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6 BROAD ST - BPA-05-834
� � � oJ . , . ���� ��� �r � ��dm�.�r� m� �s�r a�wa c�O ' CITY OF SALEM N v�`�- o� — s �,. ' l-�� , . � W.� �, , ,_ �� ���ti ��� at n»wmMcotp�a� v«No_ �as�asas � 3��y� S�� b PmpM1y�oard In •.. Ih�Ca�vMon MM4 . YN Np_ BtNLDINO PERYR APPUCA110N FOR: Pertnit to: (CUde whichever app�Y) Roof, RM�cof, In�WI Sidinq, Con�ruct D�tc. SMd, Pool, R�poiNR�plso�. Oflt�r: PLEASE RLL OIR tFaIBLY i COYPLETELY TO AVOID D�LAYS W PROCEBgM�q TO THE IN8PECTOR OF BUILDIN(3S: '• Ths und�rsi�sd heroby appHes fcr a pert�it to build acconuip,to ths.loNowk�q sp�ilicatlons: _ ,r �s N.� m,� h�� f � �v� I,���-S k�- . ._ Address 8 Phane 6 �rt.e�� S7- (`1�') � �/�/ � G �- Arehitect's Nama Addreaa 8 Phons ( ) M�chenics Neme , llddreas � Phone ( ) wnm�n.rxrpw.a wrar�r S�� �e ��^-���.� �w a o�a�� �,�,��( n.dw.wq.ror now m.�anw..� a=— W11 a�lak�o aaram to aw7 AW�I�� ewmwa ooa �'��(�D ` cny uo,,,,.r a�w��o.N.r Ya.. I�ro..rae ��� Lic. / $ f� Of t uNo�t� �m �neRrumr DESCF�PTION OF WORK TO BE DONE ' / ��`d k �tiv-liL7�`� {'�as} SCv'l-G2�(i ,fJa�.ln I� (q �'�lK.o2 S2�S'dN x � ' � /KJ U�✓�. � . •� st . . . � ... ..a # � . q�� ,� ., ' �. .�: . ._ . . y/� / �� . MAIL PERMIT TO: /�l�'�14 /(/q lt�t^=S k r � 'TM' a � ���i�.� S i �$ � ' ' :� S/a �,�,,, !/12 �I ���t � -... • :� . � . . _. � � � , � � - . 5 � �� � ,J � - - � � � - � � � � � � � � � � � � i � �;�' `� � �. .. .� � � ' �_ . . �, � � " o r� -- � � � � � ' � � .. t � � �C M � n, � � _ `1; ' • �� q MOF�'TGAGL; INSP}�C`l'ION I'LAN " NORTI-IEf�N ASSOCIATES , INC . , 401 SOU�I I1 t3R0AI:�WAY LAWI'2ENCE, 61A O I �i43-3�22 l�L:(978) b37-3335 FAX:(978) 837-333 . dfOR%'GAGOR: dIICHAEL J. & PAlCE NALIPINSK! DEED REF: 1258d%Z66 I LOCATION. 6 BROAD ST PLAN REF. , I CITY,STATE. SALEM, MA SCALE. 1"=20' ' DATE: 12/24/O1 JOB /�: 201/12172 ; � 32,� 6°`� .X/ i MP i � � �3,� SHED '�" 0 � � m m i 2.5 STY WOOD � # s M j 48" i PLAN REF: I MORT. lNSP. 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I$ �� . i I ' . �.i I � �., ' �. , , i i i i j j � i � � � T yr � I . � � 1 _-- � � " � I � - -- --- _,... . - _ ' . - � — _- � --- __ _. : -- - __ � �- -- - ---- - i- - - - - — --- - -- �_ �J • ', A � i __ _ _//�-.0 " ' _ _ ___ __ _ _. _ __ . _ _ . __ .� _. . • � _ . . . _._ _ . �fiaflf�=:-�''L>!N=_.:__ . _ __ _.:.--- ----...___...._ I ' 1�7�"_ / �-O '� _. _ _ _ . j • —7V �11�.� .�_7 /✓ v' 7�-1 �f l.O Dl�� ..._ ._ _ ' _�_ �_ /'O . PR-4l�l� �'T!�-�L�'_._ _. _ . . ._ =3 _d�it:JON - fi00M '�_=- " _- - -- _ _ _. _ _ r�ec-�n����,._ �s. _ 2oo._y:_. :.