5 RIVERBANK RD - BUILDING INSPECTION fL11418106T-BE fILf"AG APPROVED BY T44E
m3pFtrn PP"TD A.PEB VT f3F.INf s GRANTED
CI
TY OF SALEM
is Properly Located In ✓ Location of
tc
a I*mWa OWrkx? Yas_No laildiaa
Is Pmpany LOOM"in /
9 tow owwrnaon Ma? Yes V No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
ReWiReplace. Other-
PLEASE RL L OUT LEGIBLY i 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 . /� / t `�—
Address A Phone g yc� ✓£n �� �`� ( t
Architect's Name -
Address & Phone f
Mechanics Name
Address 6 Phone 1
WhO 1s ar purpose 01 twYdrq?
m"m a t A*Q? Iv 0v n a dw Wq,br raw many families?
61
wtr bA&V ocnfomp to taw? L1�S Asbestos? W cL
EWWAd coat//Z) � MY ltWW a IJ A U:oZA]pp6*ctm=t
e G
Yoae Improvement
Lfit.
e f
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO; /
No.
APPLICATION FOR
PER/IIII T TO y F6 L/
LOCATION Q /J
PERMIT GRANTED
AP�FD
INSPECTOR OF BUILDINGS _
• 1
The COaratteat eel"*IM4wohU$dIs
Dept 01IadtrOW Aeddeso
C,dlat 6/7hrrut+r km
6"WasWXSIowSbWd
Besteat J" W11
wtt�aargsjrtt!Ri
Workers'Compensadon Insurance AfiMn t BaOdcM Contndon/Eledr cjS=Mh=ben
ApipMemd h6 matto>• Man?"
Name
Addmst:
pia-Lcv_t ... VGA : PSme�lk g7& - zc/ clz- 7G 0--r -. .
'1"Grp*"*"Wra*
1.❑ I an a emr and i
fcmpwleal(so xOd/mpai-dimele bsYe* d tss 1b,lighwax 6. ❑New aaalabteoTob
Z U I am s sole p m psma6 Hemel an tbs amebed meat= 7• ❑R®ode fen
nhip and bsys no eawl ea 7bae mb-aostraemaa bays 1. ❑DemoOn
wodity,fans is rapt cW*bmance.
ftilft
(No wad issmsnca . 3. ❑w6 aro i ao+Da :'md�' • 9' ❑ ad Mon
ngs6ei r_� ogfDa�lime 1&0 Eloc0feal repa&s or addMoss
3.0Imabomeowser doing as.wet of a NM* 11.0P mblejrepaiscraddhions
myself(Na WO&W otm¢ a 15$�1( sei�
ar1Yehsveiq 12 p��
k rephe"t, emplepeai•vW . 13.0 Omer
am*UNIOno4
fMYappseNs.d mcbfacednweAn®apt q@aKtlo.tslorda,MeaOr4.wf�r��aoayolioYtaawasMlar
lta�awc dabbYame amiea.+�sa7 AmdwwbsSemn "min...a;ay.sr..amie..r..taa.at�.oca
tCarneatia area.et AYtiai'��ra.a mamma k .3rt dawl�s..m0(sr ..rarrwo�ra'oeap pogoY 6db,�
y o qi?wpbymdYer bpvmwb�r wwdna�e�wa ba�bpl�s4�fK�•Ddwrbdr/�j.aa�Joi.sbla
Isaesnee CosgmyName; v�vL✓�Lu�+-if /�'[ U�U,o��._ �„s ern-��— . �e9
Foley s as Sdf-*Lice th /?v /P Eapi oa Data
JobSiaA4dn= 3P-Lcl-
Attach a copy of do wo&W eompaatlon po ft decisratlea pap Ohowfol the poda asmim and apirWan date}
Fat7me toneatre oov'x*s r P gn"ed trader Section 25A of MGL 0. 132 en lad b me itwoefdos ofafmind penalties of s
fine up to i1,J00.00 asd/ar onsyesr fi*ixnmeat,as weB ss dva pmWe in me ftm of s S'Ip WORK ORDER and a tins
ofup to S250.00 a dry against ms viobnoL Be advised mat a copy ofdtb smcmast nary be ftwarded b ms OfSW of
Isvesdgaaons of me DU far fiwaace oovarap vai>icWn
I Ap FW rvhy at*undw At pebw ard &Wof rAa►uFa bfivatadoaorovllr/ tr/rsr arr ea7t
Phone iw
O,Ofeld au onbt Di rot avdtt lw rAb ens,li dr roaylet�/bj rb,aispwtp iolefai
City or Town 2ermMieease 0
Inning Authority(cirde ones
1.Board of lieafth L Building Department S.City/rows Clot LOther l IDretrleai Ia,peetor S Plumbing Inspector
Contact lersom place h
Information and Instructions
Sting,: .,. ...: .... foe their anPIOYOSa Lam :
w is an >r myaootradciLie4
ageacbmsew an
dyed,oral USGUS or wdmes.» eati4ti�„y�p oe moh
as"as�fvidoal.parmmbip modado�oapaatioaar o decant CWW^or ti+°
d�� eapptr b a�i.teomPr>K � entpioYtrg emPbY°eL 14?
