96 SWAMPSCOTT RD - BUILDING INSPECTION (9) -PL-* t1SsWST-BEfILE� APPROVED BY T44E
pNon TD.A.PFAMIT BEING GRANTED
CITY OF SALEM
, c— ��
No. / er/�d Date
pp
s . t a.
SwN c
Is Property Located in Location of C?43!-
the Historic District? Yes_,No_ Building VAi T �
is Property Located In
the CoraervaUon Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: ;R7f=T rns
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 --756/�-1 IzD sous �a�ivP
Address & Phone 7A -5 7ti J LA
Architect's Name
Address & Phone
Mechanics Name 201o7A5
Address & Phone ow ) S s` yogi
What is the purpose of building? 5 i d2FlyrF
Mal"of butiditg? :57Pe If a dwelling,for how teeny lamYles?
Will buildng conform to law? Asbestos? Aid
Estimated coat 0 /V,, yYS OD City Ucertee• N A state License� X «
0
/"RtL 1012/ Hara Inprovaent s /rM are-,
�o77D/A � ture of
yU a ss
SIGNED ODER THE PENALTY
o t9d 3 OF PERJURY
DESCRIPTION OF WORK TO BE DONE
('0UJTrU!'T eye room s
MAIL PERMIT TO: 7oto�-A:S An 7s Jo > ,B/rr 4 51 PA IM o/soA
No.
APPLICATION FOR
PERMIT TO
�a.✓s�cT ,{1,yrediegP,�FlT,eos�nr .
LOCATION.
9G s� A
PERMIT GRANTED
Ada
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APPRO 4D
w.f
I P _T9R OF B INGS
no CoaOuroSIvedth ofMa sechuseffs
Dep t oflndui&W AwMayfs
600 Wis6JhS&ed
Besfoay MA Mill
wwMtardas�ol✓Qi '
Workers'Compensadon buttranee A®daft BWMen/Contradors/Elec rkisim umbers
A
Name
. —Q�
A —A11,11
Addra s C�Jtv✓t
ettysaqp V?�,z1. .s phm* 77,P - ardy
Are you an , Cfeet tkd appropslade boa
1.❑ I am a empbya wish I am a penal easuaesor mill
employees(IA and/or parl•dm to havelti of Aa nkLeansssso s 6. ❑New ooaadaedoa
2.� I am a aok pmprL' or pa:ba6 tided as din smadsed r)tert t 7. Q ftemadellog
S*and Ise n0 empbyea Tice mb•convwm have S. ❑Demolidos
watift i v ms is any capeft oomP,•, ,ems 9. [�Bn�'Id10s addition
[No wod='cm ;6 mauaoee S. ❑ we are a
_ u9loar�syees dteir 10.0 F.Ixorieal repau0 or addidm
3. 1111111 11hMUMMLdoing 4 WO& tigbtof ' • etIM 11.Q Pb®bingnpairs or addition
myseh'.[Ns wad<els'.Comp a 132,�l( ai �eUve'iio 12.13 1t ofnyaus
iossraamsegsire�y: �PbYa+ (Na r 13.[3Omer
•, .ppnrasma�eo.rinosd ofi�wS4e' +�as•t. aoep..uo.0dierkamdW
1xomio�n..wtMahmkaY.mav0adioiM� aOdaa94We*adds1 aai�a.a�.�ir:ahmitan.. .rsa..rb�MI&
tCa�sawn mdaa3Ybcd'�mt rev8ed�.adBload dirt dovtq ar aiseraria�gou wew..rodbs•Sup yos.r
Idosdoiwpb tw 11pWF(AWS WW*vMP C#MVMW"&AVWX&jbr MW M~-NdbW if#4pd&,yd: dMSlat
tM
WMMW CampmyName %-
Polley N or Sdf-% .Lin.i. 3 6 3 -2 / Esphadon Date: 1- �3/ /-0 6
Job Ste Addrw 16/h ,Eia��CC 1 Y � 0°)l Chyftow7ip.
Attack a copy of the wortere convessa don poft declaration pap 6110wtry tie paBey number and cgAmtlon date}
Pa>2me to sectre ooveege ar n3quaed mda Secdon 23A of MOL a 152 can lead b me
fine ap b S1,50OAII and/or one-year impritoomen.,,as well as dh7 �d0s WORK Ol penalties of s
of up b S250.00 a dry against me violsew. Be advised dint a D is me tmm Iseof STOP WARY ORDER Sad a 9ne
InvadY+dons of sk DIA for imaraoce wvenge vaiAcsdon. otmi amemat may be lixavavded b me OtHce of
I r barby em&7 he On dal pexaMiss ofpa/a7 rAW t&1MfW=d don provldrd abbo/w AsAnd e rroca
Simatma Data
7 _ a a,
O,ofeldl ass odl� a eat wnUd b,rAb dnd,ti bd rodspleld bj cd�!.iarew o,Qfeld
City w Towns Pa simcenae N
Inning Autiority(cirde oat):
1.Board of Heald L Budding Department 3.Cllyfrown Clerk I.Eleetrkal Inspector S.Plumbing Inspector
Ober
Costal rertas: Phase M:
Information and instructions
a errs is defined a ftim
"n.pwm gP°OmR n�OW C0�"t O
at iDVH,es01 or writ es
a om JCV1 co of my two or MM
�domed as"a iadividoa�Pat4as�iR qua daeased amploye4 err�
How",d
reeeiva or tsatttea alas �p N mom a other aft®Pioy�employ" ar�i�'. .
