14 RUSSELL DR - BUILDING INSPECTION -K 'i9HiSreEfiw9- N� APPROVED BY T*IE
cpT Pp}3 '1p PEAI11Wi�T.59WG GRANTED
CITY OF SALEM
—ZO U e` �s�.
No. Dater
Is Property Located In Location of F�/��`���
the Historic District? Yes_No_ Building `�7 l M
Is Property Located in
the Conservation Area? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo Reroof Install Siding, onstruct Deck, Shed, Pool,
Repair eplace, Ot er:
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specificationsr
:: 0 woo 4
Owner's Name
u� 9s 9/ ) 932--92�Address & Phon
Architect's Name /�/t or� s
Address & Phoney ,/m✓�r���� / j ams a�9`/9 Ko'
Mechanics Name I"d
Address & Phone! a�/
What is the purpose off uIlding? ��,,�pp �
Material of building? /,(�/ wffi/ IIf a dwelling, for how many families?
Will building conform to,law,?, Asbestos?
Estimated cost 0/ t 7 mil/ City Ucerue# N P' State cense# .
190 Home Imp ant
Lic. i
Zq ignature of Applicant 7 4�
b SIGNED UNDER THE PENALTY
C'��7�- b ��z ,QS��IboIOF PERJURY
DESCRIPTION OF WORK TO BE DONE )
MAIL PERMIT TO: � D �
f�
No.�1- Load
APPLICATION FOR
PERMIT TO
LOCATLON
PERMIT GRANTED
APPR FD
INSPEGT9R OF BUILDI GS
�o ,.. . OF SALEM,, MASSACHU5Er
PUBLIC PROPERTY DEPARTMENT
g ® 120 WASHINGTON STREET, 3RD FLOOR
y SALEM, MA O1970
-s TEL. (978)745-9595 EXT. 380
�qmr� FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of,}��GL c 40, S34,I aclmowledge that as a condition
of Building Permit# L1E�-2°'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 de 's will be disposedof at: /�/O/i r�
ellLocation Location of Facility
r/ 6f�6� 3
Signa f Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
°a7,ro
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 cIR, S150A, and the building permits or licenses are to
indicate the location of the facility.
fo Are /r rrmonwr.a o aeeachtcsefl`,
s 1Jeperfmanl a/9,�r:,�.�f�a��.n�
James J.Climates ))talon, ///assse".1b 02111
Corrmrsswiv
Workers' Compensation Insurance Affidavit
ze
with.a principal place of business at:
. 1ck7/aute/tb) y
do hereby certify under the pains and penalties of perjury, that:
0 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I undrrarana that a con of this i,,trment will bt ionearded to the Offce of Imesoravons of the DIA for eoverate verification and that haute to mwe
coveratt as reaurea under Section 2SA of MGL 152 can lead w the inoovtien of criminal oenatk$cOravdnt of a fine of sat W41.S00 GO andlor one
rears'6 Wwnrhrnt as viceu as civil"whit in the J r of a STOP WORK ORDER and a fire of $100.00 a an adwt tne.
edQQthis , � day o
c 0, �2f
rmittnsee/Pe Building De pen � I /3
Licensing Board
Seleecmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
Drivees License
-0o/e$ D B-0s1Yp 3 a NBei�phl Elaaa
WILLIAMS
MARK ,I a
0 CUFFORD 8T _
TAUNTON. MA
02780.2031
I e �
.'�T%•: ". /�. ter.
`�'3' •� ✓,<ie {,00vi�naruuea� o��/�aaGac«ucaelta I
II
A
;Board'%f Building Regulations and Standardsil
One Ashburton Place — Room 1301
Boston, Massachusetts 02108
t'T
Home, Improvement Contractor Registration. . I
_L-------=------------------------
Registrations 1.13458: Expirations 6/16/Ol I ��,g. a , Id � ;;;
I .
Type: Partnership,
NONE INPROVENENI CONTRACTOR
ReOislraties: 1131SA
Williams Brothers Home Improvemen 1 - _ Espinlion: 6/16/Ol
MARK WILLIAMS Type:) ParhersbiP
9 CLIFFORD ST '
TAUNTON MA 02780 Will ns Brothers Role Up
G� w NARK NILLIANS
ADMINISTRATOR 1 CIIFFORO ST
, � 1AtlNTON NA 021pr
CITY OF SALEM #1809 Driver's License
p LI;lFBff s -z a2 ILA .� 0 8119
BUILDING LICENSE
This is to cert4 That WILLIAMS
JOtN1K VIK.LIAKS JOHN B
45 GUBAI.A TERRACE 48 OUBA,A ToMME • rRs '-:
$}.,TAUNTON 'Mau" TAUNTON. MA
Has been granted a license by the Building Inspector as a 02780.1814 '
B AlIGPBUi.n�]
"odfA 1998 Building Inspector .
0
r
1'
JUN-27-2003 FRI 09:21 AM RUTKOWSKI & KESTENBAUM FAX NO. 508 991 5461 P. 03
IMPORTANT
If the cei bficate holder is an ADDI'rIONAL INSLJR D, the policy(ies) must be endorsed.A statement
on this ceiliicato does not confer rights to the certificate holder In lieu of such endorsement(s),
If SUBROGATION IS WAIM), subject to the terms and conditions of the policy, certain policies may
roqutre an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endersement(s).
DISCLAIMER
'i he Cei lificato of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer($), authorlged representative or producer, and the certificate holder, nor does it
affirnialively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
......._--