16 FOREST AVE - BUILDING INSPECTION (2) "PI ISMWT-9EfIL{$*ND APPROVED BY T*IE
JUSPEC100 PRIOR TD A PERW BEINGS GRANTED
r CITY OF_SALEM
No DaM
,�� ,ate Ward
zo"ast t
Is PMPWtY L00019d in ti»M � Yas No Location o€
__ Deildlns /6
Is Property Looded in
ti»Conservation Ann? YN NO
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
epaidRep Other: C'vkf,w day r
PLEASE FILL OUT LEGIBLY dr COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned herby applies for a permit to build accorcLig•to the following
specifications:
Owner's Name s'y
Address & Phone S�tam 17781 S- -R'r�,3
Amhftect's Name
Address d Phone ( )
Mechanics Name affq
Address & Phone `CS Fa�- Gr (y7X i 2,65'-7z.5
WhO Is tir purpose W b k*q? o(aav-
MOMW of fx~ II a dwafwg,for how mmy fsmon?
Wa h a ft conform to law? Asbestos?
E,wnakad coat 3 5-6 2 , CRY LkWW« sMM Uarkaa« Owl R y3
Signature of Applicant
SIGNED UNDER THE PENALTY' �
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0: �DWi �-r-
No�>
APPLICATION FOR
PERWT TO
LOCATION
PERMIT GRANTED
A/P/PROVFD
rD
INSPECTOR OF BUILDINGS
q-1ne C04),
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 129774
Type: Supplement Card
Expiration: 11/2/2005
PELLA WINDOWS AND DOORS
SCOTT HOUSE
45 FONDI RD.
HAVERHILL, MA 01832
Update Address and return card. Mark reason for change.
DPS-CAI 0 56M-04iO4-GlOI216 = Address ,] Renewal — Employment _- Lost Card
,�� �le -t�iarsv�xmuoe¢lt/ c�;�aaoac�irzav,!!a
V
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 129774 Board of Building Regulations and Standards
Expiration: 11/2/2005 One Ashburton Place Rut 1301
Type: Supplement Card Boston,Ma.02108
PELLA WINDOWS AND DOORS
SCOTT HOUSE
HAVERHILL,MA 01832 �'
Administrator Not va id without signature
✓7+e �nomvmanuiea�!! o��-Lr!awac�i�wlls,!
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
q
The Commonwealth of Massachusetts
- Department of Industrial Accidents
w»_ Office of Investigations
;rr 600 Washington Street
\ry'y Boston MA 02111
Workers' Compensation Insurance Affidavit
Au Gcanminformation: 'kas i' IT1 b
Property Owner Name:
Job Location:
Crew:
Phone#
❑ I am a homeowner periormine all work myself.
❑ [ am a sole pronriewr and have no one workute m any capacity.
.� I am an emntoyerprovrdine workers' compensation for my employees workms on this Job.
Companv Name: ,�'lC� /,\`l��pWs, aK�
w "� a�•s
.address:
City: T-gverwltl /►�/� G 8
3 Z Phone# 'gQ Q -8`6 - yg$6
Insurance Co. f 0�•d I n S Cj ro urJ Policy oawBKLyz6y
❑ I am a sole oroonaor,genemi contractor.or homeowner(circle one)and have hired the contractors listed below who have the followatg workers'
compensation notices:
Companv Name:
Address:
Cit_v:
Insurance Co. Phone#
Policy#
company Name: ..:.: .., •> . ,:�. .: - ..
Address:
City:
Insurance Co. Phone#
Policy#
Att2¢h acidationat Sheets ifneeess
Failure to secure covemee as required under Section 25—of MGL152 can lead to the unoosition of crumnal penalties of a fate up to$1,500 00 and or
one vears' 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 verificatiom
I do hereoy cemfv under the pains and penalties of perjury that the information provided above is true and comet.
Sienamre
SGo44 #"Lre Date
Print Name �� T C �4 �f
Phone# �� 866-9886
Official use only. Do not write m this area,to be completed by city or town official
City or Town: ❑Building Department
Permit/license# ❑Licensing Board
❑ Check if tr mediaw .snonse is reautred ❑Selectmen's Office
Contact person: _ Phone#: ❑Health Department
11 Other
`" Pella Corporation
LA
Architect Series®
Dgubfe—hung
Vent •Low—E IG
NationalFenestradon Argon Filled
Rafing Counc�
R2597
ENERGY PERFORMANCE RATINGS
U-Factor (U.S JI-P) Solar Heat Gain Coefficient
0.33 0.30
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0.47 - -
ManWacNrer stipulates that these retlngs mmotrrl to epplitabI NFRC procedures for determining
whole pmtluW perbrmerxe.NFRC[stings ere tletemlin0 for a fixed set of emdrenmemel mntlaions
and a specific Pr size.For more inlUmrsssr,c,a(641)621.11C or visit Pella's lveb sAa at
www.pallacom w vba NFRCa web ails m www.MrGorg
Meets or exceeds C.E.C.Air Inliitration Standards
• WMDDW AND DOOR !2-�W
MANUFACTURERS ASS=TIONH-R15 45x77
CONWRW TO ANSUAAMAINWW1M 10
OP151 OP30 with Kit OBAZ0001
Complies with HUD UM 111 (Pella, IA)