owner of a dwc ag boom bavbK ant aatae that&aa apsommlt and who taida Mad%or�� s booze
dwe�boosa otamtha wm�p>�p&a of jay�be deaud to be a cmPU"
err M the 11>Ogm&orbtst'idM appmmesnt
MC;L cbaptw I32;42SQ6)she sum mat"every seats err tool lltetdt{■t[MY sW wlthithald the dnares or
aa or per
rea�awai of a lkemit b Opwate a bsdaas as,to eoadrad bafidlnO V Na oea'aaoaw*"fW UW
vst wb has west proms a "Neiman
atw IA 423C(7) mr ON"poftd shall
Zi mina as �'Ix 1he pace ofpublk wO*Md k w1�0 of aompxaaca wtm the imar�noe
���vofthis chWaffbavabeap"Od0dtoAllcmnc KAWwM''
_ ihebo:a that apply toyeor aitoaebn ao4,it
affidava omnple O
gamy mb-e s)►addrw(a)eu4 phone m�ba((!s)alb aim their eOmpluym odic that me
iasor WONSAN
I.imimd Liahfl*CMp+M(LLQ or I.imioed I.iabili4Y Puosa> �widt no employees
use not rega>:ad to 06�0ra°0° If atI1.0 a Llp does have
maubaa err patto4>ti hi advised mat min affidav#nW be submitmd b&e DMwUamt Indu of st d
��,�,a POWs e Ado b0 i dP date the a The affidavit should
of inanuee eovaapa
be r d 1D thaAocidI=IIfxw that&a application Ex the permit err HCeaaa f berm t requk a oob�a wo of
gbgald you have mY 4 °�the law or rt you are tegaised
Inds' at the nuttba#at dbduw. Self immed comDaaia should amen dm*
1��e7G 1!�eall the Depsrtmeat�
sel�iofm>tom lietasa oa the
Q4'or Tows Ofttdals
please he sore that the aHfdavit is ONVlcm and printed k&ly. The Department ball provided a space at the bottom of the affidavit for you to®out is dre event the office of Investigations has m contact you tVdmi the aPpmML
ntmiba
most submit DA*IG pamNIkewhich will be used as a refarnce mmba. In additio4 SIRaPp�
pkaw be sue m fill is m pamit&cm liratiam m yew,need only submit one affidavit indiwtiad caareut
that
��• .. . sad nndar"Jab Sits Addrees"the applicant sboald writs"all hoatbos es (sty Of
tuwn}"A M a '� has best ot�eial4i statnpoA o1> by a�7!a lows allay be lnovided to me
Ulfta
apphigot as paoof that a valid aMdtvk is of fik far A0me patmv a NeMM A nm busio i!n c veamre
yew.where a home awnar a eitim is obvmfag a hIame a permit not vdMd,to nary letsinaa
y to ban leaves eto.)said pasms is NOT ngaaed to oomplesa thin affidavit
(ill a dot Haase err p�
IU qfiloa otlavatigattom
would WM to thast you m advaaee far your coopaadon and should you have any guestiotM•
pkate do not ltesiWe 1D eve us a ca9.
The DepartmeoYs addrab mlephoae and fa tmmba:
The Commonwealth of Massachusetts
DgMIM d of Industrial Accidents
ova of favesdgadoas
600 Washington Sftd
Boston,MA 02111
Tel. #617-7274900 eat 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
• e
CITY OR SALKN9 MASSACHYSIgTTS
PUSUC PROPZRTY ONPARTMENT
120 W""'NG"" STI[[T, US, fume
SALEM, MAf"CNUSnn 0I970
TCL[►NONt2 $78•745-9996 SRR 200
RAXS S78-740-984S
3allm B1L�n�rLne.h..���
In
accordance with the visions of Pt'o MGL c40 3 5 4. . a co
Building Percent is that the debris resulting from this work shall befdisposed
Of iu a properly licensed solid waste disposal facility as defined by MQ,
Chapter M 3 150 A.
The debris will be disposed of in:
0RA 4111 P (Location of Facility)
3i o p ant
Date —4
192"
120,'." , 71;a
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95,e" 84r'
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All dimensions size designations given are 7/1�/'\���gyppJ�� This is an original design and must not be Designed:4/6/2006
subject to verification onjob site and TECHNOLOGIES NA released or copied unless applicable fee Printed: 5/2/2006
adjustment to fit job conditions. has been paid or job order placed.
Tobin Movers I All Drawing#: 1