66 BROAD - BUILDING INSPECTION n
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mspEG=PWR TDA.PF.FII�IT MWO GRANTED
CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) not sroof, Install Siding, Construct Deck. Shed, Pool,
dReplace, Other-
PLEASE FILL OUT LEGIBLY i 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:
Owner's Name o�u 4
Address & Phone
Architect's Name
Address & Phone ( 1
Mechanics Name f l /oaf r
Address & Phone 4> r��`4-v.Y )VI'll
What is On purpose a W~
MaMM of bidl Wq? a a dwe".for how many fambee7
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aotae Lpro.e.ent
La
�,,\ c. 06 L Signature of Applicant
�/� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO:
• �`-/�f ��/ Sao /9 G�
No. h ' D
APPLICATION FOR
PERMIT TO
/
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LOCATION
Cod 8�4�
PERMIT-GRANTED
2.0
AP RovF
INSPECTOR OF BUILDINGS
The Commonwealth of Massachusetts
Department of Industrial Accidents
i1 office
600 Washington Street, 7`Floor
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit: Buildia lumbin lectrical Contractors
A
name:
/z,n . LL�
ad es:
city .� �1�� state �/� zip ���lJ phone#
work site location(full address)�
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one workin in aTca aci .t Building Addition
am an employer providing workers' compensation form employees working on this job.
address: e'-
714,
❑ 1 am a sole proprietor,general contractor,or homeow (circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name,.
address:
inks ran�ee�� :.�. ...,.
,ra , nolicv
company name,
address•
♦ nbpn Sk
insurance ca.
Failure to secure coverage as required under Section 25A of MOL 152 can lead to the Impositkm of criminal penalties ors fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify unde�'ns an en lies of perjury that the information provided above is true and c rrecd,
Signature Date J' G
Print name C- 4�r+ Phone# �YS
official use only do not write in this area to be completed by city or town official
city or low rmit/license#
xn: P< ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
contact person; hone#; ❑Health Department
P ❑Otber
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