44 PINGREE ST - BUILDING INSPECTION (2) , a
fL11d181 T.-BEfKA04 19 APPROVED BY T41E
JNSpF=PP" TDA.PEBMIT BEWG GRANTED
CITY OF_SALEM
No.2Za2,V_-od �-
:y'it
is Pmwq
Located in Location of
Iha tYttoria omdc? Yet No ftUAlm qq Pi
k Properly Locm"in
ftw Corawy ion Mal Yu.No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidm* . Construct Deck. Shed, Pool,
RepaidReplace. Other WUl A,l E .
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS.
The undersigned hereby applies for a permit to build according to the following
speodicatlons:
Owner's Name
Address & Phone `{�PG i�e 5 i 0910) 7W-3007
Architect's Name
Address & Phone I )
Mechanics Name ,
Address A Phone /5ow k JA 76S
WhO is ft PuMm d OW N? �aLCk
m"W a bAmv? G'p 0 A n a dwNWq,lor how many IaMftS?
VNY bwkk*mdomr to law? c!tt-:5 Aabwtoa?__,
Ewmawd eat l�i,SDD 'm Cny umme e N A state uanae e 0 661`1 6
Home urravemeat
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
DC.Vin D �`X-� 1 JI s �AT Y'�� CiDL-j •
MAIL PERMIT TO:rt /, � S o ' A a U—V1 ti mb+S
!E5ZA V4 A ol9zq
NO. / 07 J
APPLICATION FOR
PERMIT TO
Prato Df gW14 ee.3 e�'a
LOCATION
PER—MIT GRANTED
_lyN� 1 2.006
AP ROVED
f9
7,1E OR OF EWJILDINGS
J
Z
CITY OR SALUNg MASSACHNSaTTS
PUBLIC PROP[RTY ORPARTMUNT
120 W""'" ft SynMr, 3110 PLme
S" M. MASSACHUSa S 0I970
're"P t4lb i7@-743-9896 MM. 380
PAM 976-74&g"41
Debris Dfaoeac� v..--
12 accordance with the provisions of MUL C40 3 A a condition of your
Buildin3 Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid wsstefti sal facility as defined by MGI.
Chapter IQ.3 150 A.
The debris will be disposed of in:
(LocatlonofFaality) o
_ r t�
Sim of Applicant —
O
Date
Tha COM"Atse a[tN ofMamhttsdia
Departbsatt aflsrlastrialAa
6"Wa"S"&Wd
Bos994 J" aill
WOMAUMSWAW
Workers'CompendadOU b Mc.e AfiMS tls BWMeM ContradMMedrJda *ftmbers
ADD f6rm Ntant hation Please h{e`t
Name 1 s;c�� e�y�e�7 L&��y`�.�a-h�o-
Addrmm- o VO
SUA-
pbmk
Are yo■a■ _
1. I am a employs wilt �r -•-�Q I sm a Seaaal eoatraebr and I
employes(fA=d/apWWma}a bmisoedtieaahtieeahacaos 6. ❑Newooaetaedost
2 031 am a mob, ip- i ar paraw Had on mt sttaried meat t 7. ❑Remodeft
slip and have m avian to Tbse ab-aoubamaa have s. ❑Demolidaa
Moi
swry�adio(aNd:oer gwmsake0deLrdg�j aotlicoa%i'y•e e�arn i�g..a�oml:ios
wrOg° � s. ao 9. a� sal,d�
reDdmLl_l
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111 '
( i��$ 1.QPIbig s5s
oorrs aaddddiddmn
COWASYMS. I .0i ti psa
o mssni s L rt
&4 au, DPnk
;Any mlicamillid o�a4at.nk.bdm&or*&,�t
elY of arva�morbn p•9..toby 4.4t.d e.bJ�ara`.masiaa alet mb�aa a.nr.ea..a 6Nat�.ma
�Castie.ntbddst4Ybni�trr�dmaadHkad'bad8owd�araoetalrrr�ee rriariws,e'ampair ridaa
I tar t/raspbltrrAs bpnW anrdaa'e�aytataafirs bass artirJlrs4eirjftjy •Ddn►btArpdFj a1 fo1 wile
� t
lmar>soeCoaope:yNamx_�-�� Q.ti.l �"�ay�,�,�-S
pc&7 or sdom uc tr I K is`\% —7 4 ( j 3 0 6 Dos Z O
Job she Addres O t 4 76
Attach a cepf of the workers'eompasadoa paq dedarallos papa OMwdg tie pa6ey ssmbar and a*adam date)6
FMIM b Malin osvesa�e s sr I i I ®der Sectim 23A ofM(L a. 152 es lead to an iosposidos ofaim ssl penaMm of s
