98 SWAMPSCOTT RD - BUILDING INSPECTION /)
l
pt*NS1 "T:gE FIL{-04mo APPROVED BY T+IE
�NSPFCIOH PSW TD.A.PERMIT BMG GRANTED
CITY OF SALEM
Date y`2y— 6P
No. al�12;7
Vi
is t
Property located in / Location of ( O
1a
to Histato MAW? Yen No_
Ituildfng Scuf1�A1�bZ�
is Ptoperty located in
IM Corwetva lon Area? Yw No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply Roof, eroof, Install Siding, Construct Deck, Shed, Pool,
r eplace, 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: j-6) aru �?kG.y -
Owner's Name
Address & Phon
Architect's Name
Address & Phone L-
Mechanics Name ��
Address & Phone b /�/2(J D F� L9 - s_ 7 �?
What is to purpose of twnng? 11.1 U
Meterkl of bulld ? '&1 —j a a&m*ft,for how many families?
wo bW"coiftrin to law? Asbeetos?
Ee num coat Ir5�, 00 CRY ucer"e N A Bata Lke� e
Home Improvement
Lic.
Si -ature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
S7 t eP oo r
MAIL PERMIT T0:
No. ✓� -O6
APPLICATION FOR
PERIIBT TO
LOCATION.
PERMIT GRANTED
�b 2.0
AP ROVFD
INSPECTOR OF BUILDINGS
ne ComeasonweeN ofMgssodntsetts
DeparbneW oflndus&WA=Ments
tf'ta ojlnNeltgteNs
600 Washtnatwa Sheet
Boston,MA U111
tvw>R,tressaott!Ofi
Worker'Compeosatton Insurance AtWavitt RuAden/Contradora/Elabidaas/Ptumben
AvAcm t Tabirma n Ptase Print Laidbly
Name �. L✓�
QQ ,
Address: o
«ty/S'tatelZiper%��. Phoaeil'
,.,
Any a ember!Cb"k ft`ipproprh to boss' TM ofp1*ed"vdMft
1. I:m a empbytr wilts 4: Q I am a geeeral counselor and I 6. []New
ooammedon
empbyees(mB smd/ar pasFtk4e}a Lavo Lked�e�eema�lon
2.❑ lama"! g 'j- or partner- Sodom the sturbed Sheet: �. ❑ RemoaeBng
a3ip and have m employes These mb-aoaft"have a. ❑ DemoliUoa
waddWlixtesis argF c+Paci4y "" i oe 9. Q Bo>biog additim
Rk�•�, S. ❑we ate s 'cod its' • 10❑Ftearieal sep�ies or additions
regnhed 1..1
ofBtas bsye then
3.❑ I amahomeownes.doiag apwmlr Hof « WM 11. ret� or additions
(1110 aF' 0. 15$ It(# aok�ehsve'no 12. sepaus
imasramoesequQeofyt. employees.mumanql., `, 13.❑ Omer
lump. �r
�Auyq,pUe�tdiacbecbbu/t=dWwfi.1* tdMwWwbdov�6wlpeAe4. a�a�tloapuLieY
t}loaM w;osut®tGh�d"bMcd*dnmdittitWWksudOftWQ eW tim submit cwwafflAntb6cotinasuck
tCmn�cem Mctdrekttbbca'mct dhr8cd��ddfliced cksW dnv(ea Ar�tdmlrc8co�cton sudtbii Mmkra'cosy,r�r intbtf+mtiaa.
rmrgieetploierA.Slip.ovl�it;x�osftos'eowpsasemforsbwrasiafiragetwlpfijlaNt lfoloiobmArpdiryardJofafa
all« jj
Imivanc a compmy NamPe (o
Policy N Of Selfrios.Lin Expiration Dace: 3 —
Job Site —
Ansch a copy of the workers'compeasodo■policy dedermiles page(stowing the policy number and expirsdon date)6
Far'hae to Secan o 3des Section 2SA of MGL c. 1S2 cam lad to de iegosidon ofaimmal penaltics of a
time cep so 91,500.00 amd/ef one-year®prieouU1em,it well a civil pcnwes in the fmm of s STOP WORK ORDER and a tine
ofup to$250.00 a day against the violmor. Be advised that a copy ofthis Statement may be forwarded b the Office of
Iavadptiora of die DIA for iou"m verification.
