19 WINTER ISLAND RD - BUILDING INSPECTION (2) r
pL."S*W6t.BE{*{$#ND APPROVED BY T44E
Mp==PH= TOA.PEMIT WING GRANTED
CITY OF SALEM (,
No O Date L
it
i
is PM"Located in Location of ( r
OWHletOda DbUtd? Yee NO Building SC}�C�M • slate I S
isy Located inl9 l�1, 1r2 1
m C reemadon Mee? yea—
BUILDING PERMIT APPUCATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, pon(strunct Pool. Deck, Shed, ,
Repair/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:
Name
Owners am
Address A Phone /� u �^r r�nAUl✓ j ) 7 - '17 k 3
Architect's Name
Address & Phone 1
Mechanics Name S-A A� r=
Address & Phone k �QWE c�ti ) M 12 l , r� o
What 18 uw PLUPoee at bulldW : l
Mai"of b,kkv? �/b o n a dwWV, how many temiies? 1
Ww i wwft cordorm to law? 2 Mibntoe?
Edmated coat_CUy L"m e N A State
Boom Dwraveeteent X
Lie. / i v S c0
Applicant
g;rUNDER THE PENALTY
0Y
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0:
c �, cK V1,Ah'v1 L � � lnI
No.
APPLICATION FOR
D /PERWT T�O
LOCATION
f
PERMIT GRANTED
Al, 2d a6
APPR VfD
EQTOR OF BIAILDINGS
ne ConumxwtroUlt qfMasechUSMS
Dc m*xertof1xdks&WAwMdatb
OfflM dim"
dot washi tt"S&eett
Bos&4 MA U111
svtnsnNOAPtsW&d
Workers'Compensadon Insumee Affidavit: BnlhdelslContradon/Elec rkians/Plamben
ADDlkint Inftsttatlas Plan Print L.eIM
Name ` ✓A C a n w
Address: h A Yh LA vv �
Ctty/staeer*� 3,e ... MA OfNrih= :
Are pm an 64&tw firopr+ai.boss' TypeG(�ed��
1.❑ I am a empbya w i.& Q I am a genad eonaactor and 1 ❑N OOOanaeti0n
_ yoQloyeea(8iH aodfoe paeFtkne)° hav to s nsciafaslma
2 I am a aok pmpietor a partoa6 Hoed ca dw ameied sheet.t 7.
skip and bare no employees These sub-mairawn have L ❑ DemoWm
wasfia� flit aaa i�aces capac> R' ,me unm 9. Balling addition
(No woke:'camo boarance . 3. ❑ we ane it " ids
oftesi*10 • �' .Btetr 10.0 EWcdial mpsus or additions
3.(] I am a bomwownw.doiof aA work p r tof " wk- 11.Q PkombLa rgabs ar addidona
myseK(Ne Madresi'.c mpg a 13?,11( i"0:41 eluve'm 12.b Poofnpain
issaeaacategoked�t: 0 r 13.0 06ar
�.�r q�lir,�Ar�lsh bent ii m�s°bo�gi4[w�tio�beb�iov6�Odrw�f ao�a�lfa�pdioY iof6am�ebr
t Nosrownss�msmk�idrvk ion drll s ddV�r•at ad�dF!'�oararosa�adoor�aemie°snr.esaaa s met
tCe.a.or..Mdrettiiobc�'a�tre�ea�drodeliort�lrtab aremtifnlr �cleoaMj**wO&we coop VOftjgxU=dg&
r...r� i•rAnr bpw s�►sodas'eowpeiva�e�s 6u�o a ;rh►av a ijrrf* add.is Arp ft asid job*0
fa fras.aGa. // 1 '
]marmoa CompmyNansx hfo "I 6 n 2s
Policy 0 or Sell=its.Lie.A /SOU Papindoa Dato
Job SiteMdsas 1 �it� � h�� {� �\ Qo�< ' (f tyftwzkr SAle n O IS' T
Attack a copy of the wmtere compensation policy dedar adea pap(shmrbsg the Polley camber cad esplratioa date)6
Fa�7me oD aecaia raven ear regtsued nada Secdon 21A ofMGL& 132 tens tad io the bWoaidon ofaimiml penaldea of s
Sae up so S1,Soloo m or one-year&Wbonment,se well as dvil panties m fe form of a STOP WORK ORDER soda Has
of up so$250.00 a day against the Ablasor. Be advised that a copy oftbb atataomt may be fbrwuded to tke 0921w of
Imetipdons of the DIA fa hwunce mverap vaiHados,
If An kmbp rba��psaallNm oJprr/W dw ANbjamaika prorurd above As bar Axd arreca
glm= S - o
phoze
O�lela/asr oalp De eaI wrbt Gs tbb any fi be rowplsYt/by cAya►anns*j*w
City or Town PermWUotase N
Inning Aotkority(cirde oze)t
1.Board of Health 1L Budding Department 3.Chyfrowe Clerk &lrleetrleai inspector 1 Plumbing Inspector
ti.Other
Contact Person: Mat N:
Information and Instructions
_:... aaada.fac,ir�r�of
