6 SOUTH ST - BUILDING INSPECTION 'PLIdt1S"WOE f L494AD AMMOVED BY TW
J UPECSL18;PWR TD A'PESWr BEwa mANI D
CITY OF SALEM
No. Wt� 6�
a OEM
Word
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ft CamwvmWn Am? Yak—No 5°k
Permit to: BUILDWO PERMIT APPLICATION POR:
(Circle whichever apply) Roof, Remof, Instal Siding, Construct Deck, Shed, Pool,
Repair/Replace. Odw.. Jr'; ciJ�h
PLEASE FILL OLfT LEWKY i COMPLETELY TO AVOID DELAYS W PAOCE88M
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accorcLig,to the following
speoHications:
Owner's Name
Address & Phone
Architect's Name
Address& Phone
Mechanics Name /fwi') a /c/
Address 6 Phone ,2 S /7 rs ti (9 7JI y.z 7— g/? e
What Is OM pupm a OuWW S,••vale-
Matrw a mrpw u'a v a dwwrq.for how nwryr wmmn?/
WE a+rarq axronn to low? -e 3 A*M n? O
t:MYnatsd cat o � � � ply ucatiM r 8hM llasrMs• 6 �/3 3 y/
So*ure of Applicant
SIONED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK.TO BE DONE
,,p 3
t • 1 x
i
MAIL PERMIT TO: /Pow
APPLICATION FOR
PTO
LOCATION
PERMIT GRANTED
19
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J7
INSPECTOR PF BUILDINGS.
t
l
The Commonwealth of Massachusetts
s Department of Industrial Accidents
OflICAO/I0Yi1��8tl00f
600 Washington Street, fh Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name:
address:
city state, zip: phone M
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole 3roprietor_and have no one working in any ca acity. ❑Building Addition
I am an employer provtdm$workers compensanon for my emQloyees working on thtslob
&� Or erg, a 7' rr xs
address: "d
city:
a d ;
wliv 'ay-,
❑ 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:
comoanv name:
address: 2 S i"'-,7
city: otione 0.
__F d
�O #
company namer" r}4
k.:. r, ?av Ahv :' v5e zy o-''t &yy3} :' 2 ,
address: > : r pr`r -tz, .. '` `a'. s ..,rx rr t 4e +x*`+
",v b
j a .:- s , .....;� ,__.. a _...3:•)...._.. '. .x,? t'r>x' ? �' Ts k° Y" S+` .es
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 S1,500.00 and/or
one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 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.
1 do hereby certify under the pales and penalties of perjury that the information provided above is true and correct
Signature i�J._..-C ./��c.iVti Date 1 /�/Ud
Print name Phone p 7,f— 219 7— i
official use only do not write in this area to be completed by city or town official
city or town: permil/license N ❑Building Department
ng
❑check if immediate response is required ❑ e me Board
❑seleiedmem's Office
[]Health Department
contact person: phone g; ❑Other
(mduJ ScP�lix91