8 PLEASANT ST - BUILDING INSPECTION gPL1 S~*EflLl ND APPROVED BY T4IE
J UPECIJaB.PIWR W A'PEMT AEINQ GRANTED
CITY OF_SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Instal Siding, Co suw Deck, Shed, Pool,
Rapair/Rapiace, Other
PLEASE FILL OUT LEGIBLY Jt COMPLETELY TO AVOID DELAYS IN PROCESSIM
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accorcFAV.to ths.followinq-
specifications:
Ownses Name L' R itt n» /�'1/r�F,�in ► 4
Address a Phan (` yn
M,hitscre Name
Address & Phone
Mechanics Name 9
Address 6 Phone 76 Wa&kO /� k'� (q)h S?
what is to papa.it Wa*lg l e o
Mftw of NOW G ) aD tt a dwMNq,lo►how maly la rAm? 1
wa taildY n cameo to mw7 'vLL Meuloa4
Edmalad cog fo.S71 D a " CRY L wm r stw dome a A; '
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S of Applicant
SKi1NED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE '
-
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MAIL PERMIT M. 13-" 9�m'-/--F S ( f
APPLICATION FOR
PE W TO
LOCAMN
PERMIT GRANTED
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7/7D
INSPECTOR OF BUILDINGS
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9848
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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: feli311)p
Location of Facility
91gWiture of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
t)3 �2na-xj
Name of Permit Applicant
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 ca S I50A, and the building permits or licenses are to
indicate the location of the facility.
- The Commonwealth of Massachusetts
G Department of Industrial Accidents
`a —= OtA60!//aY6�8tl09i
600 Washington Street, 716 Floor
Boston,Mass. 02111
/Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
name:
address:
city state• zip" phone k
work site location(full address)"
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I ayma sole pro r�,t®etor and have no one working in any capacity. (]Building Addition
~❑ I WOMAN
am an employer providing workers compensation for my employees working on this job
company 6"',
L L
,/j,,pp 1_. tb ,;y ♦� F rya "�' t p, R,
City' .. Ler .,;.ry a�.rji ✓> f��"_'"£' jl�l w''i14k '@ '�s � 1v„ di
s.
❑ 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:
company nape:
address:
city:
M� h a
e .. -., iar.ag�o-ag Pti' wG.g.h�^ +tAiNt;i'Ri:. xs s+;,,�f rkr*Fv`�e
company name: .. t.,.,address- 2 r a Z'�'g,;fk=,' � �ffi �.; ffniff' F✓,r.'.,w9skw",�+. ,tt.'''t'
Yj
70d"d
Failure to secure coverage at required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue ofS100.00 a day against me. 1 understaud that s
copy of this statement may be forwarded to
ihe.OMce of Investigations of the DIA for coverage verification.
th
I do hereby certify under the pa—inss a(nnd penaUles ojperjury that the information provided above is Ira and correct t�
Signature /J ,�/-� /J\,,,, Date
Print name Z! A,) C117 fi_w4-� Phone N 5��J �P
o
fficialnly do not write in this area to be completed by city or town official
permitthcense a ❑Buckling Department
mediate response h required ❑Selecting Board❑SeleamepS Office❑Health Departmentn: phone a; ❑Other)