--=--___ . ; i i . 1 a , � . � :� , f�*N6�IMl6T�lEfIL�9#ND APPROVED 8Y 7iiE �Fprt»,�rp���a�ur�wa cau� � �� J� ' CITY OF SALEM ' � �. 3/3` G6' � ' w.b '`� ,.. z� a�� Is Rap�AY LoeaO�tl h iaeaeios oF Mw FYdoflc DWtlQ? YM;Np__ �yy�y� k ROpnb LOCwd b :� tl�Corw�Nllon An�4 . YN No BUILOd��i PERMR' APPUCATION POR: Permit to: (Cirde whichsver aPP�YI �, Rwoof, ImWI Sidfnp, Constnxt Deck, Sh�d� Pool� R�idR�plso�. Oth�r: PLEASE RLL OlIT I�dBLY i COMPLETELY TO AVOID OELAY8 W PROCEgBNp TO THE INSPECTOR OF BUILDINf3S: , , Ths und�rsipned hereby eppdsa for a psrtnk to build aoco�ip,to th� iollowinQ� ea.oN�t+orro: . r Owr19r's N9me �''�1�IZ� V V�cci�Ct��cJC , .. Address � Phone 3 � �1Y�.rL� � ((.;i? 1 (;�6 -275 3 Arohfte�t's Name Addrosa 8 Phons ( ) M�Chenk� NM19 �ry . �!.'��u,a,�+Q � ( - _ ndare� a� P�,o� c� r�� —G�6�753 wn.��w.wno..w eurdr�r 1�nvn�,. �+■w a arw�q� /.�oo� a.dwarq.b►no�w nw�anwsz=_, v1A a�larp oor�fwm m I�w�r � Me.ao•� ewmwa ooa �.b60 � ply ucww r 81w uoNw N �S c�(' 1 c� r Z ear Ia�ro.�.me ._�� �. e � o qpp�icant ��� ��J uero�n� �rr oR�uar DESCRIP'TION OF WORK.TQ 8E DONE ' ,�y . �'� � � �.5� l°y��� ,� ,�1��c �ewi o ��cUh �l�on1�� .�I�� � �u �ti z, ,� � s -7—r—�— � ����a-�� S�« �,�.�I/r ' 43,�. . t 1 '1 � � �,✓ ' .,� . . ` _ . .. I1����� �' • / AAAIL PERMIT T�: t '� ' G�--�� �M ' . '� � l2 - 6��"6 ��,2 6 � � . . .. A :� � � . ' �^ � ;, �.�, ✓ � � � � �� o �. . . � � o - . rf t�i > � - � � � � � � ' a , � _ � . � 1 � R P i� — �� The Commonwealth ojMassachusetts �,� � _ DepartmentoflndustrialAccidents fy� O/HCO011OYBS�tl90t �� _ 600 Washington Slreet, 7`�'Floor . �4�� � Boston,Mass. 01111 ' lWorkers'Com ensatioo Insurance Affidavit: Buildin lumbin Electrical Contractors <-'�m. _ r," �:,^. . e �.� ., :iv 1' n 1 address: r� ( /�.`QGr�, �� --� ci4Y S��`e-�^'`- stace� ��� an• �/�(zd phone# �s ���—G�i �.7� work sire location(full addressl: �� / ❑ a homeowner performing all work myself. Project Type: New Construction emodel 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition , �❑ I'am an employe�roviding workers compensat�on for my emPloyees workmg on th��4sy�ob . "k" xx R��' �4��{p',�a�srt��a�§`S*'��s*k� v� �,�,}� y b3 '.�& w" . t m ri �,�. ,�F'-�'.K'�°, �"-�,T'g'+.,4'f't��.,�5'.��x .��h"�-,`� .�.�`.. .7�"c�w."��F.!�:�,fr�'`.rt,�'"x'3 . .-� , 'q_ ., ' . � r edd�.:�. �,, , . � ." � � '` ^�, , k g r# �� mima��a�"?.^.. �� �'�"�".'�'��` :����.^�" � '' ��ty ��-o�-:':� � �,� ����.��„�,��.�}�o���#�'f'1��7�G ,�'������'�.,.���lc�y�-<- .�., �a� '. 4.a`r+'rrN3a'�`w,r�� � . �, ». c y . kr� �?