LJ�d� '' Ce �, If a dweling,for how many famules? IS jil
Wtu building conform to law? yCs Asbestos? I„pr..
Estimated cosf ov.v clty ucsnsa r N P' state C'S �olt5 i ,I
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floo Improvsaant
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Signature of`Appl cant
SIGNED UNDER THE PEN�� ;������'!
OF PERJURY
!p ( ' DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO:
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Condominium Trust
July 15, 2004
Ms. Sara Bruins
9 Patriot Lane
Salem, MA 01970
RE: Renovation Request—9 Patriot Lane
Dear Ms. Bruins:
Please be advised that the Board has approved your request to conduct non-structural
renovations to your kitchen as presented in your proposal dated July 14, 2004.
Should you require any additional information, please contact this office at 978-532-
4800.
Sincerely,
P li herman
CROWNINSHIELD MANAGEMENT CORP., As Managing Agent for
Hamlet Condominium
-IfanagedBy Crowninshiefd9danagement Corp., 18 CrowninshiefcfStreet, (Peabody, 3�A 01960
(Phone(978)532-4800. Ea.,(978)532-6023. E-mai(CWPTW.54321
3.� � �i' n�n�n1 L.•,
Coccym�monwaahk 01 ,f IW 6acrweffi
6 ,� !Jeparlmu� o1.7adas�fseeitisalt
` boo Wall"_31mal
James1camooes l�oaloa, !/IaulaJuww 021 11
CottsasSOM
Workers' Compensation Insurance Affidavit
/�Lm 4-0
{ava..rr.e.�el
. . with.a principal place of business at:
/$ �lrUe2C t lcfcace yrF,�� LCH���J /� � C)jC J'
. . unseat✓alrr
do hereby'certify under the pains and penalties of perjury, that
Q I am an employer providing workers' compensation coverage for my employees working an
this job.
Insurance Company Policy plumber
1 am a sole proprietor and have no one work'urg for me in any capacity.
O 1 am a sole proprietor, genmt�ClDnzmcxor� or homeowner (circle one) and have W. the
contractors listed Belo o owing workers' compensat//i��on politiees:
. - ja�/I't30/lNC. VRr9F?tf� /�/v'Y"7tFIC—
Contractor J
ins Company/Policy Number
Oral f 2ero fCcll
Insurance Company/Policy Number
Contractor Sf+F�Ynu/Lt�/icl Co .
�rtdif/ U;a9�,n L �c'N�•LY��/ — /y� C�DOC� ! :'a g 1 �!
Contractor / Insurance Company/Polipq Number
O I am a homeowner performing all the work myself.
I unoen ana wt a cool of tho wterosnt W% De ion aroea to 0M Office cl In vutavoft of the DIA la co*orare e"WKadOO MW wt raaurt IS teeure
co titian v tev4rec under Section 2SA of HGL 15 2 can kad to Wt inoonu0n 01 comma'otnanks eoraatint of a fiat of w firs 1-SWA0 mWor eft
reap',aruotnexnt v va of ciri xtnuin M the loan cf a STOP WORK ORDER ano a Ent of 5'00.00 a on apietH a
Signed this . Ll day of
c set/ Fcrr;,iI et r uilcing Geparcn ant
licensing E.eare
t Seieeemens Office
=lilt} Gcp:�ncn*
l PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL. (97 6)745-9595 EXT.380
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, S11{50A
The debris will be disposed of at: /X lJ/C ry S,�� ri/1 Srt tc ry y✓�A
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
L✓��trA^/7 S 171C/?.4 (0
Na/me of Permit Applicant
Co .
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 c1II, S150A, and the building permits or licenses are to
indicate the location of the facility.
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All dimensions-size designations gives are This is an original
verification
and must not be Designed:5!2
subject to vercation on job site and �E��s�iosiss II released or oopied unless applicable fee Printed 6/2/2
adjustment to fit job conditions, has been paid or job order placed.