3 BENGAL LN - BPA-2006-768 REPLACE PATIO DOORS +L-A rSliAttSfi-8Ef L. AfPROVED BY T44E
IAISPFCJ. ,Pt�1D1R TD.A.PERMIT $EWG GRANTED
CITY OF SALEM 3
'��A Date /
No.1 � V�
ffl
Located In Location of en! A
Is Property Building G
the Historic District? Yes_No
Is Property Located in Yes_No
the Conservation Area?
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Conptru p�k j 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:
Owners Name
Address & Phone
D i 3 y
Architect's Name u c V I S
ll
Address & Phone t
Mechanics Name ° 7
1 )
Address & Phone
What Is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law?
Asbestos?
Estimated cost r!/ city License A N A state License u S n 20(01 0 9/
gone Improvenaut ((�
Lie. Sfgnature of Applicant
3� O� SIGNED UNDER THE PENALTY
OF PERJURY
}� DESCRIPTION OF WORK TO BE DONE
av / Ai 'GXI $ � � N2
w O0' cA 7) X1 Z
MAIL PERMIT TO: 7 3 (� CS
No.
APPLICATION FOR
PERMIT T
��O�a� e S
fJ oav—
LOCATION
PERMIT GRANTED
APP jFD
INSPECTOR O BUILDINGS
1 .
�v
CITY OR SALE149 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WARIIINOTON STREETS 2Rp FLOOR -
SALEM. MASRACNUS;w$ 0I970
STAMLEY J. UE0YIC14 in. TELE►NONE:
MAYOR 978•745-9393 EXT 380
FAX: 978-74o-9e4s
Salem Boildlall DeRadjWnt
1Debria Disona9l god
Building
1n accordance with the provisions of MGL c40 S 54, a condition of your
Permit is that the debris resulting from tbis work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
ChaPter III, S 150 A.
The debris will be disposed of in:
2 6 3 r,y cS�LrY� �
(Location of Facility) 4/4 ,n1
Signature of Applicant
Date
The Conn mmoUi ofM46achuseds
Deporhnew ojlndaa dd Aeetdents
t ojbviesdge ons
600 wwhusfow Sbeef
Bosfoay MA 02111
wwwearaassewadt
Workers'Compensation Insurance AfMavit: Boflders/ContradonMedridsu lumbers
Apiplicant hftmstla Plesse Prid Legibly
Name L
Address• GV C S 11 1' Ci LJ4
City/staterzi� �i ! _ phone 0 1 7 Y 1 6 6 L '
Are you as er!Cluck for`'
rop Type of projed(required):
1.ClI am a employer with 4: I am a general canfeactor and I 6. ❑New contdnction
avloyces(fin and/or pw1-tim4e have hired The ruw463"Ch=
2.❑ I am a sole pmpeiegr or palms- Barad on the attached sheet t 7. i
ship and have no employees Thew sub-eontrsckn ban 8. Demolition
warkioris fw=is agl6capschy.. '. p *811111000. 9. q Building addition
[No workers'Comp iaasraoce . 5. ❑ We ate>i '>md ice'
offiidit liaye ese isod their IOU Electrical repairs or additions
3.❑ I am a bomeowner.doing all work r>Bbt ofezerpplios PerMGL• 11.Q Plumbing repairs or additions
Myself[No watko w'.camp C. 152,#101st bave"ao 12❑Roofrepaira
faaarasoeregnaed,]t .. fir 13.0 Omer
COW Insurance
'�Y applied dw ebab bane ai mat W o 58 spotW mcd=tdow*Awb a 0W..eaa"p'000yep.I por*7 m6,;maiaa
tHoneowmsaVIP=boaShMin avve "andoiescepreactaadfloss*#ae4 abmitaamafdavitb6catinasoda
tCoatn•4stYadwAd6boxmeafrarbada WMIaW doff ftm*ftsmnrb(f sovoAclonaedawkMaakrnt'ramppWigkor=eka
fan iWestpbyer"Isp dteforksis' 77
�anrpatrrdogbe7srursajant)diipfeyseg aefowbdlrplfeyaslJobafb
lnsmancecorpmyxamtz I1A1�
Policy#or Solt ins.Lie.# p Expiation Date
lob Site Ad* C �I Q l l ��� CSty/Stataft: 39 c h- "'0 01907
Attneh a espy of the workers'compensation policy declaration Page(showing the policy camber and expiration date)6
Far7me in secure covira®e as required under Section 25A of MGL C. 152 can lead to the imposition ofabAW penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as Civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violabr. Be advised that a copy ofd&statement may be forwarded to the Office of
Investigations of the DIA for insoraoce coverage verification.