cen xd Laver dtagar 152 requited an cagtlg M0 under aqr H bOYh
danachosdis,an„ atst. as dophym is de5aod as'...every DE1s�i.tae rervioe
cc implied.oral or writ!,
sa doss oosporsdo�or aha leial aft or say two or mots
ofPnPIOW itewf o coops 1"W aed'oetidzoi s enuty,w4loYmtaoPlopara• q'S°
III receiver a trans!of as individpal.Psstttertd�ip►apoaado� sod vA*rerides mere%of the o�d�boars
a boUM jS htg sat nw dt d Coa or repa4r worn as
hates abutldmg mast°"ambecaossoftackw to
ployawabedeemedbeasomPloyec"
4 os the grounds
MGL cbapgr 132,425aQ&W swes dot"0�state err load nt"d"afsrx7 aha/ �the 4naoee or
to operate a boslaers or a c..b.d bWWbW Is the for WW
reoewai ofa Ikeus err psrmlt 01 0 ofcestpww T*b the Wave"eoaraPr regsdrsd'
ISOMMM
wbe lug
1 �4�re n"New" ,•Nemiar dw ao�vmdh os as of jM Dclhial mbdMdoW shs�
eater Ito my oomtsd for the p anoe.ofpnblie weak=A acceptable evidence oleomplta«a are ioosmaoee
Of thir ehapta bra beer presented to then acarhpcdaf su4todRlG•
Applicauft the bones that MP*to yaw srmation snd if
the wodcera•oe,..d=akin t=*le*,b1►chuldag w�their eettiAcate(t)of
WMWy,jVply )eaods,addtm(es)=$P�mrp�ba(f)aloui other tdun the
bmnwa Limited 130bft�ssdw O=or Li nbd Liabr�'Y Ps�sbiPs(lam,w&no emVbyw
are not reqSW,oCUvWo*M9Cp=WCoUdMhWftsooa If as LLC a LLP doer bave
Sara PC required. Be advised tbtt s '? ids a the MS a®dsvit sbcald
of imarao .covaatia
AcddenV bCom dw�dent the appliadon far the permit a litxntsa b beieg regaato,d �aDWI't of
be-MI-A. � ShpnM Dava sny gaadoes regtadmg the law err dyse erne roqusad dMM arts thdr
OSM pieara caII the Dep rUo"at the aombet Self-iaroted'oomoptmiss
gemsa noa�er on the Boa
CHy or Tows 011ldde a space at the bosoms
please be sere that the of davit it complete and panted k &ly. Then DeparCnent pmv�ded Ucat
of the affidavQ Sur you to ffi out in the event the Office of Invadpd m has to Contact YOU
regarding spp
please be sure to ffi in the pamiWcenae n mba wbieh will be need as a refaesiee mmher in add"as apP�
that most abmit OWSPle Pam aPP
hesdons is soy given year,need only submit one at'M"indicating current
policy in£ormaaon(if neewary)aod.nader"lam Site Address"the applicam sbonrld wri10"aII loathes is (COY a
teeny"A Wvr of1De a k>5.t has ben o®eisigt ramtped 4 t A fild" S�out w
apPW ar proof that a valid afiidava is an ire forMo P mt rdated to day busims err w mrereiai venters
ear.where a boos owaQ or dthes is obtiio[ to lac thin a®davk
(ia a dog Kassa or Pamtt to boa leaves etc.)aria ptsttoa it NOT ragaiced oonrp
world Mw to thank you in advance for your coopaatioa and sltoeld you hm any gaado»s,
The OfSa of iavatrgations as a�
please do mthe iWe im
The Department's 2M9M telepbooe and far amober.
The Commonwealth of Massachusetts
Departimeot of Industrial Accidents
ova o(Invesdpdong
600 Washington street
Boston,MA 02111
TeL #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
II`
Revised 5-26-O5 www.mm.gov/dia
CITY OR $ALUrAq MASSACHUSaTTS
PUMUC PRCPKRTY 0KPARTMtNT
120 WASMIMG"M STIISST. .7A0 ILOOA
SALEM, MASSAOMUSgM 01570
T[LA►MONaI 576-745-9609 RIM. 380
MAXI 970•740•9M4
4.
sdem Build a!l�l�rfwr„�
Debrla Disooe� gam....
In axordaw" with the provisions of MGL c40 3 54, a condition of your
Building Pernnt is that the debris resulting from this work shall be disposed
Of in IS properly licensed solid wasW�isposal facility as defined by MQ,
Chapter nL 3150 A.
The debris will be disposed of in:
( Acation of P
'tY)
V
of Applicant
Date