40 SUMMIT AVE - BUILDING INSPECTION (6) VL-eMs M T� eE fiL{-B-#ND AfaPROVED BY T44E
MpECIDR jpWR TD.A.PERWT BEING GRANTED
CITY OF SALEM
No. �� ; Dale / �6
Is Property Located in Location of
the Historic Disldcl? Yes No z Handing Ld 5tIA'111 g-AV6-
c7�-1,6n� M'g
la Property located In
fM Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct De Shed, Pool,
Repair/Replace, Other:
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
Address & Phone f
Mechanics Name
Address & Phone f
What Is to purpose of building?
Mttedal of bulking? If a dwelling, for Prow many farnilles?
Wiq bdidng conform to law? Asbestos?
Edmated cod, ,fo City Licenses N P' State Li ff
Hane laproveinent
Lie. t
ature of Applicant'
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
1�0llSE '
MAIL PERMIT TO:_T /� ///✓1M� C S/��Cy - /�Ifi O/�7�
No. _L
APPLICATION FOR
PERLOT TO�
LOCATION.
PERMIT GRANTED
�130:I 20
A ROVED
INSPECT- OF BUILDINGS
, NTIre t,wruuoxwari�oj1l�ilsancitlseus
DgpardndW ofIn&s(r(dAocldaua
offlee0nad
600 wshitsili,e saran
Bos904 MA 02111
tvwtrt.ass�op!Bn _
Workers'Compensation Insurance AfNavitt DWHenlContradoreMedrkUnWPlambers
ADDHeant hftMatfda Please Print LeyMv
Name
Address: UM 441T
city S2 L-ate 27
Are you a. ClOet the ppeopriate bass' Type orprojeet OvIldreft
.
1.❑ I am a eesployer w.ig i. Q I am a senew Cmdraclor and I & ®New eonsttsedon
envicyees(w and/or part.time * here hires&o m10 F , he Peoea
2.01 am a soh:pntprietor or partner. Bead on dw attached diet 8 y. p Remodeling
ship sod have m employees Thee sub connelms bays s. ❑Dc=Hdon
waddwANvwi•aw eapecity. i'.�' ,ttuU=M 9•. addition
(No worker•comp•immranoe . S. Cl we aie i omppndoa red ib.
required}_ oe6ca.ri yre ae� sbeir 10 p Faecuical seas or aaditiow
3.p I am a bomeowner.dobrg aA work right of pelts( ' 11.0 Plumbing repairs car addidmu
myself[No vodwW.000ip a132,41(� ao� 'bsveao
12.QRoofrepa�ks � L
seq�it` 13.0 Other 10KC �
insaraooe empkryeeg(P[o' :�s�o�'. .
Cww-memanoe'
•Airy ggHe.0 o.�Laet.e.a r1 mos.to ap oYt4t• •each�ovloa m.irw�000pa M yuxoy mbimu(or
t Irmo.e.s.>!o alY.maaviera+ddes.q aaraad�a epiaa0id�co�l:Acnrilir aemlr..w.83awa ie�atiu�,.ch
rcmnes.A.t 3sateh�',00e rera.s a.adaic.d ieeu ieo.dq�r oaa.br�lra�3ao�parae�irwodoa'omp poH�ed'a�rtl.a.
leasgsewPblorJ�fbPro�rdwo�a+'�oarpwu�srbrawiarfiJirwpa�plils�t dilOrrbdYrprllgaslJoiafb
wourance CempanyNan e:
Policy N err Self-imp Lia i► Eq*adon Date:
Job Site Address ( y/g ;
Attach a copy of the worheM compeaaadon policy declaration pace okawft the policy s umim and eaphuion date}
Irasn=10 set sre oovaape as regnved under Section 23A of MGL a 152 can lead to the imposition ofaimbw penalties of a
he up to S 1,500.00 and/or one-year*riaoomem,as wed as eia penalties in Me form of a STOP WORK ORDER and a fine
ofup on$230.00 a dry against the vioiaw. Be advised t a s copy of this smcul t may be lbrwudad to the of&c of
brvcsdgadm of the DIA for hmwm coverage verifiradm.
a
Si�atmrt� ��Am*a brjorarrtlossOrovl4/eborr to ow and crrrecs
Date /�,7//la
0,oleld um a66 Do orf wdW b,Air vee,to be eowPMd by el&o►baw of jWd
City or Towns PermWi�eense><
Inning Authority(circle ose)s
1.Board of Health 2.Budding Department 3.Clty/rows Clerk 4.Eleebud inspector 3.Plumbing Inapeetor
dv Other
Contact Person: Phone N:
Information -and Instructions
amchnsM Genad Laws dopm s d &a a allo--aoplaplera,I
0
m mif:tsmte. as °ae6ndd>s _.evaJi Dom° _.
