2B STILLWELL DR - BUILDING INSPECTION ` -FL:*ItS1WST-9E f L+-�,AP4"ROVE:0 BY T+IE
J p TpA ,Pf A TP.A.PEMT.BEING GRANTED
CITY OF SALEMNOT
77
Date J 9—DCo
No. it e
\�YhINB CAS i
Is Property Located In Location of
the Historic District? Yes_,No Building
Uf.
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof eroof Install Siding, Construct Deck Shed, Pool,
Repair/Replace, her:
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
specifications:
Owner's Name
Address & Phone
Architect's Name NSA
Address & Phone
Mechanics Name IZo6 e+ .1 L e use
Address & Phone
What is the purpose of building? �` w
Material of building? ( l 9 v c , If a dwelling, for how many families? I
Will building conform to law? y eb Asbestos? N
Estimated cost b d0 l City License # N A Slate License #C b ( I 3 Z(°
Home Improvement Y
() Lip. ' n Signature o pplicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �au �a rrr'" 2 - •Si`i!(u'e !( 4)r-
1
i
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APPIROVtD
LH �'
INSPECTO OF BUILDINGS
k .
4
The Commonwealth of Mauchuseft .
Departnt v of IndustrIdAccidents
offlee of ltrviesdgadens
600 Washingtow Sired
Boston,MA 62111
wwwtatoscgox/dGr
Worken'Compensation Insurance Affidavit Bn;>ders/Contractors/Eledridans/Plumbers
AoDdcmd h6rmatioe Please Print Legibly
Name P.ober6 J_ ' L `l, eureux
Address:
Cny/Stau/z*p: �;;, ,, era o lq � Phone#
Are you in eri Cheek thr PPeePrhte boas'
Type of
1.❑ I am a m�with 4'. 01 am a general contractor and I 6. ❑Neeww construction
required):
employees(W and/or pamd"3010 ban hired the'aud aa eoeunel
2V I am a sole pmp:icon or partner- listed on the attached sheet i 7. ❑ Remodeling
ship and have no employees These sub-coatracton ban 8. ❑ Demolition
wori ft fa►ma in azw eipscity. War gip•ms!uanca 9. IdtlrWing addition
[No workaa'oonop,insurance s. ❑We ate a oorpo apoa and ib' lad Electrical reiW a or additions
regMW&I- ; ofliaia Kaye c,c their
3.❑ I am a bomeownat.doing all work rightof :`p M(3.- 11.Q Plumbing repairs(w addition
myself[No wotirers'.comp: c. 152, ji(d ao Webavenp 12.0Roofrepafif
insaranoeregnirouk)t: emPbyces LKowotltaa' 13ptOiliere /c res �a
comp.insurance iegoIIedr J"Z
*Any eppUcWandcbmbb=01modawfWw^*sctlmbelow dwir.w,l +e,npm.aospoftbinnndoa
t Homeowom ato submit�s�dwit iodieQioa me7!a+dome�A west eed�hJis`wWd�mgas�moR sa>ane•srw segdsvn odiedina sock
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Insurance CompaayNama
Policy#or Self-in.Lie.# Expiration Date:
Job Site Address: Cky/SmyMip:
Attach a copy of the workers'compensation policy deelandon page(skowhag the poney number and espiratiou date}
Failure to satire coverage as required under Section 25A of MGL c. 152 can lead to the imposition of amninai penalties of a
The up to$1,50o.00 and/or one-year hWrbGM0M%as well err civr7 penalties in the farm of a STOP WORK ORDER and a fine
of up to$250.0o a day against the violator. Be advised that a copy of this statement may be focwwded to the Office of
Investigations of the DIA far insurance coverage verification.
I do hereby meaederAe pence endpendda afperlery chat rho brfarewdoe provIArd above b&w and eorrem
Date k
Phone t 9 7 K- 7 S— G4(/.
O,oyefd we oelp Do no wrftr bs A&are,to be cowpferid by cAy orMW*jkjd
City or Town: PerInivueene M
Issuing Authority(drde one):
1.Board of Health L Building Department 3.Clty/I'owa Clerk 4.Metrical inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
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CITY OIr:SALEMI, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON BTREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
9TAML9V J. USOVICZ, in. TELEPHONE: 978-745-9993 EXT. 380
MAYOR FAX: 970-740-9844
Salem BuOJns!nMart en!
MdA D2MdZgM
In accordance with the provisions of MGL c40 S 549 a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
C �s I �,I,>La (Location of pacility) ��/ /-ice
Si
gnature Applicant
Date
1