20 FEDERAL ST - BUILDING INSPECTION (10) ' 4
II.M T-SEf-fL{PiidD APPROVED BY T*IE
.=PfXTOF,I ,PR R TO A PERMT.BEING GRANTED
_ CITY OF SALEM
No.ED J F�.t� ''�\ Date
h y pry. a
Ward
� �✓mne�°'°� Zoning District
Is Property Located in Location of the Historic District? Yes_No_ Building eat SA
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) 44;N
nstall Siding, Construct Deck, Shed, Pool,
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 t 4k h
Address & Phone 'Za e�,�� , (/� 2 (`P75') ��S- ({36
Architect's Name
Address & Phone /� l // /I ( )
Mechanics Name (tt[6 w��o�s� �� f�as--e—
Address & Phone yf F7 " /Leal (4F7) a�s-72-5S
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to llaw? Asbestos?
Estimated cost 324, City License it state License *
Home Improvemeqt
V ` Lic. 0 17.Q
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE AA
MAIL PERMIT TO:
Not
APPLICATION FOR
PERMIT TO
LOCATIONr // C7Tl
d re�XLPrti � td—
PE,QRMIT GRANTED
19
AP,RROV�D �
(/J . ,
INSPECTOP OF BUILDINGS
i
1
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 129774
Type: DBA
Expiration: 11/212005
PELLA WINDOWS AND DOORS
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL, MA 01832
Update Address and return card.Mark reason for change.
%I Address ❑ Renewal Employment Lost Card
,a ✓�ze �Joon�rtarei�r,¢� a�✓ltawac�u� . _ _ _ ____
Board of Building Regulations and Standards License or registration valid for individui use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 129774 Board of Building Regulations and Standards
One Ashburton Place Rm 1301
— Expiration: 11/2/2005 Boston,Ms.02108
Type: DBA
PELLA WINDOWS AND DOORS
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL,MA 01832 Administrator
lee Coomvmrartrieal/le o�;�aaoac/ucelQ ��
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 081843
_ Birthdate: 02/06/1966
Expires: 02/06/2006 Tr.no: 81843
Restricted: 00
STEPHEN T DICKINSON
17 BURNSIDE LANE '
MERRIMAC, MA 01860 Administrator
L
The Commonwealth of Massachusetts
-4 Department oflndustrial Accidenu
'``' '" "4 Office o Investigations
,fJ`� f
600 Washington Street
Boston MA 02111
Workers' Compensation Insurance Affidavit
A Grant information: ,,
Property Owner Name:
Job Location:
City: Phone#
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity.
"n;':"...: .o„nyrv":>%<`:Y«x'^<.:y..>.or,.;",.;;n..';.<sx�;.y: Y^ccn•n+ae �:.:.,�.,
.,F�it'.;�.i;�?;,
,>.. < <...,. .. loy
I am an employer providing workers'compensation for my employees workingng on this job.A
Company Name: Pe IlC1 W�tnApw.s and Ddars
Address: q S FONDZ (Lee .
City: { --gverwllt MA ble3Z p Phone# Too -846 — 996
Insurance Co. kr+fOrd Ins. Grovp Policy# OR WOKLg96y
( ..:. .:... :'.�...... .. �.. ....<^ eV.,)
.i"<'. «neAJc.
.:. ., ,.::o..aon � - :^ ..y>»wa aO�t "'. '�• 'A�bi�rX'x' v���?j$wkf':'Yaa'?, ',..:
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'
compensation polices:
Company Name:
Address:
City: Phone#
Insurance Co. Policy#
,. v:<.?io'.i5:
Company Name. �...;.»
Address:
City:
Phone#
Insurance Co. Policy#
!Filu
re tyesy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Siemmre
Date
Print Name Pie 1/4 4 / r,*1ows Phone# 00- 866-9886
Official use only. Do not write in this area,to be completed by city or town official
❑Building Department
City or Town: Yennit/license# ❑Licensing Board
❑ Check if immediate m ❑Selectmen's Office
is repaired �Health Department
Contact person: _ Phone#: _ — ❑Other
P"JOUCI PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FUMM
SAL,EM.MA 01970
TEL.(978)745-YS95 EXT.360
U* FAX (970) 740.9845
STANLEY J. USOVICZ, JR.
MAYOR .
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the pmvidm Of MQ,c 4%S34,I aclmowledge that at a cm&dm
of Building Permit S .all debris r=WtMg from the ,arvgy
govaned by this Building Permit obeli be disposed of in a po;opaly licensed solid-waste
disposal facility,as defined by MOL c A SIM&
The debris will be disposed of at
Location of Famft
3Patm of Permit Applicaat
FULLY complete the hollowing infounadon;
(PLEASE PRIMP CLEARLY)
6Ly�
Name OfPermhAp Hem
Fhm Name,if any
ysh�o,` �< <i
Addtw,City&state
The above ablate mogmm that debris fiom the danolition,renovation,rehab or other
alteration of baikfkg or atr whn be disposed in a properly-licensed solid-waste disposal
frcility w defined by MGL cA S I SOA, and the building pamits or liceam are to
indicate die location of the facility.