66 WHALERS - BUILDING INSPECTION DATE: U6 07,E
Citp of drPl7i, a �aL�JU Etta
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
Build ingPermiV-,Application For: -
-(Circle whiehever�applies) Roof,Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildipgs:
The undersigned hereby-applies for a permit to build according to the following speeificati�ns:
k� -2 2�/
Ownerti Name: (qqQ�f�/L(l L,�. &L57-A Contractor: `r'v�i �4—S
Street� (p �/LiN-L (Citp �/� L Street-,;-.-)— CO-&-N Z riry
State 4 Phone ( ) State ?hone (gz
Architect: City of Salem Licq
Street Cily State Lic#bag f7 L HIP a
State Phone ( ) Homeowners Eumpt Form yes no
Structure: (please circle) Single FamiLul6:Fami1)y4 Other
Estimated Coat of job T 0Q
Will:building confirm 4o law?1 yes no
Asbe403? 7yes, no
Description'orwork�f bPedone:
Drawin Submitted: es no Mail Permit to:
���
"Si ature of ,pptio'#jion;,5,i�G >ED DER THE PENALTY OF PERJURY
CQNST,RUCTIQM���MII'L fiED'VPIT. SIX(OWONT>IS OF FERMIT 1S$ ED DATE
Department use,only., Pe*il•# ���'�Z4ning MspUt
Permit fee T
COMMENTS:
No. I!o G — Zip t
APPLICATION FOR
PERMIT TO
LOCATION
6,G
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
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600 .Lylwt Sind
James J.camlwei f>oslon, /ffassacLeaJ 02111
commrssnotw
Workers' Compensation insurance Affidavit
(a�rwr.er.in.e)
with.a principal place of business at:
tcsMsr+wslrs
\doo hereby certify under the pains and penalties of perjury, that:
PTA I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 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
() 1 am a homeowner performing all the work myself.
I unoerwna out a coon of this statement"-a be forwarded to the Office of invesdrauons of the DIA for coverage verification and test Give to wave
coverarr as fewred under Section 2SA of MGL 152 can lead w the imoosadon of criminal cenaties corsutint of a flint of to e041,500.00 snd/dr one
rean':norwnr e t as vivo as cm cenaldes in the form of a STOP WORK ORDER and a fine of S IOOAO a an arsinst me.
Signed this . day of Z2�
'Licensee/P�errnntee Building Department
Licensing Board
Seiectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375
{ OF SALEM. MASSACHUSETT5
v6 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
3
SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
�p FAX (978) 740-9846 .
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid waste
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: E) S
Location of Facility
3
P_j'9jjgaar=of Permit Applicant D
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ame of Permit Applicant
Firm Name,if any
Address, City &State
The above statute requires that debris from the demolition,renovation,rehab or other
ed in aproperly-licensed solid-waste disposal
o building or structure be disposed ,
alteration f g
facility as defined by MGL c1�, S 150A, and the building permits or licenses are to
indicate the location of the facility.