0011 CRESCENT DR - BUILDING PERMIT 0011 CRESCENT DRIVE 129-2004
GIs#: 7759 '711
COMMONWEALTH OF MASSACHUSETTS
Map: 15 CITY OF SALEM
Block:
Lot: 0515
Permit: Building BUILDING PERMIT
Category: REPAIR/REPLACE
ermit#, -' 129-2004
Project# JS-2004-0212
Est. Cost: $2;875.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERARD PELLETIER STATE-066066
Lot Size(sq. ft.): 7411 Owner: WILLIAMSON WILLIAM D
Zoning: ' JR1 Applicant: WILLIAMSON WILLIAM D
Units Gained: AT. 0011 CRESCENT DRIVE
Units Lost:
ISSUED ON: 12-Aug-2003 AMMENDED ON. EXPIRES ON: 05-Feb-2004
TO PERFORM THE FOLLOWING WORK:
129-2004 REROOF. FRE)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET,
Electric Gas Plumbine Buildin
Underground: Underground: Underground: Excavation:
Service: Meter:. Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Treasury:
Water: Alarm:
Sewer: Sprinklers:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF
ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2004-000229 05-Aug-03 2388 $20.00
GeoTMS®2003 Des Lauriers Municipal Solutions,Inc.
CommonvilAk of 11/a6jac�weff
6 �tpa.Gaunt o/ Jaduatrinf sccia rata
fn�600 Wae{ainyton
James I CaMDoet t��M ///aaaacLtaslb 02111
Carmss,aia
}Workers' Compensation Insurance Affidavit
/
wich.a principal place of business at:
do hereby certify under the pains and penalties of pe ury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
/ capacity.
am an a sole proprietor and have no one working for me in y
0 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy.Number
Contractor Insurance Company/Policy Number
Contractor
Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I understand that a coon of[his sut r enr""a be ionearotd to rhe Oftce Ol Imeadiavens of the DIA for coreraie eeeiracaddn and Uul laiure W aea,re
co" aic as rMi.eo under Section I SA of MGL I S I can lead to the i mcwtion of Ronna,ot"Lles cdriudnt Of a me C'up w41.500,00 anwor one
years' iraoruonmrnr x.,ru as circ t,ujaes in the loan of a STOP WORK ORDER and a fee of S 100.00 a am stirot me.
Signed this day of
Lictn�e'/Permittee 6'uiT�ing Geparcnrent
Licensing Board
Selectmens Office
Health Department
T0 VERIFY COVERAGE INFORMASIOt4 CALL: - i7.727-4900X40? , 404, 405, 409, 375
nor OF .SALEM. IY ASSACHUSETT5
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
7 SALEM,MA 01970
Ttr TEL. (978)745-9595 EXT. 380
�Grma FAX (978) 740-9846 .
STANLEY J. USOVICZ, JR. -
MAYOR
4
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# ,all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S150A.
The debris will be disposed of at: l Loo
� cation of Facility
Applicant
- Date —
Signature of Permit App
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
( �L-0tI f 4'eC'v
Name of Permit Applicant
'elle. nom- C nIA
Firm Name,if any
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.
-PL-*NS-MttS -9E+fLfC-1fID AfkPROVE0 BY 744E
UWSPEXTPR ,PRJOR Tp.A.PEANAT.B,EWG GRANTED
CITY OF SALEM
No.12- I —2,D(D kA .� *\ Date
41n60'�,1
Is Property Located in Location of
the Historic District? Yes_No Building Ct-fSC1 of Dy
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof,-4
a of Install Siding, Construct Deck, Shed, Pool,
Repair/ eplace, 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:
Owner's Name ( "�� �✓ ��i Pvnsa>n
Address & Phone C r-UcMr Ov - 7c14- r50
Architect's Name
Address & Phone )
Mechanics Name 4
Address & Phone /I ( )
What is the purpose of building? i Gtet7C-4,
Material of building? v✓da d If a dwelling, for how many families?
Will building conform to law? eJ Asbestos? 17 d
Estimated cost UO City License# N A State�License # OG C occ
Home Improvement
tic. I Iam r , Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
L0,01DI, - CIO layey y
t
MAIL PERMIT T0:
/C) I-vU�Ic1, � st •
sa6vi, /�U . DIV 7d
i
No. 12q -20011
APPLICATION FOR
PERMIT TO
LOCATION.
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
f-
t J