7 PRESCOTT ST - BUILDING INSPECTION r
J
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�1.1AISiMIiSfi�EflL<46- iD APPROVED By T44E
.D>ISpECIDR PAIpR TD A.PERMIT BEING GRANTED
CITY OF SALEM
No. -� Date
Q%-oh '3
Is Properly Located in Location of
the Historic District? Yes_No ttnilding 7P
� sf
Is Property Located in 5a�m
tiw Conservation Area? Yee No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
spaid,Replace Other:
K I c n
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:�r fi n GV��YZi^C�
owners Name
Address & Phone 7 d96 06 73 S/
6a''t m
Architect's Name
Address & Phone Lri
Mechanics Name r�i�i l :5 h l7 tin !J aT::) -
S Address & Phone /-)d 99V 6 5�7k1 77V---33 j3
/ what is to purpose of building? 2-& '
Material of building? a)Uvd If a dweYing, for Crow many families?
Will building conform to law? Asbestos?
Estimated coat l3; �— city License r N A State License# D 7 3 3 7
noins improvement x `
Lie. 0 !03 CO L/ i/1 Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
rim vdGe
MAILPERMITTO- 7 �]6 )- Pt) 5� 17r���r� 0 t�7 D192,3
No. /z 4h
APPLICATION FOR
PERMIT TO
LOCATION.PERMIT GRANTED
y�/olds. 20
AP
vFD
INSPECTOR OF BUILDINGS
w
CITY OR SALEMj, MASSACHUSBTTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON ST11[ST, 3RO FLOOR
SALCU. MASSACNYS[TTS 01970
STANLZV J. USOVIc=. JR. TSLCPHONS:
MAVOS 978•745-959S EXT. 380
FAX: 978-740.9*4o
Salem $uildlno jk ft*,l
Debris D �sl >?...•...
In accordance with the provisions Building Per of MGL c40 S 54, a condition of your
Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter M9 S 150 A.
The debris will be disposed of in:
(Location of Facility) 33
Signature of Applicant
q d�
Date
y The CardntoantMoiYAr ojM4iSWhr Sdb
' Dcpad7dnutt ojbtafidaMd Aaldatts
Offla 01blusdowdow
6"woah ns"Smoot
BoSM4 Mr! 02111
tetvtttaNUSOWAO
WorkeW CompeMdon Inaarance ABWavit: BWMenlContrndors ecft1dan Mk=ben
AppHeant Intormsntioa Piaae Print Lesibly "
Name 1 �5' ,l �l Qd1� Cam
Addrm- 3t
CityMa%7* an 16 PhOne*: q7S- I33 3�
Are you an emIgjM clines tbtapproprtate hosts' Type of
Prelect&qldreo
1 ] I am a emplcya wits 6. p New oonra m
employes(w and/or Fiamb ow bxn bleed f so&Ciotadm
2.❑ 1 am a sole, I it - air parma• Bstad oo dw attached d o&t 7. ❑ Remodel
ship and Bove no employes These anD-aoehaqun bm E. p Demolidos
waddW less me is xW Capacity. 's',a®P' .ttt 9. (� addition
(No we&=,GOT*hwumee . 5. ❑ we sic i du aeQ its •
1 ap
of$oe4���dei� ElectrWrepaira or additions
3.0Iamabomeownr.doftsowalk ribbtof �betlll( 11.0P1®bbilupsuaatadditions
mysex Rb wakW-Comp a 152,41( ao� '`lisve'ito
12.Q Roofrepairs
msoraoonsequired�t' "•r 13.0 Other
t$00.OMOfr�.amftad.a�vit�}�p dob��wt O74 a101 Itf:►meidr Coge�dolruWY aa�mit•ofw�drvlt mesh
Tema.eta.auel.eb+Wbua,msrdra.e.dd�aed.he�tAn.�q�.e.nrsrtar.saa acn.atb.rwOdb *non,tdbi
MMMM
Iearelrearploywtbefbp trerdns�eoaspssrraYlesbsswwteijermyaafyfiyift adewktupofkyewdjobson
In mmee CompaoyNama
Policy 0 or Self-im Lia 8: Exphadon Date. l Ip
Job site Address:_l cy Q,( LL ' City :
Adtach a copy of the workwe compensation pofky declaration psW bhowb g the ponq somber ant eapiratloa dose}
Pat7me b scram wvaW as required®des Section 21A ofMOL a 152 cm lead b the jModdos oferio"penalties of a
fiao up b SI,S00.00 and/or one-ycw hWb mneot,owed a dvil penalties io tiro farm of a STOP WORK ORDER and a tine
of up b$250.00 a dry against the vioWw. Be advised that a Dopy of this statement may be faswa ded b the Office of
Iavadpaons of the DIA for in uanee wvende wrificados.
