15 FRANCIS RD - BUILDING INSPECTION fL�INB�AIl6pTWlIER y� • PE�\A�P7PsRROVuE/�D BBY-17m
CITY OF SALEM
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Permit b: POW
BUILDM PO APPLICATION POR:
(Ckde whW~apply) Roof, Rowl Install Siding, Coal W Doak, Shed, Pool,
Rspownsplaas, outer: L o v e L. L..+ Sr S'i yea U F' l-I o L4.s P
PLEASE PILL.OUT LLXIISt.Y A COMPLETELY TO AVOID DELAYS N PROCE>IENiO
TO THE INSPECTOR OF BUILDINGS-
The undersigned trereby applies for a permit to btdid aaoording.to the.follwaft
srsdfloaft s:
Ow mes Name b csr. A Ln k L F
`Address A Phone l 5 A,,,: ( 1 g1 14 g -7 '7 y
Amhtiect's Nun
Address & Phone ( 1
Mechanics Name - -p,✓ Cj 6 �p L-V Cc,,s I-
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91111 111 11 THE PENALTY'
OF Ilmu Ili
DESCRIPTION OF WON(TO W DONE
MAIL PERMIT To. L p G , b_,, l_Y Cc, v-J 7- f C/ 7 ( V q 1.,�j
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-_" - - The Commonwealth of Massachusetts
Department of Inditstrial Accidents
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r 600 Washington Street, 7"'Floor
� y Boston, Mass. 02111
Workers' Com ensatlon Insurance Affidavit: Burldm /Plumbmt,/Electf teal Contractors
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9 name:
address:
CIN
state' Zip
phone#
work site location(full address)_
Lf I am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
Q1 am a sole proprietor and have no one working m anycapacity,
`+. Buildin�Addition
'I am an employer providing workers' compensation for my employees working on this job.
company name: Ly
address: I11 Lt /]-'.:yljt.A. t i✓ T p
ct rv: T .J7 A b o `/ � ( �/i�� phone# /� O S ,3 1 S
0 p 97 D Z)'6 1 l.,,7? Q Q y.
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
(he following workers' compensation polices:
company name -
address: -
city: . . .
Insurance'.ce.' Ohe ' '
comp9ny name^
address: -
city: phone#:
i nsurance.co. olic. #
Oft&S 4.LlL =092MA372Y W.
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imp
os(tlon of criminal penalties of e fine up to SI,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORN ORDER and a fine of S100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby certify under the pains and penalties ofieerjury that the information provided above is Prue and correct.
Signature Co Date �j — I '1G v 7/"
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Print name (y ( b,y Y Phone# -1 p I�--f
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y, official use only do not write in this area to be completed by dry or town official w b.
f
city or town: permft/license#
❑Building DepartmJ
❑Licensing Board
❑ check if Immediate response is required ❑selectmen's office
contact person: ❑Health Departmen
phone#; ❑Other
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500-7,45.9595 tit 390
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of HCL c 4,0 , S54 , I acicnovledge chat as e
conoicion of Building Permit 0 i , all debris resulting from the
construction acziviry governed by this Building Permit snail be dispo5ee c)
a properly licensed solid vaste disposal facility, as defined by hQL c ! "
5 150A,The debris will be disposed of at ; Av//o t,I f1 S t �o Cgtir ,
location of facility )
.q_" G � j
Sigaicure ot pplicant Date
Fully complete the following information
(Please print clearly) p.
Name o Pe ermit Applicant
Firm Name, it any (�
( 1A V C i c7
nddress , 'City i Scate
The above statute requires that debris from the demolition.. renovation , rtaat
or other alteration. of building or structure be disposed of in a properly
licensed, solid waste. di4 ossl facility as defined by MCL clll , 5150, ant c-'IA.
building permits or license's are to indicate the location of the faci '_ic7 ac
DESCPIPTICIAI na: wnov -rn:na nnalr
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