77 PROCTOR ST - BUILDING INSPECTION (3) t
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DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED �\
Location of Building'1'1 vC�odCoc 3�.
Building Permit,Applicatioo For:
YCucle whichever applies) Roof, Remof, Install Sidin Construct Deck, Shed, Pool
Addition Alters �o ep�ir/Replace,Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGDBLY & 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:��: �.� �a\ y Contractofz'4�1-lj
Street Street-1-1 Qco�oc�.� Cite....
State Phone ( ) State. Phone()am)
Architect: — City of Salem LicIL_
Street City State LiclQ'---et�3a�a_HIP#
State Phone ( ) Homeowners Exempt Form_yes no
Structure: (please circle) Single Family, Multi Family Other
Estimated Cost of job S \ 0
Will building confirm to law!_ycs no \
Asbestos?_yes ✓ no
Description of work to be done:
ings Sub :_yes no Mail Permit to:
i d.
Si afore of Application, GNE UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO B COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Perm]C#\_\1 \ Zoning Map/Lot
T�� T
Permit fee S
COMMENTS:
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The Commonwealth of Massachusetts
Department of Industrial Accidents
y 600 Washington Street, f Floor
Boston,Mass 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
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city a-�� `''� _ _sttaz S zi t:A" m CC\�aFl -n�,NS`M phone Mat-R
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work%6y IMAh,IA(fill)Ad!]RV$1: �Cadree �.
( 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
am a sole ro rietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers'compensation for my employees working on this lob
tY tx,\ '' P i•ER+ ..Y aE y$ � : *�saatY -f:.
add
city ( 4 �`• aft♦a�•�( i�}.. 44ni:J�i�
sallies S.
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❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
eomnsey name'
address:
histo
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Company nonce:
address:
city.
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Failure to secure coverage as required under Section 25A of MGL 152 can[ad to the Imposition of criminal penalties of a Rue up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER soda Roe of S100.00 a day spiost me. 1 understand that s
copy of this statement may be forwarded to the Office of Investigation of the DIA for coverage vedtlratloa
l do hereby certify under th and penallln of perjury that Ike information provided above is true and correct
Signature Daze O
Print names \r. Phone
ah
uncial use only do not write in this area to be completed by city or town omelal
city or town: permiulicense a ❑Building Department
❑Llcenina Board
❑check it immediate response is required ❑Selectmen's Office
❑Hnitb Department
contact person: phone a; ❑Other
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM. MA 01970
TEL. (978)745-9595 EXT. 380
40 FAX (978) 740-9846
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
govened by this Building Permit shalt be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c R S 150A.
The debris will be disposed of at: TN6m�c C. <-A S� �
Location of Facility
Signature ofP t Applicant I Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applic
Firm Nahie,deny
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 cID, S 150A, and the building permits or licenses are to
indicate the location of the facility.