I As bwrby"Fdp aae'errbe prbu eadpanNar ojper/wy Am&j 6rjonaeden provllyd b ave eas'averees
d/0
Pbaae V -33 3
O,oJelel sre ow4t De ad arEU b+tbb ens,1.be eowPldt/bl elp arbaw ejJleld
City or Towns Pen mk/Ilceose
fawlsg Andwity(drde one):
1.Board of Health 2.Budding Department 3.City/rows Clerk 4.Electriesi Jnspedor i Plumbing Inspector
6.other
Contad?emu: Phone A
a
Information and Instructions
e. .
defileda ► �° 41
�p , a air any oo of�rar
Mew of impliod.Dal 09 Winen
defined as"an isdlvidual.parmas w
amoda"enlpm doa dr aha legal entity.or any two or moue
As�,h aed isehdiog the lepl rtyraem�Qf a doopted a fur
of dw to�IDL is a joi6tenoaprde. a>roda. a other l*d caft enVIWM®ploye� q As
.
owner f and who WON umi%or the o���'�'
dweninabouseuving cot coon than throe a 17— aonanC=er repair WO*on aach dweMS home
damhose of tmotber wm,,,mp>�P P�� fa06 employ�bc decand in be an emP1o)^et:»
Cr o&the g�arbu11ft A-1
otbecoun
MGL drapes l52,12SC(6)alan ahtn"'"'T o"or toed seadq ageaey shd wWdm"the Nwaaoe or
raw"of a BM widow or permit to°Perm a�'ar to coaatred bGWbV la the eommonradh for M
*a the Wsrasa eeveraP ro9 »
appeoset who hm ad prodwoed WePtoM m' a deO m afire shall
Additi O&W'MaL dwptW I=4�(�tea"Neber the oontmonswalm�otaomp>ianca wig&a
eater im nay ti0s the pafotman°e ofpnblie wog}taltil aaeptabla
of thisch*terhsvebeapmawltoAppReSSIS
thsaootr#�K, »
the Imes em VpV loyattr dMatton ank if
am mac='eompenn m stidsvk c=Wkte�4 by with their catiAeatds)of
please necelmy,MVP
, ... mb.00nesclor(a)ndW O addtaa( it d L p>M n utunbi (L win no employees other then the
hdwd� Cubit compai a I1.0 or LIB don have
as ladmalal
.. raNited d
mtalbera partaefl.are lie advised diet this sf6dapitnmY saboat0ed b the Department
erspbyaa.s policy it M&Madozoed Aho b0,fM to dP and date the afndavM. Tha at9ldsv/t should
of inemance coveragebdogmFeStA of
be r d AeddcfA b the that�e application for dw per a din You=��io obtain s warkets'
in ..W—Aadean. Should you�'ay 4�z Self mind'aompani d W enter dwir
cOmpmid=p°6*plena aaR the at the nmabea*Od
� goraae comber os the dins
Cl4 or Twa OMdad
please be Bare that dw sodavk il complete and printed k&br. The Depucme°t has provided a space at the bottom
ticanc
of the&Mdsvk for you to®out in tier went dw O®a of lavcsdpd m baa to contact you f> dw�pl�
anmber wbkh w�be used as a reference umber.
Pletne b t sun to fill is the
p gcad m is any Liven year,need�,mymq one atHdsvit indicating current
sat►mk (if
D 'e write"ail local m is (cfty m
po if sewsary)asd nada"Job Site Aldred'the appticart aboold
be to�
iaformaCos( a town cosy provided
»A Copy otthe s>bdsvit that her bw of > �►L -A- a�d'vii�ltbe Mud not each
appucant as ptaof thsl s valid affidavit 1 on Nb a Seem AIMS I> cot rdased to any bushm or eommcWial veamre
year.Where a home avant In bins teavea �p is NOT m►°ued so mmica this atBdavk
(L&a dog Name or pco*
The Oda otInvndpti°m woaM ac Intbaok you in advance far your woperauoa and should you bave any quesdom,
please do not het We to give as a ca9.
The Department's address.tekphom and fens v=ber:
The Commonwealth of Massachusetts
DeparWWd of IndustrialAccideota
office of Invedigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-03 www.mass.gov/dia