17 BARNES RD - BUILDING INSPECTION "PUNB111111WIDE fRA 94AD APPROVED BY 774E
WP==-PWR TO A'PE8111f BEING GRANTED
�— CITY 0F_SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, R Install Siding, Dea, Shed, Pool,
papairl Od . _de
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undrrrsipned hereby applies for a pemft to build accorcLig.to the following-
epedfications:
Owner's Name 2") k PrU Ve i,,c�e e-
Address a Phone 1 +3 o v .e s V , 5&A
Architect's Name
Address Q Phone [ 1
Mechanics Name �)D/U
Address a Phone pV'1wvh/c4L'4 d o- ( y
Wht Is to p xpow ar alYerg4 /C e g. e-4) ,L e--
md"at bul w p a q,for how many l On? 1
WE t dit o x".. to low? Y'P s AseWw? /yb
F.wnwaa awr Jvvy sty ua • etata uo r 0 ! 3
ue i/u313y
. afore of Applicant
NED UNDER THE PENALTY
OF DESCRIPTION OF WORK.TO BE DONE OF
t
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MAIL PERMIT TO:
T (
No.
APPLICATION FOR
PEFWr TO
LOCATION-7
PERMIT GRANTED
19
7 vFD
INSPECTOR OF BUILDINGS
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9848
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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, S1150A.
The debris will be disposed of at: g.,
Location of Facility
Zgnature of Permit Applicant D complete the following information:
(PLEASE PRINT CLEARLY)
:7 0% LLTIAILGE
Name of Permit Applicant
VL1`(-k co,
Firm NanuWany
IQ VA4, JC s1. NA lble ke
Address, City AOState
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
t:
The Commonwealth of Massachusetts
Department of Industrial Accidents
O/fleeO/luvestlpetlo6t
600 Washington Street, 24 Floor
Boston,Mass. 02111
/ Workers' Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
name: proyeviC'k e 0,
address: T C;e_ ir"t 2 5 {���C • 'mot p —7 c ^7 �!!
city �Gt,�eIt. state: r 1 � zip: �� /� ohone# � TO — / ���^/ ( 2
work site location(full addressk
❑ I am a homeowner performing all work myself. Project Type: [I New Construction Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
da 1 am an employer providing workers' compensation formy employees working on this job
as' 44.Av.'s'i* i.`�.trk �'S' ""'axe
addresdg�. �':� qV �;�� Ch CJ • » c `x ( rJa izFir;' � 't � F r� ¢
e{tV•
in u
•❑ I am a sole proprietor(J!nest con ,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
comoanv name.
address: -
city: nhnneM = a
F'.+r4' sa.•.{<ar a x 6 4{ #9 �" L.* �,`-' $%ia, fi^ ''f "M :,'x' k .* y .. a a .f;
Ina!
m r e l a2fb +., { e,:.7'N.
• fir .�. Spa >' „ .
company"mine: * i. ^ '
addreain G r..�" � 7, im 1ZV •7wY3 "rra > vb
„_9^ .s'T,' 3,°`gait•,a}'Y t ,. try f exv R✓, .� •4' is e4...��,
1 a .•;;�s Ae 4 �� :.k � �'V e 4 s'�ex4•
h ;
Failure to aeon coverage as required under Se ion UA of M=152 can lead to the Imposition of criminal penalties of fine up to 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwardeSl4o the Office of Investigations of the DIA for coverage verification.
l do hereby certify u e i and pen �r of perjury that the information provided above iswime�and correct
f
Signature / Dale
Print e C)O IJ Phone# Tt'S l— —2
official use only do not write in this area to be completed by city or town orr vial
city or town: permit/license# []Building Department
❑Licensing Board
❑check if immediate response is required ❑selectmen's Office
❑Health Department
contact person: phone s; ❑Other
or„w s.px Land