�,Q ar umtea alas ia&'&A Pam ► ad who non&act%or the ot�ot'a
ywaer of a dwcftbm"wing Mtn e the th[ae r�em� m ar* °R meh dwe0hri�
baaeohootba!Wen4b� raehOMoff" � tibeaemPbYas
ar as the g one&orboildwt abA wahhoY the Ion""or
• ar tool�tttptsef
MGL chaPas l5Z 4�6)go S .T07 St a e a eoaatrnd ban4s0 In theaos�far as
rsewai d a lleeaaa ar POOR"IF MA Idasmpgasea wlfi W httsrases taenrap r�trlesd. ahati
iAgj�py,bdi tl.Chwe. a pwm w a."Nebbar the Zwoowan IBM new di�w�me` i�asaea
elm into arty aoango fbt the paw°t ti the eaptacfiai.satAosRlen»rdeet a dasP
terkenmsof dh WptQbavabaapraented
cbwft theboua>bat asp*b�aibados�'if
ant the worlcaa• atljd"° n�(f)along**a their arNfit'�asda)of
Pkare till :.. 40> #lb (Li p)with no es�Y°a COW Wa me
soces y,�b OrLb"tiab� ISCOb�
botsea Lhn bd LiabiNbr to arw ionranaa Its Il-C ar LLP door have
membem ar passes,an not rogoit d maybe mbu**d b&a DePartmen d btdatt9rial
eaoptayea.a POW s sa4a� Be advtaed . rip ad date W atddav& The af8dsvit ab old
Aacd�s eau of i�anea W"ff"s ar lteeasa is being regaated. the D
be rear:a 0 ma CY of W"'a that>be appNados sa>be P�a im ar ifyoa are regased b abda a '
d�actdeas.. °fir o b s the mother lf�bebw SCUM red'C.PoPaing ab0°ld Oda weir
>trmdteraa>b° this
pq or Tows OMdaY a pace at the bosom
pleas be Sate that the SWevs it compleb a�pritued legibly. The u hameaz °d �
Of the affidavit far Yon 0®out to the event the Office of Inveatigadom base>n contact Yon an appliad
pieare be srue s®in then pami<Itleeme numbs wblrh avt'fi be n ye s are only�- affidarit mdicat�natal#
appNeadom is any given Yar need only
that moat s°btmit n ifiw P the M a tcwa IncaSay io provided to the
mSormattos(if n16 WO )and nada Jab Site Addrea"the.W& ab°°Id�e w�loadom to ( a
��"AooVYOffsailld"Wthasbeenoflciftaaa�OL� Anewa�davi>�tbeslfodoateach
Vv�s Pinang n a valid affidavit it b fits far�D mk�al0d.to sY b�ar eo®aeial va mn
it absitdag
y� where a home owner ac dthrra is NOT n4aaed a caopbaa thin affidavit
(La.a dog Name er rog a ban lava es.)raid Petas
TheOffioa ottaratigtsiona would&O to thaot you is advance far your coopaadon and shontd you have MY quatiotnti
plate do trot bedtttb>D give a a Ball
13e pep�ent'r addteaa,tekpbo w and fee n®Der
The Commonwealth of Massachusetts
DVa"cat of Industrial Accidents
Offin ofIaveWpdow
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 Of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-03 www.mm.gov/dla
CITY OR SALTM MASSACHUStTT=
PUBUC PROPKRTY OtPARTUENT
120 V1fAfMING1pM OMKaT. ate /L"a
9"610. MA44M MUSaTM 01070
Tt�t►MOMtt e70-71e-e6ee MM. 200
/Att /78.71&6"4
In accordance with the provisions of MQ,c40 3 34. a condition of your
Hm7dinS p+ ra t is that the deWs restildn` ff0m this wO*shall be disposed
Of in a propedy licensed solid waste'disposal facility a$ defined by MOL
Chapter IM 91 50 A.
The debris will be disposed of in:
v (L acatioa of Fumq)
3i of Applicant