48 WARD ST - BUILDING INSPECTION fi lSitl0ST-gEf� -E r ,,',„PPROVEO BY T44E
IAISFf xL i I�1pA s D t? T aims. GRANTED
CITY OF'S 4`LEM
No. I ' Date 7' -03
Is Property Located In Location of //� ( ja/- S� /
the Historic District? Yes_No_ Building 7 UUU V
Is Property Located in
the Conservation Area? Yea_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Reroof, Install Siding, Construct Deck, Shed, Pool,
Repai 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: S//� C
Owner's Name (l yy -e C p L MG t!I (-e "4
Address & Phone / '/o ? S S4 e✓�? N)
Architect's Name
Address & Phone )
Mechanics Name r rz
Address & Phone /0 S um e - SQ lem ( 779) �V/76 - 7s
What Is the purpose of building? /
Material of building? \ If a dwelling, for how many families? 3
Will building cont to law? �\ Asbestos? �T
Jmat t City License# N A State License « 0R l 53 5
�ss L 6 Hose Imptovesent 22,& ZT z
Lie. a
Signature 6f Ap licant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE 1
/ Qsa�r r2 �4r�`;' 1 re olli/
brit%S w ere heede� /10 2ceve] f
�G�le/�Gll��1 4�d C/4✓h49P - '
MAIL PERMIT TO: (reo 1�r' ru Zo r zy /0 Su we r` ST,�
u
i.
No.
APPUCATION FOR
PERMIT TO
LOCATi
}
PERMIT GRANTED
"- 17 - do, 03
APPROGFD
INSPEOTO_ R OF B UILDINGS
k / �
m � �.ammonwt.aJ 0 aseackwei`is
5 �ePnrlmertl 0/9,�,Giaf..?«< :n�
600 ///atsrywyyalL.11on-3Ireef
too James J.Camooeil I , sachuaalfa 02111
Cwnmrssaxser
// Workers' Compensation Insurance Affidavit
Ir _ l7'20�fCc/ Zn�'7 /
(aeareseyer�inw)
with.a principal place of business at-
/
�Q S0,14vuer 7 et? ® �/Q
fcstrn 3fq
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Policy Number
I/ I am a sole proprietor and have no one working for me in any opacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
1 underuond wt a COPY of No statement will be is r aroed m the Office of Imesdgaoons of the DIA for coverage Yeri&adon and twl!mute to secure
coverage as ttvirm under Section 25A of MGL I S 2 can lead go the irwos,tioo of erirninas oennties corsatint of a fine of uo w41.5=00 anwor one
yeaR*imoroOm t as.5o as cw Penaldes in the form of a STOP WORK ORDER and a fie of S 100.00 am "
agt me.
Signed this .� d day of J ly d U3
Licensee/P rmittee Building Department
Licensing Board
Seleccmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375