77 WEBB ST - BUILDING INSPECTION s
iVl*A1 JdWt-BE f4L£9•44N9 APPROVED BY T4IE
ASPE=pA pp" TD.A.PEAMIT BEING GRANTED
CITY OF SALEM
Date
is Property Located in iodation of p
Uw Historic District? Yes No,_ suiming R& J
Is Property located in
the conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, tract eck, Shed, Pool,
Re sidRe I ther:
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 1-3
Address & Phone 77 �—Gg3 711 j ) _71 —37 zs'
Architect's Name
Address & Phone (
Mechanics Name
Address & Phone
Wirt Is to paupose of bonding?
Mam"d buldng7 L oo l �lS1R ucY�� n a dwenng,for how many taindles?
WIN WkW Q cordorm to law? /C S Asbestos? ANY �rl
EsWlrted Cost 1 v,—'M °° City Licerr"s N P. state Liosrm N 65 O']137 z
//I/� /� ties Improvement —2
///J F V 6 I.ic. i I (-S'Z. X lic _ \j
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
vt�+(T 4Y Z
MAIL PERMIT TO: MP
No.
APPLICATION FOR
PERMIT TO
Cd}3rN4Z5
LOCATION
7-7 a-o-� 38 157-
PERMIT GRANTED
APPROVFD
�SpeCTOR OF BU INGS
The CoMrrtoarwed"0jM4iW 6UW is
DepmriisatM ojlndresfHeiAexide7ats
ss 06,Q?a h O
Bestoyt MA W11
tvWWmWAPWIIfd
Workers'Compensadon bminince AHM& tt: BddenIContndor MedridamMumben
Applicant Inf rmatton Plgae Pript LettiMv
Nam 1JPvjD 57
` I�eRcta h1�R:5tit:NYC �fL�iar�cl �
tjty&,fttV7* phone#., -7 91 - 7 r� 17634
Are yem s•em�a?Clam the ;appropriate bats' Type orprol«t o"111111reft
I.D I am a employer WA 4. (21 am a pmaai contractor and I 6. ❑New codnocdon
employes(� �P��),d have hied t5emhtiadaaaesota
Z I am a sole pso,aster or partner- lilted as the straried them t 7. ❑ Remodeft
ship and have no anployees These sub oantramrs have & ❑ DcumMoa
wakinsftmsimasioapeft. /'. y ❑Bm7dio<addmon
(No wotkea,comp.insurance S.
W e oosppt�lio�> mo Elegsial repass or additiamst
3.01 requhe&}homeowLmrdoiogaAwods roof MGL' 11.0Plombiosrepsusar;additlom
myselS(No wasted'comp a. 1s2,41.( 1.0 ire hage'iio 12.Q Roofrepaua
itsacaooeregstsahjt. ,: r 13.p Omer
;AnygwWAM&ddawimboaAt�dotipoodol blowdwriaa1We..vu •aoepmnamrftmro�w
t]t0®OMafa wtp ootmlt$1�oet�Vit sodko olo dokoa 44 wet and doer ttjr�'aoadda 000ai isw adjmlt a erne Fm balesting weh
rCmtnr ton dot Auk dds boa mod dhrbW a addilload eked rlowhe ft man Wo s6 oonumlon mHtri wodom'emP tdL7 futbrundaa.
I man sit'oaapbyerANtoprovtlbtd"rim eon'pessedoafasrrartafermrsm Aj+rtn BllowItmbepa&yanJfobsiar
lefwwsd mre.
boammw GonvmyNama
Policy#or Se1Ems.Lie.#: Expfratbn Date
Job Site Addsesa Cjty/g ;
Attach a espy of tho werkere eompemantlom poley dodaratloa papa(slwwhrd the Polley ammber grad espirades date).
FaAme to seam coveraSe ar required order Secdoa 25A ofMGL c. 152 can lead to the hpoaition ofai®al penalties of a
Bme up 10 S1-500.00 m (ff one-year fiuPisosment,s weD an civil pemldes in the foam of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised mat a copy of this statement may be forwarded to&a Office of
hsvesdgacons of the DIA for insurance overage ve iftadon.