bee ap to$I,Joaoo nWar mo yew s wen s dvn ls"ds Is me tbmt cf a STOP WCPX ORDER and a Sot
ofop to S23o.Oo a day apiaat me violm Be atAW dog oopy ofmb sortemst spry be @srwarded to ma OSke of
Iavadpdoaa of me DU for ism m oovmpe v=Ukadoa
Ids Atnbjsw &mAw Aa pabaa and ptssaw tflv/W W At bfirsrwk-J1r "Wd Jsm Is tsar mdmree&
ph=i I q `7 S '7b 9 '� 19�
O,�IeW nrt oft Di n<f»viler ur rAtr tnR r•bt rowpfiy/bl rb aiaaw tolelaL
Chy er Tows rermh/1�erme N
Inning Authority(drde oae)s
1.Board of Health 2.Bundla j Deputmeat J.chy/rowe Clerk 4.ElectliW lsapedor I'lambi7laspneetor
6.Other
Coated rermm rhooe m
Information and Instructions
,foe mein cnvlawft
Gaooa,Lawn Cbqow 152 req.ira>ntapowl
tanloa gtz WAW MV ooaaadofbi%
�b tbie s Ord
a w at wrinea,
wMey"a,rp,r,tioaar aba trpt do
m��yd,d,edaa"a' mamehd�ms�alaW �aaaewa8 tei
.ttbekrevies ebq 'bdv p slip aoodaaoa at Omer lew e�avwbgl � ..:
.W of a dwclliotbOOW m'bg 10 t more tba mra wbo rrsida mania, boas
who coPloys Palo"la do maisuww%ammuncoaa at V ���at emPbY�~
bOO,O of amt>fa maces Sbatl wbomm dwtit arPleY�
Oran me gmOnbabu'ldbtg etdr or toed accubs soma'W wmbbm the bwr oe
ma oy, w 152,PgXd)aLob"A b�Waaa�q eoSaered b.mifa0 V tbs a m.a�for ate M
rcamai d a seem or Pus svldeaor damPgwaa.0 the�aaa eo waist n9�' shall
, ,tSt wM boa eaf Pr�A�ear eidw me oou000 weM�'�d�polhial a °u
AddidoeanY+ ago ix be cow bw any cmD Of prbtle wea sari amptebls wucm'e of cmvliseca me imatama
mPkcmmtaOfd&dwpwbavebaaap'c+�mmoc mc�imono W�
A ffkaata gmeboaa mat W*bYam �•
if
the�t affidavit o°.°P1eq►'by, wim weir 6wscase(s)of
Please 9>I .. )wool addrat(m)au¢Dboas nasbaG)along w�m odkw dm dw
�U,p�7i *99='br ,altalLC or LU dow bave
mmobaa a P�are not re9uHadadv>can
ad mat tbia ai vlcmabC mbmrtod b m6°spar ° amoa
, ,poHayra "Ofi eovaap /WaMi��'inn+d.tarr.deaa � d
bAMMOM e s d a ft�do me applicsesd fegis ma 1r�" y x@ 1e abuk s wokeW
lndnatdd Acc�' �deaII bum d me� below Se1�me.e.d TOnVO ac'bod'carte mate
I' �i�o.ere ttsa
c"at Tows OfScws s loss provided a space at the bdteora
Please;be met that me swavrt is aompleoe and prktad le&ly. The pep
aoaa bas to contact Yoe regarding dw VPllc='
of the affidavit far Yoe t4 HD out is the evcat>be Office of Im�ause ' mmber 'a addtdon�an aPP�
be sme a a in to pamdlkcme naaba which wig be aSad s n ed o*a cwcat
pWac*d mad s.ba3k maldpb P appliaatiasa is airy given Year;nod cnlY"' one badams is (cRy Of
dm tt iadipttag
if necagwyy)and nnda"kb Site Addrw"the apPlioaot Sbo.ld wr �� b
Pow» mead*Abwbaao��OE bY!�l- g Um,jfiMw u provided
t
do
e0wn� Mhos a valid aflldavh is as fde far mists Pamiet a A new
c"m
'PP a Name a permit b taaisea veaau+e
Yew.where a home oarnar err dttaea it obtaieiog it NOT ragairod AD coarPieee ibis affidavit
(i.e.a dog Sccme a paWk b bites lava ere.)Said Petfort
wwjd blre to tbmk Yea is advance for your=Paados and should yea have any q ndOrv.
The O�oa oilavattgadom pk2m do me bedwa Oterr a oa9.
The pcpaomcnt't addre%tekpbow and at umbel:
The Commonweal&of Masswhfm to
of Iadtlsi! d Accident
Of m of hlves*doog
600 washington Strut
go"MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia