17 ROSLYN ST - BUILDING INSPECTION 1 4
`
What is the current use of the Building?
.Z 3 Ffl� t�l
l�r z If dwelling.how many units?�3
Material of Building? Asbestos? 7
Wig the Building Conform to law? Y�
Architects Name
Address and Phone
MeehanWa Name
Address and Phone S 1 17��
��n Supervisors License>Y t�s4� HIC Registration
Estimated Cost of Project Ste° Permit Fee Cak ulagon
Permit Fee S �' Estimated Cost X S7I411000 Residential
_ EstImSIOC
ICOstX11"4100000mmarclai
An Additional$5.00 is added as an
�— Administrative charge•
Make sure that all fields are properly and legibly written to avoid delays in processing
The undersigned does hereby apply for a Building permit to build to the above stated
specifications. Signed under penalty of perjury
Date o
a i
a
F. •3 a V ' y 3
—� —Crry-OFFS
PUBLIC PROPERTY
DEPARTMENT b
VA1O` 1301rrwurw- *!tn=•
&MMy•WAsUon:sk-1'M 01970
•tl•19-8-745-25 S•FAX 976740-9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANcv FOR ANY EXISTING
STRUCTURE OR BUILDI G
1.0 SITE INFORMATION
Location Name 7 R,DS i T. Buiwkw
Property Address:- N;.
�l•2rh /l. Dtv7t1
Properly Is boated In a:Conservation Aree YM Historic DWWd Y/N_A r
2.0 OWNERSHIP INFORMATION
2.i Owner of Land
Name: f`cn i
Address: j L"q CT. 1
Telephone -- i—k3 i -- S I
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIJNGnExisting
Addition
Renovation Number of Stories
Change in Use
Demolition Approximate year of Area per floor (30 construction or renovation
of existing building
Brief Description of Proposed Work-
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S)le
Mail Permit to: �/ �s �� /�,� a-F& b
QTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Tit 1711144S."m.IRA*w"40. tied
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Nantel A- -G- C�7`I.p C_ C_i
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Ci �— "1� Phcoe+w �78-7�ca—sr�c
Are you en..plialm Cheek the approprtass
I. lama employer with 4. Ir1 a s postal ooahaceor and I K
2.011 (lhu eedrar p O4bW}* ewe hind te. d. D N*w canes
popelamr or pwomw Hand m the attached sheet,t 1• ❑Remodeling
Ship and haw no mploym These M&COommeons have L D Dmoudott
Working fir me fe MW capacity. wakaa'COOP Z*FAWO &
Pb wodwof camp insurance S. D we m a aapondom ad it 9. D illinums addd0°
3.01 requhd. ofBcas hew ettateI theb 10.13 Eleetsied mpdm or additions
am a homeowner doing ail work chill of eaenpdes per um 11-13P11110311hIll mp d n or additions
myulL Pb workaan'Comp, a. 152,11(41 god we haw no I Roo[
iawoaaerequited•]f gym.INeworimm 13.E repaint
ins ]
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*Asr Applb�•dwi chub brain mall dw a on dons"tatse rleelytt.kwaA�'
tr.ro�eta.Aeea.ttOi adasra babrbs arrw e.bedl atir�.eieOarlan �rN.11i s,.rAs'
=ca+.��o.s.a.trre...r.rid..eru.rr.rYw+i.s...e.r�e.Ys...dou.atli.artra.�, itA�.rai..
°# "IrprerWnd~Awv.Co'ev"Indea fnm"acefmayamplaym ddetob tAe
pyeadJal slAl
h mm"Company Nam/. 7p iV.5-.
Policy Nor Sal4ing,tie.i !�L� (.431 357S 67090(v paadaa naa IrLI3 n7
lob Site Addraa / Sr ,v ST. S.o-1 � ce4
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Attack a copy of the w orkare'compewtion pogey declaroba pap(showing the Policy ember and erpk%dm date)6
Failure to score covenp as requited under Section 25A of UM a. 152 can Ind to the imposition of aimioal pet.ltia of a
o(u up
to 31
and/or onoyeat i dlpwdwnmez*-ga well as Civil penalties in the form ola STOP WORK ORDER sod a fine
of up to 5230.00 a day against the violator. Be advised that a copy of this statement msy be forwarded to the Office of
InvcsdPdons of the 01A far insurance covmp vaif(cuioL
Ida hereby eardh under tAe pmW and panardes 0/oed&7tAt tM/slorautlowOrorfld above is&""dew?"
oa-• S�Z� Coy
Phone At �7 7 f3 - 7'rzo- Sri
O,Qferd use onrp Do non write IN Alit are4 to be cowpkud by ey of mm o,Qfc/art
City or Towns Permlt/Lieew i
Issuing Authority(eirele oag):
1. Board of Heglth 2.Building Department 3.City
6. Other rrowl Clerk 4. Electricaldospector S.plumbing Inspector
Contact Perms;
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1781 39 f� ?6?2
NOV-) 0-06 11 .43AM F •A STEVENS44
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;�; Y..•..�.4e,.,'+'.A.}..•S•.a...�..wia •y.a vh{;3s�.�;t4"s�?.v►ai«t:�w?fi:i..•"►H7 i+tA+�;.M1+'�Z+�"y�t r''h`".5�n1 . a` 'Si a.».•
E A STEVENS CO INC j
389 MAIN ST BOX 188 j
MALDEN 14A 0 214 8 S E
iN3l1AED i A&F CONSTRUCTION COMPANY tHC
BOX 142
SALEM OA 01970
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♦Yw......<. d:} n•.1.a•J..�. r.,/..fij.... ,. , . .. �:� n..
lwwls is TO CjFgTiFY THAT THE POUCIES OF I?QUWCE USTSD BELON
INDICATED, NCTVVITMSTANDING ANY FIC-OVIFLUMIE;NT, TERM OR CONDII
CEATiFICATE MAY BE ISSUED OR MAY PENTAIN, 'fMS INSURANCE AFF
EXCLUSIONS AND CONDITIONS OF SUCS POLICI�. U NTS $MOM W
co tY�6 0� INSu�H 000CY NUM86A
1
GE,LRAL UAINVW 9906911
}x co MCRCuu.GENEML LIAMIN
CLA►iaas turAaE O=UR j
®WNEA'S L CONTRAMA'$ PROT
AU=G8iLE WAejuTY
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11 -20-06 02. 04Pm FromwA I G
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PRODUCER I THIS CERTI
i ONLY AND
Parents Ina Agency ino HOLDER* T1
94 hymn St, Ste 1 ALTER THE
Pea body, MA 01660
j
COMPANY 4
INSURED
Antonio Franca
53 W Canal
Salem, MA 01970
TH15 15 M GERTI Y THAT THE POLICIES Of INSURANCE LISTED
THE POLICY PERIOD INDICATED, NOT WITt'ISTANDING ANY Pft
OMMENT WITH RESPECT TO WMICH THIS CEIMPICATl2 AWAY 1
POLICIES 4E5CRIEEp HEREIN hS SU JECT'TO ALL THE TERMS,
♦ AW VA\eM l��ALd AtT-... .wr... ,r_, a. ... r- - .- .—
�.� CITY OF SALEM
�= s
PUBLIC PROPRERTY
DEPARTMENT
\1%y ol, 12C CO.\il ll\(,i ON S KEET•SAL7\1,MASSACHI SL rr5 v 197�
To,978.745-)595 *F-ax:978.74G9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # __ _ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 1.50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
._J3 F -- __P
(name of facility)
l adurei� �)f CaeilAy)
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