4C FLETCHER WAY - BUILDING INSPECTION (2) -PtJ S MtJ T-BE f#L+_ f .APPROVED BY T44E
,=.P,ECTp13 ,PF1 fl TD.A_PERMIT.BFMG GRANTED
CITY OF SALEM
No. !-�� ..� �,\ Date 8 ' S ' o3
,5
Is Property Located in Location of
the Historic District? Yes_No_ Building {
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R _ eras Install Siding, Construct Deck, Shed, Pool,
Repair/ReplaceOther:
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 / Q, char•4L M a �A,&n
Address & Phone W l4,k-e. A (91B) 'IN 5 l9il
Architect's N e
ess & Phone
Mechanics Name ZI JAA 4nm e _ _,4)o TV t CeS
Address & Phone 39 S
Wo+rCes er , Ma . d14-7p
What is the purpose of building?
Material of building? If a dwelling, for how many families? l
Will building conform to law? Asbestos?
Estimated cost -�—City License u N A state Li en e a
Ilib -2-004 , Home Improvement
Lic. 1 J Z6A43 �
Zgoo � 5ti�3 Signaturere of of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIP T ION OF WORK TO BE DONE 1
(�1 Q Qlac2nl�n� 1 I n,� Wi nAows 4 on ruJvr:zl
MAIL PERMIT TO: t-4 sm Q _ )w f\-Q,r
No. I8(o ZOoLl
APPLICATION FOR
PERMIT TO =
LOCATION.
PERMIT GRANTED
�L) �c t
`INSPECTOR BUILDINGS
AUG-21-2003 THU 12:45 PM AMERICAN PROPERTIES FAX NO, P. 01
American Properties Team, Inc. /�
I
TO: Tam St. Pie e-Salem Building D ent
FROM: Jill DeSantis Property Manage
RE: Rick Madde 4C Fletcher Way Pickman Park Condominiums
DATE: August 21,2 03
Please be advised,tha the Board of Trustees for Pickman Park has approved
replacements window by Home Depot providing they match the existing windows, and
can fit in the existing pening. They will not allow windows with grids, crank outs, etc.
Obviously, we also re uire the permits be pulled in advance.
Should you have any i uestions or require additional information,please feel free to call
me directly at(781)93 -9229.
cc: Rick Madden
500 WEST CUMMINGS PARK • UITE 6050 . WOBURN • MA • 01801 • 781-935-4200 • FAX 781-935-4289
.0mmonwaAk o/�aseachcasef`b
�
- � Japartrnanl o/�"w'•'trinf fascia rtla
rn,boo WaaLrjton Sirael
James J.Camooefl ///aaadctiauallj o2f i i
corrmrssgna
Workers' Compensation Insurance Affidavit
e.f- R M A- Ao►) L Se C u i e e s Zr,c .
wich•a principal place of business at:
3Zoo Ca� � 41I1r` G 1' arVwc t Z00
tr+�rn�s+ri r
do hereby certify under the pairs and penalties of perjury, that:
(�y I am an employer providing workers' compensation coverage for my employees working on
this job.
mRCLe, � T���sl� w� g696691
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 1 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/Polity Number
0 1 am a homeowner performing all the work myself.
I unoencano wt a cony of[his statement MI be for arced to the Offce of Inwdgavoat of the DIA Ior coverage verAtadon and etsat Ware to aeeure
coverate L red• ec under Section 25A of MGL 152 can lead to the in=goon of crsnina, otnanin corsudnt of a fee of va M41.500.00 and/or one
red uo as+a as cm "naidu in the form of a STOP WORK ORDER and a fine of S 100.00 a an at",OK.
Si ed s day of AvGvt�_r _ 2-063
Licensee/Fetrniuee Building Departnrsent
Licensing Board
Seiectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
f 4 OF SALEM,- MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
1; SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
�G FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
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. S t r� S 4 v a �S mot
a
j—LLocation of Facility
„�/1 \,_� S 0 3
Signature of Permit Applicant Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
'""
S Cx 1^ L�3f2o
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.