20 FEDERAL ST - BUILDING INSPECTION (11) 10b*NSiM W9Ef&:E"*1D APPROVED BY 744E
JNSPECM9 PWR TD A PERMIT BEING GRANTED
CITY OF_SALEM
No. Data / Z7(•'�
1`. ire Wald
Zorrng Dlshlcl
Is Property Loeated in Lmation of
IMmmoncDid"d? Yea No _ Doi7dias 77 RJ4-4-,l
Is Propuly Located In Z
VW Connroadon Area? Yes No—
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
epeidReplace, 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 accorc -ig,to the following
specifications: /
Owners Name K� ��
Address & Phone OD Pe
Architect's Name
Address & Phone s'co7/ f )
Mechanics Name Pe 1� (�\ s F AI us e
Address & Phone Fa�,t (f??) 76S-77 SS-
What is the purpm&buildplgl
M WN 01 b~ n a dwoft for how mnly Imam?
Wa hukkV conform to law? Asbestos?
Eallmated coat Z57 I-
cnr Lk«r.• slw Ucata.e03 l P 3 9
\�? ao•a Iapro.e.ent
ature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�NV S2 r/�Tl/�19L CffflT/GE�s
MAIL PERMIT TO: A"m e ()wVz �
L
No.
APPLICATION FOR
PERWr TO
LOCATION
PERMIT GRANTED
19
ROVED
INSPECTOIR OF BUILDINGS
Yam'
' r
PUSUC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 31ND FLOOR
SALaM,MA 01970
TEL. (276)74n 595 Err.360
FAX (978) 740.96"
STANLEI/ J. UlOVICZ, JpL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the prOVWOm of MGZ c 40,S34,I aclmowledge that as a condition
of Balding Permit S .aIl debris resulting from dw cona mcbm activity
govemed by this Building Permit shall be disposed of in a properly licensed soh&waate
diepoaal facility,a defined by M(3L c M S150A.
The debris will be disposed of at q5-
Location ofFacility
�7
igoanue of Permit Applicant .
(PLEASE PRMr CLEARLY)
Name Of F amit Applicant
Firm Name,if acy
Addnwk City&stag
The above statute requires that debris from the demolition, renovation,rrhab or other
alteration of buflftg or smIcdae be disposed in a properly-licensed SOH&waste disposal
facility as defined by MGL cEZ S 150A, and the building permits or licenses are to
indicate the location of the facility,
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston MA 02111
fy.
Workers' Com ensation Insurance Affidavit
Ap Gcant Information:
Property Owner Name: &7
�' �
Job Location: ,y.P ��,,;-� ji,
City: dee -11" Phone#
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity.
V I am an emplover providing workers'compensation for my employees working on this job.
Company Name: .? ;1 1 4
Address: t f S t City: { Qv/C�r t� l Phone# /q
7Y^ ?6o - 7Z SC
Insurance Co 6 rD Up Policy# 02-W B KL yZ 6 5/
.................. , .
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hued the contractors listed below who have the following workers'
compensation polices:
Company Name:
Address:
City Phone#
Insurance Co. Policy#
Company:Name:
Address:
City: Phone#
Insurance Co. Policy#
A.tC�i.At31: 3CE1S i `7iCOk:S:9. .:>
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500 00 and or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy 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 enalties of perjury that the information provided above is true and correct.
Sienature I t�U` =�-n--. Date
Print Name sc_.-L-4 I U.SQ / 1�C�'4 .✓1 W J Phone#
Official use only. Do not write in this area,to be completed by city or town official
El Building Department
City or Town: Permit/license# ❑Licensing Board
❑Selectmen's Office
❑ Check if immediate eeannnse is required ❑Health Department
Contact person: _ Phone#: _ 13 Other