35 PUTNAM ST - BUILDING INSPECTION 1
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CITY OF SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, eroof, Instal SidMtQ, CwWW Deck, Shed, Pool.
Repair
PLEASE FILL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCE=W
TO THE INSPECTOR OF BUILDINGS: '
The ndprsipned hereby applies for a permit to build accor(ftto the.followinp
Owners Name ncz;S n
Address a Phone U,Wick S`1- 1_P-,�oJ ( y 7h 3 75--SMo
Architect's Name
Address a Phone ( 1
Mechanics Name
Address a Phase ( 1
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r� Signature of
SIGNED UNDER THEt PENALTY'
OF PERJURY
DESCRIPTION OF WORM BE DONE `
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MAIL PERMIT TO: b �;ye-7
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_ CITY OF SALEM9 MASSACHUSETTS
!� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
40 FAX (978) 740-9846
STANLEY J. LISOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge 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 1111, S150A.
The debris will be disposed of at: bale. 'Se/'Vi1PS bvo"f( S"d e
Location of Facility
114k' )4 ��I U5"
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
AJ401 71-V Aet-j-
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department of Industrial Accidents
- -_ - Office ofinvesugamens
600 Washington Street, 7 h Floor
Boston,Mass. 02111
ers'Compensation Insurance Affidavit: BuildinWIPlumbingMectrical Contractors
name' A�UULI
/ i,A,
address: JiWe,) �
RJ•
city prGody state zip'0 phone# G fp l --) US
i
work site location full address :
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
j I am an employer providing workers' compensation for my employees working on this lob
1 J Y' *3-r a wrTy7774
swan `//�� . � •,.. tf 1 1(1�f :r e"r.._:'r E ..'. a. r ..a ,t,..�a:au .-?us` wta .. %}-"'#
company name: /14,, � f� ,1
address.. f1P� f'["(/,'. ., y�* f:^yv=rs� t�,y..=5 r
}—/75 ;.
ciivt
/a1l7te L i,
insu ncCO. .' , lie #
ZZEEMEZEEZEN
❑ 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:
company name.
address: -
City: - phone# -�
insuranc o. x r - oli # +`
e
+ ,t
company name:
address:
city: Y phone# + ' ' t "To
insuranceeo. a.. �, r-r_ �` �` sic `# Kr,�•� .a . �ra' `%s .r` :'a „•, . ,
Failure to secure coverage as 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 fine ofS100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification.
I do hereby certify
uun . !/(��/•//�of a and�pennallttiie-s—o-f perjury that the information provided above is true and correct.
Signature �D"" Dale 7l lt (7��s/4
Print name / /�ll�"7 �� 77(" Phone# t Y_ve" �r �AT
official use only do not write in this area to be completed by city or town official
city or town: permit/license a ❑BARoard
[]Licensing❑check ifimmediate response is required ❑Se❑Hcontact person: phone#; ❑O
4t,lsnd Sep,.20031
`-� Boordf Bee'i o 2ing ego ati
- -- HOME IMPROVEMENT CONTRACTOR
01
Registration: 139797
- Expiration: 8/25/2005
Type: Partnership
TOP NOTCH BUILDERS
ADAM TRUFANTI {
2 CEDAR ST CT
SALEM,MA 01970 .r- Administrator
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