I a flair eael� wider i ke pdbar sad psaahfa ofpar/ary A W AN Lefwmadod provided above aw and earrses
Simatue A -� Date `1 IZ f CMG
Phone#: t t a$
Offleld as*oalp Do adf wnbs he Asir area,to br evaWkeedby cAyo or odlyd
City err Tows: Perudmcem#
Issuing Authority(drde ones
1.Board of Heaitk 2.Bud4flug Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumabing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
r.aea ahapta 132 ngnicea all emPloyt4,� , *Ck of
Parts"is an is defi60d a"...wad Dom , DndEr airy
or bPN 4 mat of wraDe�"
amoch&%ampmatios fir otha legal a*,m Soy two or ttsoae
An is defiaad se"a°ioditridwal,partuasbiP, of s deceased Ggft*ear,or tba
of die forepins�Vga it a joisteataprise, iachsdiog the Lem a• ,q
meeiira or ttmsoe of as mdividaa%parmaz*ataoostim at other lepl eatitY.eRIVICI ti!<cnVb� � ,. .
owner of a dwelling house having not tissue the three apstmnmtr and who resides rep am.or Wast on such dwem*borne
�g home of mmba who empbys Mmu to do mamuaema,comttnctios m repair
or as the Wounds mbnt'Wtai aPpnteeaaot therm sbag as because of mesh employment be desmud a be an emPlaya•"
MG.chapter 152,123C(6)90 spa dat"every date or load mmuing agesay shag"tthbom the limas"or
resiewd of a LLeeaas or permit to operate a badness or to emmetr ed bad"in the eommosweaNh for any
atddttsee daompUasea with the lasansea eeseraYe n gdred
1 eo "Neither the ea ==wed¬ say ofitt pON"mbdivb g
ioas Sha
Additionally,
Sbr rho pafmmame ofpublio wet urdl acceptable evidence of cmVHa a w�the bsm=ce
ender rate ts th aatbmtV
requirements Of this dmapa*bavebt�eapresmmd qem
•
APPlicam" �aboxes that app1Y to your mmatios 24 if
Fkaee Sit M the workers'oowpemation affidava o milks*,by S with their aati9ate(a)of
necessary,supply wb coasrac $)aameol a dt"Kes)4; phone wapiba()sb>'s with zb eaiployea otter them me
inmrmee Lunt"Liabft ComPuiee(LLB)m Liasitnd Li*114V Partnership(�
members m psrtAcM ate not ragoirad to easy Vie•compensation meatemee` If em LLC Of LU does have
a poycy y squired Be advised that this affidavit may be submitted to the Departmaeat of tndOssdd
�dos of im nmx oovasge• Also bola m dp and date the affidnvlf. 1be affidavit ahoald
Departament of
be retuned to the cilY or tuera that the aPPNrAm Eor she permit m liceom b bei ate ng reequi d. oobet�a workers'
hsve any questions tegarda�g the law lo ifyea -brequited
Indnsntai Accdem. S�McaII�DepatSmeet at the tanmber fisted below. Salt-iwsmed companies should m'�er thdr
�penmtiospwfiey4Pkiet
mmmmism°a me lima
self-instmtemee fivate mtssT>a
CHy or Town Ofddal s
please be we drat the affiMsvit a°°°Qicte and printed legibly. The Depnanent bas pmvided a space at the bosom
of the affidavit Ex you to fill out in the event the Office of Investigations has tu contact YOU nW that she aPplicaat
number which will be nand err a reference comber. In addition,an aPP>
icad
please be sure tu ffi in the pamiNficeme citations in any given Year,wad only mbmie one affidavit imdicatmg usaemt
that west submit ma Ole p ee
lefOtmad o(if necessary)and under"Job Site Ad&eea"the applicant should write"all bcatfom is (City or
to�wa)"A aoPY tithe dWevit do ba beem officisibi ststaI i QE by the�5!m town may be ptovidod 1n the
appucmd ere proof that a v m afsdavk if on file far fismae pamstr m s ecuc . A sneer a®datrit meltbe filled om each
ear.where a borne owns m ddmea is obtaiming a Hems m puma not related to amY businw oroammercial venture
(La a dog&emc of permit to btu°lava der.)said pason is NOT ragahvd b oonV se this affidsv&
advance for our cooperation and should you bave any questions,
to thank m Y
The Qffia of tavtatigatswm would lilts you
please do not hesitate b rive us a caLL
The Daparmtces address,telephone and fa number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invati;adons
600 Washington Sf d
Boston,,MA 021I t
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALZNq MASSACHUSRTTS
PUBLIC PROPERTY DEPARTMENT
110 WAS141"G S6 ST1199y, 311Y FLOOR
SALIM. MASSACMUSCM 01970
Tn[PHOME: 978-745.9899 W. 380
FAX: 978-740-944S
Salem Bo_Iidim De rime
Debris Dis I a'�••••
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 M. S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of Applicaat
/-(
vL
Date
,Dd
i BOARD OF B��rBU`N REGULATIONS
se: CONSTRUCTION SUPERVISOR
mbe C� 071372
. !Lb
dete:. 10t16/1965ires''10/16 2007 Tr.no: 5002.0
icted. 1DA =�te,57 --dMA 019A5. y _
� Commissioner ���