4 PATTON RD - BUILDING INSPECTION jPl�*jUST-9Efft:E0 'N0 APPROVED BY T44E
IplgP pA PWOA TD.A.PEWIT BEING GRANTED
CITY OF_SALEM
No. _1 Oa Date 6
is
Is Property LocaWt in � -� Location of
ttw KWoric Meld? Yes_JNo Building
is Propwty Located In
ow ewwrvabon Area? Yaa�No
BUILDING PERMIT APPLICATION FOR:
Permit to: 1
(Circle whichever apply) f Install Siding, Construct Deck, Shed, Pool,
lRepair/Rapiace.
Other: Dr car(r
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: ,
Owners Name
Address & Phoned
Architect's Name
Address & Phone j
r
Mechanics Name
Address & Phone f
WhO is the purpose d twiift?
MsW W of buYdlnp? �'J�� o S n.d&"w,for how many fambes?
wo WkkQ cortfomn to law? Asbestos? 1
EsW p\ C7 My Ucense r N A State Ucarae•
QC Borne Improvement X
` Lic. 0 Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
5��� R�-
MAIL PERMIT TO: '`
No. Z
APPLICATION FOR
PERMIT TO
LOCATION
A./
PERMIT GRANTED
a0
AP ROVfD
i
INSPECTOR OF BUILDINGS
The COa'lAtOall UM 01MOSIMhUSM
Dip oflirdttmid Aerldeitts
Offla 0/hWis 401111M
W weahlu
Battoay MA W11
. ww�wds�n✓Bi .
Worker'Compensadoa Iasarana Aldavft:BWMws/ContndaWX1edrld nW1umben ,
ADDNdat I�rmtttloa Pleas!Print Lesdbly
Name oks
Address:
CitY/S'tatdLiPe S�\_�� ^ Pkooe� 9
Are you as d*ek tiff�" bon
1.0 1 am a empbya Wilk ' ruad aonaaetor Cad 1 6. p Mew'oosaocdoat
amvloyea(f A aad/ar pw$-tbne}• bm ki"tie sdbtiasinttmm
2.0 I Caen,a cola pmprieN ' ar partoa6 timed m the attarW dwat t 7. ❑Remodels
ship Cad ban no emplayeea rub-aoatraebae bave E. ❑Demolitn
w d ft fw=fa=W ape*.. waftip'• •=UIPL bom mos 9. ❑1 addb(oa
insoraooe S. ❑ we atv aolpQ�d�i' its' .
,�., oflleai 1a0 IifecaiW npdm or addio=
3 I am a bomeowms.doing ap,wa k rkht wa MGL* 11.0 Pmmbiog regaim osr addieioaa
atysetf[No '.oamDc a 132.�1(. ad��le>we'ao 12.[]RoofrepaiA
bssaranoe:agobehjt: empbyeea. .', •' 13.[�Otber Sl oln(6r 6ZC i r
•A�q�pplkaot aW ebxti boor�l mmm dm agtt� bebw d M%�..w 'M 7dky
t 1*0xft*"a VukNOCE"Sam aft dAMkmdGas b wbo*anew m&
rta tCaomwi dot Awk Ob boa,mud adebad a iddhind diem d wwkg dto ass ermrw6maCiaro�..na�i m�Carp poloy iatbesrastitlas<
loalrewplvfotfbOrowtaltirdsgorltas'con'pesssaaionbssvas�sir�lvasp'dwpfejlrsftt DdorrbaMrpsffgalfoitglr
bgriraraflma
Insurance Company Name:
Poft M ur Self im I3a d DaOe:
Job Site Addaeet Cky'lSOMFLip;
Attack a Copy of the workers'compensation polky dedaradw page okowfag tie pelt number acid eaphu"0at dug*
Faibae to segue aovenv as regrsued under Secdoa 23A of MGL a 132 as lead to tie imposition of aimind peaaMM of a
fine up to i i rsaa00 sad/or one-yar as w 8 as civil pmalda iu the fmm of a STOP WORK ORDER and a fine 1
of up to$230.00 a dry against the violator. Be advised fiat a copy of&b slstesaeot may be ftsrw=W to be Ofoe of
Iavestiooes of tie DIA Ex mmmooa coverage vaifladon.
!do how an*Undirsw pbs andpwasNa 00ROL7 tArsf As bfwm&*w prow Wd above to a and acre t
lk i
O�?efd ass aia(1S. Da ad srrsltr Ds�a�ey Ia 1 v eow,p�sttrb�e!b!ai bwn o,�Je/d
CHy or Towns PUTALieeste O
Issaing Authorfty(cirde one)t
I.Board of Health i Building Department 3.Cityfrowe Clerk 4.Electrical inspector 3.Plumbing Inspector
h 6.Otter
Contact Persons Those fh
Information and Instructions
vianacbmans C,ewd Lon,chapm 152 nqutces an eaopla4MMS"j 4•vircd°pa'�oy of� ..
