15 1-2 WILLIAMS STREET - BPA-06-813 -Pu*"S11M tS K filf� APPROVED BY T44E
1J pECIDB PMOB TOA.PEFWT BEING GRANTED
CITY OF SALEM
Date
No.
s: A
Is Property Located In Location of
the Historic Dist
? Yas No sollAin6 J Y1 7
is Property Located In
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to: Install Siding, Construct Deck, Shed, Pool
(Circle whichever apply) Reroof,
�
e air/Replace, they.
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
Address & Phone
Architect's Name ---�
Address & Phone f
Mechanics Name7N0—
Address & Phone Nq�� v
�\ ��
I� What Is the purpose of building?
S
Materiel of brrYdng7 If a dweYing,for how many familes?
u2 �
WUI WON cordorm to law?
�� �S Asbestos?
Es#metad co o'PP� V(D City ucerrse o N A State 8
Home Iaprovesent
Lic. )nS�--1 Si ature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
lk- V\'A GAS ? ,
MAIL PERMIT TO:
No. PX -a6 " J
APPLICATION FOR ' �
PERMIT TO
� Sful�ne.cws -fn-Terrb✓ �p � 1
LOCATION
PERMIT GRANTED <
1,
20
AP PIk0 D .
INSPECTOR OF BUILDINGS
r
i
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
9TANLKY J. USOVICZ, JR. TELEPHONE: 978.745-9595 EXT. 380
MAYOR FAIL: 978-740-9846
Salem Building Department
Debris Disposal Form
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 facilityas defined
d b MGL
CY Cha
pter III
p , S 150A.
The debris will be disposed of in: /�
(Location of Fa �
c' ity) 67
Aahjre of Applicant
Date
DO ConuxoxwtaM of MatWhnsdb
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Worker'Compwadon Insurance AfWavit BulMeisContractorsMectridan0fumben
AppNewd hA=*tkAIh
Name
Are y"an
1.❑ I am a emp w sth Type Of prejed 0"��'0eeaai om6aebr and[ oomasedon
2.Xemploy "a(mB and/or paR•dme * bavo tried mraab�aealwabn 6 ❑New
I am a aolepwprieror or purls liffud on ae am"sheet s 7. ❑Remodeling
slip and Iwe no employed There sob.00uncom lave S. ❑Demofidn
wadi*tar me is as lapeci4h i'amp nnaaaooe� 9.. []Building addition
[NO worlud'comp,ins 5. 0w e are si ; 1Qnn i w' i4'
regsbed}_ often iii", 10.0 F.iee"repairs or additions
3.0 1amabomeowna.doingan.volt Ti*of r 10M. 11.Qplombintupasrsoradditions
mum[No wostes•.cosaIL e. 152,Il( lie i�Yebave`ao 12 Q lt6ofrepa5f
requbrsdjt` employees.P�Wqdxw
r 13.❑ Omer
•Ain�ppHc�ser dbebbox sit aces do50 oy4d4��AQWb$*.k..arr'aanggatloa yoiky m�im�ot
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b'/aaserloa
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Policy p or SetFim I is 0.
Expha&n Data-
Job sits Addseatti City/Staodlip
Attack a copy otthe workerd compensation po ft dedarad"page(dwwbq the pdLy number and expiration date).
pas7me to same coveraie at required unda Secdos 23A ofMGL c. 152 cas lead b as iooposidon ofaimmdpenalties ofs
fine up b$1,500.00 and/or onayear imprisonment,s wen u civ0 penaffia in the form of a STOP WORK ORDER and a Sue
ofup b$250.00 a dry apimt to vioWot Be advised sat a Copy of ats sMcment may bs Sarwardsd b as Office of
Investigations DIA for inssrence Coverage veriflpdos.
