69 BOSTON ST - BUILDING INSPECTION �LIMS1AUSfi13Efll:E 1Nfl Af�PROVE;D BY T44E
,IyS,ppXT0B pWR TD.A PERMIT BEING GRANTED
CITY OF S,ALEM
No.
Date •y L3Z
Is Property Located In Location of !�
Buildin8
the Mstoric Distri Yes_No
ct? �aCi k729C_ C/ S _
Is Properly Located in
Bro Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOUR: --�
(Circle it twhichever apply) R stall idin lCoIls2rLct�eex, Shed, Pool,
epatr e I , ther:
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 Nameu--r
Address & Phone3 F �� I S d iCF7F if S f S 2
Architect's Name z r G,Cj F
Address & Phone S I
Mechanics Name
Address & Phone
What is the purpose of building? F �'
LumW of Ix kwq? tLvc-71 It a dwaling,for how many lamdies? S
WIII building conform to law? Asbestos? !—%
Estimated cost ( (9 D Ctty license r N A state licence a CS n ?
Rite Imrrovewant V o
vLie. #�' i Si tune of Applicant'
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ISM' 1�✓� i= I<G'P S � � � n -{9y-cJr d- �1G -F-v?�r f��d.>zn �cw•
=n. nPiy
MAIL PERMIT T0: QW14 -
0 rw
No.
APPLICATION FOR
PERW TO
LOCATION
PERMIT GRANTED
2.0
APP OVfD
INSPECT_ OF BUIL 1NGS
4DCITY OF SALEMO MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR
FAX: 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 facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
igna e f Applicant
y `f vG
Date
7U Coxtatoxwa tAi ojM4imhuseft
ojlxdxsirid Aoeldtxta
ti01 ww
atox Stnedt
Bost^MA 02111
wwxtardr APWdi
Workers'Compensadon Insurance A®davtl:BnfldeniContradorsMecbids�u bers
AppNegid
Name tBuisessr7r�nlzsubr
Address:
City/Statellipen �'� Pilots 0: S 19
Are:Xm
edters Cfeek HEapproprrats bans' � � ft*
1.0 esaployes with : t. C2 1 am a smeral oontrse w and I
ye s(W asd/ar part-time}• hsvehieed rkrsab�asaaraams 6 ❑New comtraafam
2 I am a sole psrpr" " or partser- listed an the nuacbed sheet t
and Dave no employees These mb-contr ecton lim 1.'0 Dcmmolr�
wodriW ixnai.amteapecigt, !'I",.�P iaamaooa 9. Q Bolding addition
[No w0d=9 comp,inetxaooe s. 0 we are a►cosppratjeN; Its,
o trsye �. I0.0 Elec*dnepairs or additimr
,
3.❑ I amshons waar.doing apwods rigiitaf }peIMGL' 11.0 PhokinBnpaks or additions
myalt[No volkea1'.con* a 132,111(7414 "UNI'd 12 Q Roofnpaitt.
msor�oarequQe¢�t comp immanoe. r 13.0 Omer
6�ny�pptle�er dladrbm4sl nmt�Lo 8U e4441+�Yio�bdor�ov5�d�}.,p���V�a panty ieb�mdioa
tHamtowws•MoaamitrhY�davaad(a11 1 dabs.Awmkandemhj obw MWk
tCam�ean tLtetsttW hues not rhehid�.�idae�tdfat dnrisr a.eras btielrt sssJ�irrodon'omy poary hteorm.tlaa
I M Mo#MVIVYdrdw&PVWAV werkenveorWaaadosrbvwnaratJi►a4a p BdoMadvpafftgaxdfofa"
�j
Iirerrrance Companyxame
Policy S or Self ins I io S Expiration Date:
Job Site Address City :
Attack a cagy of the workers'compessa los panty dWwMfon papa(aborting the Polly somber and
Pmime to:Owls oov as es 1penafti dates
crags regorted testier Section 23A of MGL a ls2 can lead b me iaopotition of criminal penalties ota
rise up to f 1,500.00 and/or one-year 3aprisoamen%as well as civil pmahies in the form of a STOP WORK ORDER and a fine
of up to$250.W a dry against the vioLgor. Be advised that a copy ofmh statement may be faswarded b ms Ofte of
Investigations of do DIA for ism osoc coverage ve igptiob
I sD hmbp Ae prbis psnablas ojpr+/sry dial At d0wMadenPrewArd above b arm and carre tt
G Q�C aw
Phone M l GI a G/r / L�
ODlefd ass onlp De seal weld m fAib any to ba eOmP dbP efayo►bwx a,Blefd
Cky or Towns lermk/I�eense p
Issalsg Andwity(drde ones
1.Board of Heakk L Building Department 3.CHyfrown Clerk 1.Eleetried Inspector L Plumbing Inspector
6.Odw
Contact Person: !bone S:
Information and Instructions