fbim
wan 0tbPH d'Old of~"n"-
oo<pomioa dr otba IWI CU*,of acid two or more
An ewptoYars defined as"fn indfvidtral. ms ken ducarad empbYe�a
ima' euaar ms
Jul 1doMave�...
dthe i eaOti✓� aa,odanon a otba 1ep1 eaatn empioYtus emPt°�
orv�ena i btvitg aaR tree ap�o and wed Derides macs.ot,be o
dwellsg hmae dMAff wbo employs p�o do mamtattnen,Maus dO or repay work en ouch dwelims hoaee
cr a the Woos&or balding apptu'60ca shad not beeaose dswi®ptoymaabe deeoW to be as amPloydr."
M(;L dwpoar 13$125C(6)ab o sma mat"WM state or 1"d 8emiq sl aq shag wkbbold the btmastes or
to operate a bwds ar to eombid bdWsp Isthe eommonwcd*for aq
renewal of a Near ar permiteedSeeeptab alder a d V46 the bowmen eovenp regadred."
aMdr�� no �m j "Nester me ®onwatib mr mY d34 polb(al mbd abed
aria into nay eontttd the pa�noe ofpnblie worst tmffi aae,ft evidence drwucpHx=wi&me insmm=
rdquaemenb of this dtapter baud ban prettented b ms�racdns,aa>aoritjr."
, Sabo=that app)y b Your sitimdm and,if
pkM$(Lout the worlrerf'aom�atin i d&c woq=O y by�f wish their cadddate(s)of
neon Y.aDPpV mb.cozUsclm(a)=M9(:s)'addsar(ea)aa¢pbo mupba(f)aloes wi&no emp*M odw than the
in>or> M' Limited Liabilky QnVntia(=or Limited I.;abr7ity Russ*(id.P)
mambaa or patinas,are not reguirod>o carry p°dam+'Op° �01'e00 If as I1.0 a Idp dtta have
>.
Be advised mat obit atti W#n aybe subn iced tome Depastmeat d Indoshrtal
amploYeda.a policy rag°II'Dd' P and date the af<idavit. 'Ibo affidavit shaatd
Aoddenb gtr�ytsoa of iasmtw a pt Alta bea!�'��aI iaapa or Hamis being mtpnated,ad to De Khnent of
be relnrned to me city fV 4 r se aPRHg*0 law or ifyoa am re4oaad to obms a worked'
parscaIIme atthemmrbet.*Oodbdow. Solt-imorad aboaldenroertheir
sel�ioearame>iume 6 mber on the 1}aa
taq dr Tows Ofedals
late ad panted legibly. The Depaftnm has provided a space at the bottom
please be stue mat me affidavit is comp
of me affidavit far You b®out in the event then Office of InvesdPtiom has m contact you �af�plicaat
please be we 10 fill in the pamMeate mamba wbkh wM be used ar a reference number. In additio 22 Wimting a>Rent
mat most submit 02*1e par> au app&sdcos in any given yea;mad only submit one affidavit
YO&Y simmatton(if necarary)and under"Job sits Address"the app8caat should writ or s my be
pov�to dw en
M"r A COPY due atddavk dabs bow officiftbr atu 4;�itedbx_. Y
appliod as psodeat a valid affidavit is on>gs for toe pamnb or lkema cider atfltlsvit udltbe t111ed out each
year.When a bome owner or cittmn is obbi ft a Ncabe at tmotqui mod rdaM4
y busi that om of aat®add Ventre
(i.e. a dog Name of pa ma th a b lava etc.)said prison NOT
Dito
The offim dtnvwtigatioua would I&c to tank you in advance far Youdoopaation and should you have any quationa,
please do not baitate to give us a cWL
The Department's address6 tolepbow and fa under.
The Commonwealth of Massachusetts
DepattUIVA of Industrial Accidents
Office of InvetOPtlons
600 Washington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OR SALBMq MASSACHUSETTS
r0
PUBLIC PROPERTY DEPARTMENT
120 WASNINOTON STREET. 3E0 RLOCO
SAO."' MASSACNUSWS 01970
fTANLEI/ J. USOy1C=, JR• TIMCPHONE: 978.745-939S 1CXT. 380
IrAroE FAX: 970-740-984f
Sallnl BIl�rllno i1.ne.a,.�_.
Debris Dl�el R......
In aCcorBuilding
pern with the provisions of MGL c40 S 54, a condition of your
ance
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 M, S 150 A.
4
The debris will be disposed of in:
/UZ (Location of Facility)
q/G-w Can�T/1��/pN
Signature of Applicant
Date