r/r Amby come m&rLU and pena&a o04*7 tbstrbt iafdrmolos p vW*d sUm Is aw mdc&veat
sinatm 4��
I ell
PhM* SAS 3
O&W rut M#6 Do eat wrlrt In Mr any to be eoavpkd by elpar&M gaitfdl
City or Towns Permmoesse 0
Issalag Authority(drde ones
1.Board of Health 2.Building Department 3.City/rows Clerk 4.Eketr icil Inspector k Plumbing Inspector
6.Other
Contact Person: none M•
Information and Instructions
tNaasachaaeds canal Lawn chaPxr 152 regnina an aglloyeti, > a r4 my theiro cofim
pmt�m min anbin, an�,�s desned�"...ewaypaa� _ '�
or implied,owl or writm e
°r
An mWeYdr>t defined as"an iodividmal.patoerahip.aaodatio>4 eorP°raB°a car°����®p�
t wed i•a jow eamrprise, a Horrev thr
receiver or trustee otata iadiwiduaL p >wocranon or other> entity, s 6acmt emPleyart ;.:
owner of a dwelling house having not mote dm throe apartmea and who raids therdn,or the o
dw&n horse of another who employs pawn to do maintetirote,conamaction a�wazk�such d�hoaen
or on the womb a bmta tapportmantihaeb shag orbeamae of arch cmpieymenebe detaned b be an emPloYa
MGL chapmr 152,125CM able statee that"ev"ride or loaf acndus ageme7 ahawfthbold ttlereamace or
renewal of a&AS" Pam owe s badrm or to terslrrd Omildls0
appac d who has rot prodnoed mC aWens of TMh the tam=m eoverap regrbl ed
Additionariy,hsca.chapter 152;4a a"Neiman the wmmoaweM nor say of ill poNti d sobdivblimms
Cow inb any connod f m the ofpublic wet soli!aoeepuble evidem of eamPfium wilh the imaranz a
re"kementsofthisdopur have been presentedb the=*acting> "
APp5camm srtodioa and.if
affidavit completely.by dwctbli tMbous that aPPly toYour
phrase gout the workers'Compensation wdh their catidcatds)of
necessary,s6pot mb.conoaclm(s)a =e(s),addeas(a)ace¢phone mumber(i)dent with no employes other then the
iasarance Limimd Liabr7i4Y Compasda NQ or LimiOed I.iahr6'bt lfan LLC or Lt P does have
are sot roquued to carry .
pOhey b requuod Be advised that affidavit to odgemoddatethemindmL 3 affidavit ahoold
Aocfdenls wutbmamoa of that 6 a coverage or Sceme it being ugmutad,mot the Departnsent of
be retuned to the chY or lawn the the application Scar the pamoR to obtain a workers'
,,,,alA,ddsss. M,,U you bave anY 4ma"> the blw Cr if you are ro9ased should eater their
poh'elq plgss caII the at do m mnber hW SeK innmed oompada
self-insmamco Hogue mmmber on dw g0°
pq or Two Oflidele
please be acre the de affidavit is cooVlem and printed le&lY. TM Depmancut liar provided a space at the bottom
of the affidavit for you to fill out in the event dw Office of Im+estigatbm has to contact you regardiet the appllead.
Please be am to bg in the pamiNicemae mmiber which will be used of a refame number. In addition,an applicant
1hd taut submit m *It P applications in any given year,need only submit one affidavit indicating current
pofy information(if necessary)and ender"Job Site Addrese"the applicant Amid,write"ail locations in (City or
tower A CoPY oftbe aedevit do hen bees officially soopd oEmarked by de city or town may be provided to the
applicant as prootthat s valid affidavit is oD ft for lhmre permits or hcasa A new affidawh nium f111ed out each
year.Where a home owner or ddm is obtaining a liaeme or
ermh not
b to ajrete�commas v CO-I
(i.a a dog ticeme a pewit to bum laves eta)said parom
The Of m of lavatigations would Min to dmk you in advance for you cooperation and should YOU have any gtadons,
Please do not bedlam b fjve or a call.
The Department's address,telephone and fix number:
The Commonwealth of Massachusetts
Dqu tnent of ladustrial Accidents
Office of EmvesdpHont
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwww.mass.gov/dia
CITY OR SALKM. MAsswcwuseTTs
PUBLIC PROP[RTY D[PARTMKNT
120 WASNINGTON STR[ST, 3R0 FLOOR
SALIM. MASSACNYtt1TS OI070
TULa►NONt: 973.74"SYS WM. 330
FAX: 979-740.9444
Saallm BUiI e0 De ►h++.nf
Mr h DlseesM 1ffm
In accordance with the provisions of MGL c40 S 54, 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.
Mw debris will be disposed of in:
___Itvc 7�Cy� (Location of F:of
)
Si Applicant
Date
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LOUR IN8llPAWN AMCY, :A�. YIOI II IQATi D00 N Cila IpO�M.
112 state Streat T�tNa aorl6Mal 0
Mte�APlO a
HOat= MA 02109- caAmYr G CQi�
617 227-1660 (_Z �'
IA. S. CARMS, »NC. *NE N RQ w INS COM9Al1Y i
30 ARROWHEAD PARK ROAD O I IMSiniANCE COMPWY
WXFORD
9?8 535-1396
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