Annacbusetts(weal Laws cbapw 152 raqui=an emplgyessl maser ' � o g�
�t b-d&$00% su a Ayw s defined _. �ta°°tha
osPsas a imphod,txal or wrrttea"
endly,or arW twa Of more
An sm0i�►it defined a mri mchtdiM the * es�descend�a�
Of ft fer'�i Capats l� aaociatioa or odw w ea ft empbysg C"loyea Noweve 60
roodwow n dw�cUm' tin � &U&M and who raider tLereia.of d�o� Cubg
�
dwening boon of ttaother wbo empbYs pasOnr b do m are be�b be m empbyeLw
err as the gird abtrildieg theKto:laII eabocrose of noel®P1oYmmr
M(IL chapter 15%125aQ alw state tbu"ev07 Ante or leed Beashrg any steal witbbow the or
raewd of a Nam or permit to operate a bulws er is coestsmd balldta0 Is the eommmwafm far aq
..N. st w"her act prodecset areept"evidence of COMpUm wbY tM Mmww eo wW n9dre&~
odditionally,M®.chapter 1SZ 121M sinter"Neither the a im ra mY Of ]ibis sha
A
eater ism any CM03 t f0ff the paw ofpublic wedgy mid aagmbhs Cideoce of cmpltaoce wig db$oaaz O
re"kemeo of ins dtaprer Lave beer presatud b the oaolracdng.aocoq�"
APP tbebo=that apply teyorr trio»ttion amd,if
Please fncat the wodrers'eomparati °affidavit compkte>y,by decking )abog with their eadfieasda)Of
mccomy.snPPly s)mu`*� addraK )erg¢phone other d m dw
iaarmna Limited (L Q or Limited Lsbt�',4 Parmaahipe( widt m emPti>y�
mamba a parmas,era no
regnlrod b eery woikan oompemaf3rn
ingpsnum if n LLC orLf.B does turn
a pOby s required. Be advised dO ins affidavit may be mb�aed b the Deparamar of htdoaaial
to and
date the afndav& the ag&w t should
is boa of iawsana pHcxd e x& b0.� r Ucew s bc*g req�S.ad the of
be rearmed b die city or tower that'application ibr the pa&e law err if you are regaled b oblak a workers'
bbwW'Aoa&'& Shrynld yoabave arty gtresobns r below: Self-mwred oompmw should enter their
pof glean Can d w DepWbDent A the nomber.lµ0ed
sclf- litxme amber°II the
lima
CRY or Tower Otddals
Fleece be we that the affidavit s compkw mad printed le&ly. Tfu:Department has provided s space at the bO�
of the affidavit for you b®out in the event the office of lwcstipd m has to Contact you reprding the appB
Please be sure b fM in die pamWlkcm nmmba which will be used err a refaeace number. In addition,m aPpHeaat
due most submit nat>tipk panawlianse appacati m is any given year,need Only submit one affidavit indicating current
inkfulAaon(if neCEaaary)Sail under"Job Sete Addrea"the apphcaot sboald write"all beatiom to b t a
dw
IsP0117ar A copy of>se affidavit in bus beer of kWbr stmtped OLn>al dhY-'A- a gown k u be pfovided
app�as proof that a valid affidavit is m file for flame permits a llama new afNdsvit tt>ottbe fined oat ash .
year.Wbem a boors owner or dtin s isobtassg a Hume a permit not rdsw4 In any businas of oamma�fal venture
y to bum kava etc.)said pawn is NOT regaaed b complete tbs affidavit.
(La. a dog]locale a pew
The Oflica otlnvatiptiom would hire to&=k you in advance far your coopaation and sbould you bave any quesdoms,
pkate do>nt bedma b fDve w a cag:
The Department's addres4 w1cpbone and fan number:
The Commonwealth of Massachusetts
Department of Indashial Accidents
offt of Investigafdons
600 Washington street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1477-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
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.APPROVED
Subject to approve by any othe-
authority having j ctwn,
CITY of SE M, F Wr,
"ME PFEVM;TK.NL
PL:d:S ARC APPROVED SOL 7' - ..i iC`S'f4:'iCiiTi
T;cE AND LOCATION OF i!?'i !`,^� 'GT;Ox^! C. ?:_3, s
F"_ F;Rf: PRO]EMMON D '!r�S .^.RC'CU'nJE.':T'i0 A -
".AL?'S7 ANDINSPECTI N,FORCOMPLETE C= �i`U- i_
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