77 SUMMER ST - BUILDING INSPECTION (2) OPWAMfA W1KfNANM D *AWROYED BY 1W
1 ` _ CITY OF SALEM
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B XUWIO PERLf11T APPLICATION POR:
Permit to.
(cUola Whit ~apply) Roof. Remof, InsW SWIM Ccnatrtrot 08*. Shed. Pool,
spaiNRsPisa, her:
PLEASE FILL.OUr LEGIBLY•OOYPLETELY TO AVOW DELAYS W PROMO
TO THE INSPECTOR OF BUILDING& '
The undsrs4nd herby applies for a paenit to buUd accorft.to fhe.lolln hq
icons. 1 -
O s Name T_Q tp lr Idd u2 n
Address a Phone `l 1 �st i V Y1 nu r 37� (Qr�f 7 ,:')o •-&7;)n
Architect's Nmw
Address a Phons (�'7A1 y�P�-300a
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Mechanics Name
Address A Phone j 1
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DESCRWTM OF WORK TO BE DONE
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MAIL PERMIT TO:.'-7-7 : U M fX Or
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Board or Bundim Regoladoas aed SMWUWds Liege or reesirrtien vaU for f dmm an oniy .
HONE NPROVEMENT CONTRACTOR before the expintim date; N fooad return to
Board of Bniidieg Rerdations and Standards
Registration: /27346 Oae Aspparton p1m Ran 1301 .
Expiration: lom/2004 Boston,me.02108
Type: DBA
DECKED OUT
Sr0T7 ROY
31 ASBURY AVE *l(e� -
HAMILTON,MA 01982 .4dminEn:ater Not valid without signature------------
_
"T BOARD OF TNU&Y/. G R-E.,G,,,U�.L,�wGcR�INpS
'.'. tJoenae. ,...COMSTRU� _ ..
�` Number'_C5, 025313 .
Bhtyi = 1..&7'..
. sr 1i -05@$f2 Tr.no. 22291
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SCOTTD ROY _
31ASBURYAVE
HAWLTON, MA 01 commhadmer
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The Commonwealth of Massachusetts
Department oflndustrfal Accidents
alkedhNnopffm
600 Washington Street, 70 Floor
Boston,Mass. 02111
Wworkers,Comse /Pinmbtng/Eleetrical Contractors
.err" iicah�l'`nfoilo5a. -'' '""R' �''itle�`se"`If,Y� 'lee�ilv�" ' "
name: Rn V p
aftrss,131city
( FYI state, m/r
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ERemodel
I am a sole propneinr and have no one wodniig m atiy capacity ❑Bmlding Addison
.�- -� _ �._ �.�___._"=-• -'=`_____.._ _ �. .tea
❑ I am an employer providing workers'compensation for my employees worldng on this job.
Company name:
address: -
phone#•` -
.vJ��.'�.�_2�.GSua:-Tvzv Rs"�_.�a•.lYs�`v�w?uv " •��t�tJ a_ s: ^ _yx a� �r+n_�t-�ai�„�� y.s:zd.��'1'"-.-.,:;5�<_ L.
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company.name: - -
address: -
ci Phone#• -
insurance co - - Pohev#
companyn,route• ..
address:
Phone#: '-
iusuranee co. oh If '-
.. ,ro. m .c'�acaxc 4 .'E;.,s _��`-�.Y..•s+ �,� t;.:F' ..x 7x+ t.s_ � �
Atmch aadaioeaeslirefifa essa_ra;•-���,;,,�'�_.a_..,�...��._., .....:.»:� .� —:•'�=-'---"- • -
Paaore to same coverage as required order Sectlon 25A of MGt.15,can had to the impmmon of u befoat p"Motes of a fine op to S1,5o0Aa and/or:
one years'hnprimnmmt a9 well me"peOdIt e:in the form of aSIOP WORK ORDRR and a one of$100.00 a day against me I nadera nd taut a
copy of this neboo mmay hefonrarded to the ofiee ofImestigatiom of the DIA for coverage verification.
I do h earebyoYlIfy and U ains p tallies of perjury that the information provided above is true and correct.
Signature Date
Print name Phone# 9 7���{[� - ____
Irr'
} official use oaf9 do mN write to this area to be completed Dy dry or town ofidaf 4;
permfNicrose# ❑Banding Department
S city or[own• ❑IScmMugBoord 3
❑Sdec�eo's Office
Si
p' ❑cheek itimmediate response is rrgnited ❑Health Department
r?d hoce#. Other FS
i; contact pemn. p
(miadspa Ten)
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DE D OUT�I� S��1
(978) 468-3002 '
www.deckedourdesigmcom QtnoVq Lto OO
TO
ADDRESS
TEL(H)
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DIMENSIONS S146j S /`7o QL;6 Arjorf FLOOR HEIGHT
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STEPS
MATERIALS S -
RAIL LATTICE
JOIST SEPTIC
DECKING SET BACKS
POST SIDING)
FOOTING, PERMIT w� W �RT
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PUBLIC PROPKIrry DEPARTMENT
120 vasmiNaTON ST"llff, Sep FLOOR
SALsM,MA Oi no
TaL.(970)7411-9595 Err.3so
FAX (Y78)7404 M"
STANLEYJ..YL%CVICZ. .Nt.
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MSPOSAL OF.DEM AFFIDAVIT
In scomdanoe wi&the paoviei=of UM c 4%334,I wlmowle*that as a 000mm
of Bml&g Pamtit#- -aD debris resulting ftm the cmmucbom activity
govamed by this Bmlft Pam*shall be disposed of in a propa fy Hemosed solid'wuw
disposal LcBi y,as defined by MM c ID.3130A.
The delmis wM be disposed of at
Location of Fad
d -- qJ luinq
ofPesmbAppiiaot Dab
QUTASB PRINT CLEARLY) mfosmatioo..
Name of Pe:mit App}iow
Fitm Nme,if
& Aahl[v Az N army Q Itrn,mA �l� g a
Addrook City&Stdo
The above smuts�that debris 5nm the damohti
�. rehab
. rmovatioM, or otbar
alteration of bmlding or sncdae be diaposad in a •licaosed solid-
1�Y waste disposal
faahty as defined by MQ.cffi,S130A,and the handbag P or ate to
indicate do location of the f ca i y.
'9g Blr30 80,52 S ] 50s 660 t4pr GOnM gmak i15500
OS
Commonwealth Engineering Associates
This eaniflcation on Ihia plan Is mask foMOnIssg�eg ropSSC5 Oey
'nic,undmoned will not be responsible
it this plan is uead for boundnrins,rgwo,Plantirsa,apwial parmita,vaa%it' 6 in o:NiKe6,a
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SUMMER STREET
Location S A L E M MA,
W Daic 9 R9 1999 _ _ $Gal0l1 loci,— FO____, ('RI
Deed and Plan Reference:
M 71 deed Bak B 514 s. , pd
yB 4'7 1. Plan gar 4 3�r Paljr; 16 B
Land CBun CeAifiesta�_,M�_ :: ..
Certification is hereby made io:
L0 39Vd _U0IddVW AGO8t13d L6ZOLL68L6 00:80 b00Z/9I/60
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