Loading...
54 RAYMOND RD - BUILDING INSPECTION (2) _ > Z' c . ., x2. r...:. . oz Kf :�s+%k .• CD T p : O 1,7 e1+t3ks r+1 ky ,� et t,�JdiS 'A cn Y;IVA" .`, h t,c�i l Ygtwn a1 r, k47d aflArlo+,i�^ret'ti;p°x,�yPSe�A'? r, l.�u���P.+ A3 i.1:k.' K+�'wrAFav t h�lkfle�'C �E @�CM1155,,��' ' �, r,y. �,, s � r�. y�•r�.tr ie� l� .te �k�iry ,,r,�a'. ! ' .. _w . .., _e..'�'�,3.. }r'6 _.,4,':+ �C i�i:i r .l L,F�: k, t. I;.;•Y_ : t 4W lsl n.e'fy gl,e 1, !::'7+. �,: :<.' ,Wt•k 'iA" •r.' _:: 1,..,.: �, .. ...: ! w: .. OP,'A` \p1't•stysC' �7P'_;a r ili5'.4,:.:• ate}'er :a ,. ea i:y;. - .r:�. ,C,p4S,.,t;E,P L;aCr•.ct 0. C,f":4`lir lly %�.41,1 U ' Yil cW r::b COO, 4 .:,.+,, Y " ne ,rnhA;1r.+ yk�'exiri.ns 17k .. + •:qr �fYQ+ ' ,17r7Mt4�:v^•l�? ... 1 !4X �ts�lr,.(49Koq.`' wpp��'° • pr ��.':: � �i� 'i�;.0 � si:'ia ti rii Y� � 6�����r�r to fir,;.t'�{ $,Y'�Y". ,�A DATE: Cftp DfarPm, a5�at�ju�EttS PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED n Location of Building � Building Permit,Applicatioo For: '(Circle whichever applies) Roof, Reroo( Install Sidin onstruct Deck, Shed, Pool Addition, Alteration, Repair/Replace,Foundation Only, Wrecking Other. t PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Buildings: The undersigned hereby applies foraa permit to build according to the following specifications: OwneriNameo p �soLbgt: Contractor: pl/1�}/{' (N l)4at'� �1lkl U�1LYHi� Street ��} City Street 4S f A.t/Ivr � City �i MMA51n State Phone ( ) State Phone(`791 (�32'80'f0 Architect: City of Salem Lick _ Street City State Lic# HIP# State Phone ( ) Homeowners Exempt Form__yes no Structure: (please cirel Sin le • y Multi Family# Other ©0 Estimated Cost of job S S Will building confirm to law'L yes no Loo Description of work to be done: Drawings Sec witted: es no Mail Permit to: X Sigoatulvof Application,SI NED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BEICOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE Department use only: Permit'# UZdning Map'Lot�_ Permit fee$ CON ENTS: ra vil CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MA O1970 TEL. (976)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 governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MGL c III, S150A.The debris will be disposed of at: 6W, Z- � (6 Pt-6 Q+-`� Location of Facility lk 4 , 6 , 0�- Si of Permit Applicaht D FULLY complete the following information: (PLEASE PRINT CLEARLY) 1 0 L C41 Name of Permit Applicant Who o �Q hffg � C Firm Name,if any. A. 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 cM S 150A, and the building permits or licenses are to indicate the location of the facility. 1F t'i M -- \ The Commonwealth of Massachusetts r� s Department of Industrial Accidents 011lea®►►nveSORRU s 600 Washington Street, 7th Floor Boston,Mass. 02111 Workers'Com ensatioo Insurance Affidavit: Building/Plumbing/Electrical Contractors name, � v address: �citv M Li o state: zip: �In^19 1 hoone# wo k si a location PoII ss • VV l (40 ❑,I am a homeowner performing all work myself. Project Type: ❑New Construction XRemodel 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition ;s ❑ I am an employer providing workers' compensation for my employees working on this job company K,,ws1rl' address: f .4 r .,g''5 .x i h a x city, vie + 'a^a y4»j„ l.nhonc6' t :sa3:.s^�rY+`w. 'it ���ke` . s C-9';•;..� ai,ay4 ��.��e,9 i 3,e �.�a �..vsd ,f '�'s^�n q�n �❑ 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: com an name: address: city phone j K insuran ?Po' „ t'Y3 +°,s�k+', °Ht' {T$ y k SV. roues , company name: �n address: ' * Y city: r phone,* insure : Failure to secure coverage as required under Section 25A of NCL 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 STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify u er the pa' s and na ties of perjury that the information provided above is true and corr Signature Date �•t/� / Q� Print name lie 1ZIrlN Phone# IYJL'�IO�2,—bO 40 Official use only do not write in this area to be completed by city or town official city or town: permit/license N ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone N; ❑Other fra'�+Id sw=1e9)