4 SETTLERS WAY - BUILDING INSPECTION `btJ4—
/// S M E A D
No. W463
UPC 10230
smead.com • Made in USA
Plans must be filed and approved by the Inspector
(\ prior to a permit being granted
No. / nn CITY OF SALEM CC/'U_
(�� ,J Ward
HISTORIC DISTRICT? Y N 11 Date (Z 2 9y
IF FOR SIDING, HAS ELECTRIC 0 Home Phone
PERMIT BEEN OBTAINED? Y N 0� Bus. Phone k
APPLICATION
PERMIT TO
FOR
--
�VYI�.e_
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to tha
following specifications:
Owner's name and address �l�v�p k1�1G q `OCCL�1�5 W ftK
Architect's name
/R
Builder's name
Location of building, No. .e
What is the purpose of building?
If dwelling, # of units? Material of bldng?
Will building conform to law? �S Asbestos?
Estimated cost 3 040 .C)O City Lic.# State Lic.# 05� 1 {
Signature of Applicant / 1 �
SIGNED UNDER THE PENALTY OF EJDEY
DESCRIPTION OF WORE TO BE DONE
nl'TQ 1—cc)0 A-P-P l_ S
afiTin n 2j?nii A) 1 410
Mail Permit to:
F • 5 F :Y� tt•� Aej } it r,
�, �f� r )�,�. ��j� 'S� } t �• lr��it r_ i � ��r�y � I142y' t ��r i .' 1 � t 4
I
No. V / Ward /
APPLICATION FOR
PERMIT TO ROOF
REROOF OR INSTAL SIDING
y..
Location �QO
PEIT GRANTED
Approved
�2
Buffding Inspect
is I a�l9 �
INSTALL NEW
NEW WALL WINDOW
4'-9"
NOT AIR NEW DOOR
SYSTEM BUILT IN
UNIT UNDER
STAIRWAY
1ip
DOOR
S �l� a lel a41
ACCESS OPENING. NEW ALL
_, otn►S -
STORAGE AREA. UNFINI ED
(fommonwealM of PlIamac4watti
2epa,tm ntqq����ndudErial iYccide/tfa
of 600 gql/Vadhington Street
James J.Campbell Aonton, ///amac4usette 02111
Commissioner
Workers' Compensation Insurance Affidavit
(uapsee/perotittee)
with a principal place of business at:
1�RAJ ILL VV-L o tie3o
(aty/snee/Zlp)
do hereby certify under the pains and penalties of perjury, that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
i 6 S • V-6cacid e .1 1-14b,an G u u
Contractor Insurance Company/ olicy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I understand that a copy of this statement will be forwarded to the Office of Investigations of the DIA for coverage verification and that failure to secure
coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to $1,500.00 and/or one
years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S 100.00 a day against me.
Signed this LA)r }p)9+� day of Z8 19 9
Licensee/Permittee Building Department
Licensing Board
Selectmen Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 40S, 409, 375
a
,lie �o�rrm.�uueu� ��l��raafurlu�ae�
A& Aatzt.41f: o��rrtsdi its � . -
%fichael Duitaltst 414M'"mob J«
Governor wagwls-
Vitt• J _ -/, IV,
Kentaro fsutsumt �� ,
Chairman " d&W, � 02!08
Chula J. Dineato 1817! ^3
Administrator
MEMORANDUM
TO: All Buildine Dcpartmentsrjutc Building inspectors
FROM: Chula J. Dineaa Administrator
DATE 0420ber J 1. 1988
SUBJECT. MGT, con N51 Added liw rJ94. 19 of the Acfs iii 19R?
The above-mentioned statute require that debris rcvtiting from the demolition. rcnowatltte. re40bllit>nniss
'11' other alteration of a buddine Or structure tic dtsposcu of in a properiv ticcnseu sulul wane dbpotal
Ctulity as defined by MGL e111. S150A anu that buddine permrts On cccnsa arc to mavc-M.the IOC[tee--
uf the facility at which the said debns is un be utspmeu. THIS REOUIREMENT-DOES.NOT
APPLY TO NEW CONSTRUCTION.
In orucr to simoltfv Inc process anu to pnmde uniformity. we arc attaching a copy Of a hrrm-which i'en .
an either rcprouucc anu use as u is since Inc completed form will be attat:hcd to file Of cu"of bnddios-
Permits 'if license: or reproduce it on blur lctterheau.
In ase of municipal.commercial.mdusttial.or multf-unit houstna construction.the chntraefor malt flet know
the dumpster subcontractor at the time of the building permit application. in such cue. the ataaberi copy
of an AfOda"t an be used.
The complete law is contained fn Inc November issue of COOEWARD which will he mmkxl to Wmin the
nest two weelct If Will should have env question. Plast let us know.
CJDAm
AFFIDAVIT
As a result of the provisions of MGL c 40, 554, I acknowledge that as a condition of Building Permit
Number 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 MOL_
c 111, S 150A.
I certify that I will notify the Building Official by
(T%vo months maximum) of the location of the solid waste disposal facility where the debris resulting from
the said construction activity shall be disposed of, and I shall submit the appropriate form for attachment
to the Building Permit.
t2 . 28 gq
Date Signature of ermit Applicant
(Print or type the following information)
1/11V1�2 5. IJUGILI. y
Name of Permit Applicant
C fkNEt f45 �isiUSr�� S�iZUtC�
Firm Name, if any
Address
In accordance with the provision% of MGL c 40, S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S
150A.
711 debris will be disposed of in:
WR\)E lZ VW-L CM4
(Location of Facility)
Signature of Permit Applicant
l2 . 2A • 9 �
Date
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