� a tn �7 in c V li . C( � ,VL.L AB � '.r �.. �' T p�,� � ,* t .. ❑ I am a sole proprietor,general contractor, homeowner circle oxe)and have hired the conVac[ors listed below who have the following workers'compensa[ion polices: . . , � � . ._ . , a., �.. ,�.. �m� wr�-. , �S^ comoanv namr. � . . � . ' . . . �1 4 � .:4 'k� � .n A(�dflSS: . . . " . ,�•:: , hr � tl . }} �. t c .� . J � . tx; �.x w x�,��n.yH', ';.*x54'r i N U5'??°`a��'�f'��:b �{� ^�a ,?ti•4 T rd& �`n +- p,`�'Eyk �;�t xd x.t v t? +5u msuran- � . ^.a. r . A�` . , . a� ,`!',z:?a.s1".'�' ���«��`��17,�`�;�3��f .� :.vz�ra�uosr GtA'� fr . ��- e a*�n�G,tm',i*FF�"�+a�?��'.� k&��ei'�,'h?i � e �r x � ♦" .hX �q��a,.r r � "�s q,� i � „`-.+,f'�". ,, g � , c?„'R;-�y �`"� ,�"',,��"'�.a".�`�.v�����'"fT_'+��.,�£ch'ra��.' .�s7�,.-='t"�x C011108qV 08111l: � F: ''' .. ` #r `�' f�j��, �`J4t'��-�`'��`?A��'w�.;� `"";�5x"!d' °�°�'��� edl�re3S: r�s<<� e k Y : �. 'P,a„ r n "`-. � . �W � -;�t a�-, � ..r +*<.,.�'rt.�"' � x ;. �, F :.V �s+. e �: f �; r � � __ ._ . •5.. _.x -e �.�; U 3�`° t. 'b` �';.t��'*'"`@"M�4N4`.r�a°t?�' '�+'� E:.:��k'f s kis".,x� . �. . . ,8• .:.. t .-. �r x � o n a ... ,... . �. .� �.�9 . -�..;trs .. ...�.�,.,. , .:, : ��">,...� .".�: ` .� .,....x�+ ,..�,..:.�;� _.:.��,- �Failure to secure coveroQe e�requlred uoder Sectbn 25A of MGL 152 can kad lo Ihe impmidoo o(criminal peoaltfn of a 11oe up ro SI,500.00 and/or one years'imprisanment u well ae civil penaltin io tAe form of a STOP WORK ORDER and e floc of 5100.00 a day ageiost me t undenmod 16at a copy ohhis slntemenl may be forwarded to 16e Office of Inva[igelions o(Ihe DIA for covenee vedOcation. /do hereby certrJy un he pains an�la oj e�' ry!hW!he injormalion provided above is lrue and corred Signature � G4 �4t Date /�Zf�� i / Prin[narne GIZ. � Phone# �jGT —/`A'U�7� official use ooly do not write in this area m be eompkted by ciry or towo oilicfal cityortown: permiVllcenxN ❑BuiWiogDepartment ❑Liceming Board ❑cAeck if immediah response is required ❑Seleclmeo•a Offlce �Health Department conmc�persoo: p6one q; ❑Ol6er a�,;u�seni.zix�n ; . �� � � " '-3 The Commonweolth ofMassachusetts .. Aa��s_. . = 7 Department ojlndustria!Accidents a ' - 0//JCBB//p1A9sf/g8tl06S � 600 Washington Street, fh Floor ��4Z�c;. e Boston,Mass. 02111 Workers'Com ensation Insuraoce Amdavit: Buildin lumbin lectrical Contractors A".N'�":: - . . - `� t� .. ... .3!�� ` . ..s.r, s .�, . � . ,. s��_ name: ����.�.�.�j�{i� � � .� �� �y /Jl `�(1 e��T 5 I� � � ci�'_�-1 �e-� stare� [d/1.�� zip d��'�.fl nhone# 6(/ ➢� �9� �� w rk it I ai n � lad ress : . � n ^,�..