�aefined s•...everyD�in the aavioegt,
9a d a Stange.an i
• dr oma bml cofts or my tab or more
An OVIqv it deter ae"aa' P a,�a deeeofed e�pieri�°f!b0
of the is apicot eatapttaR saodadaa ac oma 1ep1 eatity�en4bl1°sl eIDPbyOeL arar►q As
Ha
fiver eC frames dam im&AA Pam► who raider ihtaeie,ar me ooat �
owoa ofa dwdlioiboarsbMWnotmore 4M d VAO for repairwo*.ou and dwoftab00iO
dwdit louse of another who emPbye Saeft shun got began of sash ctim o mmtbe cheated b be as employer.'
or as the 1>s�or building��
mCL ohapoer 132,4�M"Sam mat"way orate or focal ticddae apese7 shot withhold ve fw sawWumm
ra+ewd d e tlean or Per"to operate a b>�m or to eaMMlrnt bhp V the eammoair re
for aq
svidesea deomppasoe with the hu reaee eov�a aPe t egdred.
apptteaat whe hea sot p seed�� "xM SamWeimer me a mnonwalm nor OW d ill Dom i°aa aha9
�id0aaft' pa6mo=w of pnbHe wodt USIA acceptable evideaoe of°0� wi the iosaramoe
am im joy of mb�tor have been pmONSA to me aa�trsedofsotborip►•"
atSdsvit��.by cbeoldnj me bomss mat a p*u your an4 if
Please A bait the wodma comp�e�tea) Pbose ao>nbeiU) wilb mdr cati8ate(s)of
.t.'�'0b'a Li*ft C14 or LhnW Lis ift PIRIONSshipe(IA a'im n0 eO4iOy°0e om mere the
houfams are cot reereo,aeLquited bxm
b cagy wmkw'co®Vaawtion�0ra°00' if an U C or�f es
'err P'rt bbsOM
icy i He advised mat this aSid* nW be submimod m the DenWjWjW% epartaomt affidjavit
�Po of i�rloe covame. Alm ao i�a Small being a m�e Dap d .
be p���you�a0►4�'m me law err i[yao aro rago3r ed to abtoda aW
coovamimpo1i�7�4�� DeplRtmeat ca ne umber. below SeK-iasand bompaaid�°�a metr
setF � >ioa
CRY or Two OMdda
>r iae and printed Ic&V. The Department bas provided a space at the bottom
please be sore mac the affidavit o ' uom bar to OMMt yea nPadiag me aPPB�
Of the aSidsvit far you to®out in the event the Office of Im�estiga' numb
a T2 addttta4 an aPD�
pypes be acre to®is the pamW taeme samba wbwh wr11 be aced as nfaeoa er.
that moat sabmit moltipla P
liesdoer in any given yam.need only aubmit one atHdavit iodimting coreat
poltcy in mm�(dam)aod.anda"Job Site A&kae me a ppHwat sbaald write"all mybes be a m (d4Y O[
dtbe sibdavit msR htr bees o�cialfy ttl�odZQVYa may be prwrded 1b m0
COWprootlbat a valid affidavit ii DO Sic tint finue pamros or HeUSsea nee►afSdav@ m�tb0 Shed not crab
bo owner or dtiam b obi a Homo or Patnk not related,to any butiow or cow ve
year.Where ame
(i.a a dog Haase Of PcIzEk a bum leaves ere.)said person is NOT ngaad b e aomVkw this aSidav&
The
would b1m to thank you in advance fa your mopaation ad should you bave aanyVwduna.
Oft of lnvati na t
pleas!do not begba 0 give us a eaLL
Thu Deparmseaez addtesh telWtow and fa samba
The Commonwealth of Mamachosetts
DgmImelnt of lndttstrisl Accidents
Omer of lnveadgadons
6W wasbington Street
Bosuon,MA 02111
TeL#617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-2" www.mm.gov/dia
-4D CITY OF SALEM, MASSACHUSBTTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINOTON aTI1SST, 3no FLOOR--
9ALI M, MASSACMUSCM 01970
STAMLttr J. U80VICZ, in. TCLSrNONS: 97&745-9893 EXT. 380
MAYOR FAX: 979-740-9644
Salem Buildirm tma.t...ent
Debris Disposal Form
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 M. S 150 A.
r
The debris will be disposed of in:
(Location of Facility)
1
Signature of Applicant
Date
r