22-24 BRADFORD ST - BUILDING APPS DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof,6stall Sitlin , onstruct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
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: Contractor: ) 1-e
Street 0 Cip Street- City [—
State Phone State dLA Phone
Architect: NLH City of Salem Lic01 /39
Street City State Lic#1�oh59 HIP#
State Phone ( ) Homeowners Exempt Form__yes no
Structure: (please circle) Single Family, ulti Famil --a—Other
Estimated Cost of job S /01 OZSC>—
Will building confirm to law?—J yes n0
Asbestos?_yes Lno
Description of work to be done: .7 / �A-f ply/
Drawings Submitted:_yes_ no Mail Permit to:
Signature of Application, IGNED UNDER THE PENALTY O RJU!R
CONSTRUCTION TO BE�ICOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Pernti.4# (�Zoning Map/Lot
Permit fee S
COMMENTS:
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Commissioner
Workers' Compensation insurance Afridavit
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with a principal place of business at: c
(l'Jte/four 1
do hereby certify under the pains and penalties of periury, that:
({� I am an employer providing workers' compensation coverage for my employees workingpn
this job.
nsurance mpa y Policy Number
() 1 am a sole proprietor and have no one working for me in any capacity.
�y O I am a sale proprietor, general contractor or homeowner (circle one) and have Hired ties
contractors listed below who have the following workers' compensation policies.
Contractor Insurance Company/Policy Number
Contractor
Insurance Comp ny/Policy Number
Contractor Insurance Company/Policy Number
O 1 am a homeowner performing ail the work myself.
I understano that a cone of this tutement war be forwarded rd me OfrKe of ImestipaaN at file 01A for coverage wenfieaoon and inn fakwo m-ssa"
coverm as redured under Section 25A of MGL 152 can read to me eneouudn of mmmar oensmes consisting of a!me of uo so 51.500.00 mw*r rrfe
years'rnorromem as wee as crva oenames in we roan of a STOP WORK ORDER ano a fine of S 100.00 a dar scam me.
Signed this 30 day of .a
ap
Licensee/Permittee Building Department
Licensing Board
Selectmen Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 37S
of �'z1Em, �� athusEi
public PrnMiy E`V"rtmrztt
Wuilbing ErP8rLM'U1
(One edtm 6ran -
509-7diA595 Exi• 368
DISPO
SAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 4a llsdebrisacknowt from a
condition of Building Permit 0
construction activity governed by this Building Permit shall be disposed of in
a properly, licensed solid waste disposal facility, as defined by MGI: c III,
S 150A.
The debris will be disposed of at: �.3 `?
to ation of t?eiiity
Date
Signature of Pe. t App licant
Fully complete the following information:
(Please print clearly)
ame oc Permit Applicant
Firm Name, if any
Address, City 6 State
She above statute :e?uire5 that debris from the demolition- renovation, rehab
or other astatution. of building or structure be disposed of in a properly
licensed solid waorelicense'slarectolindicateas fthedlocationcofithelfacilitytatt
building permits
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DATE:
Citp of ai)afe ' Ima55arbu! Ee t5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED/ �ry
Location of Building
Building Permit Application For:
JCircle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alte Repair/Replace, Foundation Only, Wrecking
Other:
c
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AV.O1D DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name: KeL Contractor: �c
Street�1,4_� 0 �Cit} h�At1 Street sLT�City 0 e
State Phone f ylle State 7 Phone(77k)7�4fL— )J7S
Architect: Al q City of Salem
Street City S to Lic# 53' HIP
r
State Phone ( ) Homeowners tempt Fom�es�n".
Structure: (please circle) Single Family, Mutti Fa:riil Other
Estimated Cost of job S /0. aeD.
Will building confirm to law? ✓ yes no
Asbestos?_ �yesno
Description of work to be done:
Drawings4AVOKlicittaion
Mail Permit to:
lG.
X
Sign ED UND THE PENALTY OF PERJURY
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CONSTRUCTION T BEI'CO ETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Pernik#� Zoning Map/Lot-
Permit fee $
COL44ENTS:
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