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enl ofpsr*7 Am tAre brferareafon p vvWd aw and correct
3 ofo
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O,afdd au o+Jlt Do sd rvrtfe!n 1bb eny b be eowpls/e/bl db aarwn oalrfd
City or Town permbucense 0
Issalsg Authority(circle ones
1.Board of liakk 2.Building Department 3.Cky/Ibwn Clerk 4.Eketrlea[InVedor S.!lambing Inspector
6 Omer
Contact person none
Information and Instructions
dawacbusm Geaaal Laws dWw 1S2 taquira"A F*V tavioe. ,�ao nag hir%
ibrmtant a mil statute, as b defined s
ISPOIS 01 bn HA Oat or wrocle
aao mpm*a fir o&aup,Cum or OW two or mots
An a�Ya it delawd a"ace isdividaal.P. adjubft tb legallWagetdva qfa deowad GDVb "0e tha
Of ors lbregoiatawc= or Omer lepl ce t�cnvIO mi�P1oY*a How"
raeiva a t�tea muse havi"ttat soots min tbraa sPartmau and ate
who resides&Cain.or dw ooapastof 2L4
owner of a dwefiirg =Mud=a repay wot#a sttcl dw ' b0°°e
dwedntg boor of another wbo emPb"pCaom lo do ma because. be daabd q be M empfoya."
cr oa ae Vows&or bm'1dt"VW1&aeq shall sotbecauce of sud employmat
abo states dW"every tttte or food dead"Clay tba�wkhYoli lttforSa of
MGL chapter 132,425C(6) to . ar is eottMnut bad�st0 V tbt eammoaw for aq
raewa ef a deew or perms ape wNb the lataraaa eovende reg��»
ate wba ban ast Vn&WW MWWM"Memo of mi►divbioas shad
AdditiooadY.WL eb*tw 15Z 125M)smw"Neimer&e Oomm=w�nor MW of Pow area mr the WIMuaa ofpubde wok mart am"table&Wcwe of eompHmce w&me imwamoe
eater into say col
requircumb of*b cbaPOe�have ban presorted q tba eostracdog.aod 4i"
mebous mat apply taYooz aitoaflon
Pkaeo fi,D;out me wodters'oompemWW affidavit completely,by cbeckleg
MMUNY' G) wi&their eati9catda)of
N"V s)name(:),address( )tu¢Pb0O0 Other ma&a
teawenm L C29asra 010 of"mited F.iabih'ly Pumasbipa(1 t•>h wi&m employ sea
�bCs or partoCa.ata sot regolred a CWW We*=-O0�afm ' If m ILC or I.i.Y does have
empioYea.a policy>a m4°a°d Tle adw�d d� p the a�davif. 1La a®davit sboold
Aaddenu for oaf of io areem eovesagts Oz license bei"regaated.sot the Dot of
be remraed q d city or tows mat appbcanon Sot o pemrit law ar ifyon are rogaite 1 q Obub a workers'
bWOMW'AaidcM SbWA you have say pwdoa dboald eater dm*
at mo'&orbs pd°d l Self-rotor
eompmssdapo>icyC Ply Oau ma Dept Use.
self-insotace liceate comber ou tbasoft
pq or TOwa Ofddds
please be sore mat dw affidavit is complete and printed 1c&1Y• 1U Deparu°em bas provi&4 a space at me bottom
of the affidavit Sot YOU,0 fig out in tha event the Office of lnveatiptions bat to wnuot you regarding me appHcant
please be sure q fM in me pern*j Kane member which w�71 be used as a reference : In additb4 current
moat submit ex*1e P�O�mP tim in any SWa Y��wed on1Y submit one affidavit c
poky infmmstion(if necasary)and under"Job site Address"the app&AM sbna write loadoaa W be p is q ck a
towel"Acopyot&e atfidavit dot baabwofficiaiq�ltCrrpodltL �od�-.A�.-affill itmoltbe9MAOute ch
yeP11�s pmom O a valid affidavit boa 81a Sorllceense�not Meted q any busiow Or cQutemc l veamre
ear.Whe+e s home owmr or cidaea b obtaiaiog fete tbb affidavit
(ice a dog finesse or Pa>mt to burn lava etc.)said perm is NOT Noim q d OomP
Thu Office of Iavattgations would W to thaw you in advance for yoiu cooperation and sbould you have any Questions.
pleasddo�haiute q�ins a cad.
The Department's address,tekPbone and fa:nsmber.
The Commonwealth of Massachusetts
Depa =M of Indastfial Accident
Ogee of favesttgnttong
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Rcviscd 5-26-05 www.mass-gov/dia