���;�• , z .� � �, ..�:+� ❑ I am a homeowner erfortnin all work m sel£ �� ; P B Y Project Type: ❑New ConsWchon embdel � �jl�am a sole proprietor and have no one working in any capaciry. ❑Building Addihon ""`r,^� S� ❑ I am an employer prov�dmg workers compensa[�on for my employees workmg on th�s o,�b ., i an r . .v .c +,ye,- �"r s�� .. k �S :�'�` n ��"�f7'���;Y��;;x�t�'��^" 1 somnanv name: ,. -�,..�> , F ,*. a' f , t'"� `t" `° ."a$i ����..3i.5a'`Pas#..�E�'�1"."� sa u ^"�"�� T address. - �����' �x '���'u�t�r�'`2�;°� - . , . . - .�.�+ ,p�- :=.r_a _.'p"e:^4 �':`�.a.i'-`.�.`� ciri: �it��flM �/k "' `` ntioo r,*�, ��,, . ��. � ' �<����� - g' `/`7 �G'�� 9�r5 '� �.r �i� . F .a. in nc ° �:�:;Y .tt�R"�,3 , . ,, , .,,,.�. �.. li . �� ..,.'. � ` ._±;+`; 1 am a sole proprietor eneral contractor,or 6omeowner(circ[e one)and have hired the contractors listed below who ha� the following workers'compens po ices: somoanvnamr IRf�I�N C���e�}✓` � � * }� �, r�� addrese•� � . . . �� . . . 5 . citv: � � ehno u� � `' , s , a�I��s � ,, t „y.:�� insuranc .. . . . ,`-; ; ,� �. �"��C1� �`�`ksF-� . �. .,, �j �"�,"�� 11� niw.. ,isi,a�, r � „w.. aYx^+�i".,�� CO � 8n Bme�J.� . i�� . (`": '.. S.y :=d.F +b� 3 t ����'fi �i'�R «t yi�Z'a P edd.reea� �i� �i-2�fc�,✓a'a/ L �4h f /b� - � . '° .. °,� .'�rx�r*'�#��.�' A� �f� dCG/'/1��J!N clrh B�4lbi�eY' �67�i q-'`'�4 1 � . cin:.'�`/�"7/7-' /l�/�l-�`�� + r^, .� t f* 3 ::ww t �ehone�}�5�/���9�(��}s# a afr�`t." r � a a ri� .s ,cr�.�3 f a�u*�:*' +s`�'��.t'`` � ' a � � s�',�Ek 'n ureomco. � , : .00lievN � �: � �' �"+GC aa� a r�!am , t • �s ,x .-_t . S, r ad,k Fa�lure to secure coverage av rcqutred under Sectpo 25A of MCL 152 can Icad to t6r impoaltioa o(crlminal peoakiea of a flot up to 51,500.00 aoNor ane ye�rs'impriwomeot es well as cWil penaltlea In fhe form af a STOP WORK ORDER and n(Ine o(SI00.00 a day egaiost me. 1 undenrond Ihat a copy ot�his statement may be forwarded to Ihe ORce of tovestigatloos of the DIA for coveroge verificatioo. /do hereby cer�ify under 1 pains and pendlia jperjury thN the injormation provided above is true and corred. Signature �������y� � � .p,.,`_ Date _ /�6�d� Print name �il//l / i /�h.v� .�, l�d.�c1 � Phone#� � a.q�--o�3 oRciel use only do mt write io Ihis area m be completed by dry or lawn oRcial city or town: permiNittnse p ❑Building Deparlmmt ❑Licensiog Boerd ❑check if immediate response is required ❑Seleclmeo's Oifice contact person: hone li; ❑f1n1[h Department �re„w s�n�.x�eui P �Of6er ��:: ��r.�.. �. . :.,� .s �.. . . . ....�. �,����' � . .. ...�'r. . ., -.a. . 3 R.