15 FRANKLIN CT - BUILDING INSPECTION (2) �tN''iMl�6T�EfiLmft, D APPROVED BY T44E
.WSP CTAB PW.R TLJ A_P1:8M'T BEING GRANTED
CITY OF SALEM
No. \ -V 5 3v \' Date
J
s.1..
Is Property Located in Location of
the Historic District? Yes No Building
Is Property Located in /
the Conservation Area? Yes No l/
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
air/Replace, 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
Address & Phone I I `� '� r
' Architect's Name
Address & Phone ( I
Mechanics Name E 6d - Zell
Address & Phone
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Nil building oonlorm to law? Asbestos?
Estimated cost l 6/� City License • N P' State License # 6
Barge Iaiprovewnt
1 1 Lic. i z X
l�l ' r Signature of App6Fanl
1 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:L /7 iP /7711, 0�Q6 �✓�G� 'Sg
l//1 - fC�✓ /�OQ�- �
1 AN
� .7 ��
APPLICATION FOR
PERMIT TO
R�Rftf--
LOCATION
PERMIT GRANTED
3 2.5 LQ D,�
AP ROV D
/NPECTOR OF WILDINGS
The Commonwealth of Massachusetts
Department of Industrial Accidents
y� — t71flCdO/IRYB8tlp8tl09S
- - 600 Washington Street, f"Floor
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin lumbin lectrical Contractors
MENEMpV4.T
n lL
a >° GC--,C
city state: "7"7L Am 6l%,)CJphone4
work site location(full addressP
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction model
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
OD,4-aaWan employer providing workers' ccompensati n for my employees working on this job.
Company Rome:
address: 461
insurance co. /l//9 L �S. IrolicvM _b 6i — ) Sa�OU.7 C <
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
comoanv name:
address:
city: n1oneN*11 -
insu nceca ... n
ralicvM .. . ` . .s !.
comoanv name:
address:
city:
9 1
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the Imposition of criminal penalties of a flue up to SI.600.00 and/or
one years'imprisonment as well as civil penalties lathe form of a STOP WORK ORDER and a floe of S100.00 a day against me. 1 understand tbat a
copy of this statement maybe forwarded to the Office of InY stilt ous of the DIA for coverage verirtntion.
/do hereby certify under the pains a d p hies of r)n that the informalion provided above is true and corre t. C
SignatureL-r Date J— ✓ C
Print name Phone N
official use only do not write in this area to be completed by city or town official
city or to": permit/license a ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phones; ❑Other
mush Sc, ]apt
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
1. P SALEM, MA O 1970
}� TEL. (978)745-9595 EXT. 380
FAX (976) 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, S 150A.
The debris will be disposed of at: '-V S " /�•/'t 7, "V Sly // ��✓
Location of Faci
J
Signature of Pe&dt Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
11,17 / "�' /e, ,'z
Name of Permit Applicant
� J
Firm Name, if any
XfiDfG -
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 cIII, S 150A, and the building permits or licenses are to
iridicate the location of the facility.