I b Aaabpcaro Atpaba andpsnaNa ojpa/wry AM dice Lrjornadon pmvi*d above haw ad ceffe"
i
Phone a
O,dlcid rant only Da racer wrha In rAilr any h ba cowplert/bl edq'slaws oalelaL
City or Tows: PermWlAcense 0
Issaing Authority(circle one):
1.Board of Heakh L Building Department 3.Cityfrows Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Perron: Phone N•
Information and Instructions
Oee 152 nipi rea all=V Wtedp P wl* compensation
for their eIDp�
Pursuant oo�statute.ffi�m is a«...aaYDIM in>be aetviee gf anotha.a�a aaY ofl�q,
at m]phed,Oral Or
>;defined 8a"an individual,partuetshrp,assoeia"aotpM"O[olber legal ca ty,Or my�r OC m
An a VAWN •1 and including the legal T*=Ou tva 9f a deceased employer,
of the fotegDIDi D88a11Aa to a association err ether legal entnY+�P1oYmg�PbY� HOwevC{,I.
receiver or ttmooe of as individual,of more
ad who resides tbeseia,or the o�of'ffid
owner of a dwcltmghouse having pi y. a ilea three construction er�wc*en steel dwelling borne
dwelling loose of another who ernpgoys penom b do maintenance, employ
as er."
or on the grounb orbur7dmg ��°�notbeame of such employment be deemed in be
MGL chapter M412SC(6)also states that"every state or toed lkeasbg ageae7 d"wlthbold tk lernaace or
renewd of a ticer se or pa'mh to operate a business or to eomerad ballda0 In the eommonwafW for say.
app0eant who W suet predweed a Video"otcompHam with the isanranee coverage re9
airedL
Additional1Y,1b11s'{.chapter 152,125CM main"Neither the�onweahb nor say��political snbdiviaiens shall
contract Sot the perfi mance of public wolf unroll acceptable evidence of compliance w�dw ion
eater moo any a 66 contractingy,■
requirements of this chapter have been presented
APPgc situation and,if
Please 5q,out the worken' dMrik completely,by dockiog the bores that apply*your
noasstiiy,sippty seb-oozracam(a)nsme(sj address(CS)ace¢piim number(s)along with their cadficate(s)Of
Q flee the
insurance Limited Liabulky ComP�(�-�or I united L iabthtY PatmwshtPa(�)with no employees h
members or parteas,are not required a cam'wow' ID60ance. If an LLC or I.iB doe have
avloy�a policy is regal He advued dW this WAavltmay be saluted to the Depa Mned Of Industrial
Accidents fot cm*matwn of insord a coverage Also be rarer ice sName ad date the■tII�aot the Department of
ered
nation Sac thepermit o r ie being regaerted,
b uned to the city Or town that the application the]caw or if you are required 10 obtain a worlren'
Indwtrial'Accidead. Should Yen crave 9IIy ns regarding . should enter their
��poHc%phew caII the Dept st the uumbet 11sad below Solt=iowrcd compamea
self-insurance hcesse tttrtnbu on b00
Cky w Two Otridab
seen the affidavit is complete and printed legibly. The Depattmem has V"ed a space at the bottom
please be of the affidavit for you to fill out in the event tie Office of Imestigatiom bas to contact you regarding the applicant
fin in the pami l
please be sure to number wbkh will be used as a reference number. In addition,as applicant
ma*lc 1 tAicense applications in any given year,need only submit one affidavit indicating current
that must submit necessary* and under-Job Sue Address"the applicant should write"all toatiom in (city Of
policy information a
city er
town}"A copy oftbe s8ldavut flat has boas otfiaally atatnyod ptM#W_by the err town may be provided to the
applicant as proof that a valid affidavit$on fib for&uue permits or liceasea A new atlldavii utztltbe tilled oat each
year.When a home owner or cidacu is obOWN a liaose or permit not rdated to any business or commercial veumte
(ice a dog lieense or pew
b bun leaves etc.)said person is NOT required to Complete this atfid"
The Office of investigation would lure to thank you in advance fag your cooperation and should you have any questions,
please do not hesitate to give us a all.
The Department's address.telephone and far m ubw
The Commonwealth of Massachusetts
De;W11nent of Industrial Accidents
Ofce of Investigations
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2"5 www.mass.gov/dia
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✓� 19dIIY!)!(YIW1824(IG t�:lt'LQdORdutde(Q
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
ti4 Registration: 101849
Expiration: 612912006
Type: Private Corporation
i
RAIN HAWLEY CORP
Alfred Splller
263 Western Ave
Lynn, MA 01904
- Administrator
I
,/Ne �oontono7.u�eaQ/ �✓l�ira�ad�«dedd
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 020004
Blrthdate: 06101/1928
Expires: 06/01/2006 Tr.no: 24942
Restricted: 00
ALFRED R SPILLER
NE SALEM ST#35
SWAMPSCOTT. MA 01907 Commissioner...
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