18 FRANKLIN ST - BUILDING INSPECTION f1.sAlsl�Atlsi-BE f gE94rN0 ApPROVED BY T44E
pWDR TDA.PEMITWING GRANTED
CITY OF SALEM
No.l T Q6 —\` \ Data 3 d
J.
is Property LocaW in iodation of r
Ow F WAft DIaUId1 Yes No bdming c� Clank a S�
is Pmpwty Woakd In
tlw Cawwvadon Mao Yas No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
dReplace, Other:
PLEASE FILL OUT LEGIBLY 6 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:Owners Name Ckolj � �e Vas
Address & Phone
Architect's Name
Address & Phone I
Mechanics Name fx4t"et rn rr —
Address & Phone /0 Fyaok l6'w sT•
Wtwt isttw purpose of W d*V? a pk"
and W of tm.&H p4 P.c wvn/ n a dwwq,br how marry fart m?
WIN Wrldtrq=dorm to law? 4 AG W ?--kli
E&W wled coat W 00- oo city Ucerwa a N A Stara Ucerwa a OS 6 6G6
mom Lpto►m ant
a's`' m 6�P� Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ish
MAIL PERMIT TO: b [' cc�J L flPh �1 S�
W,�c,--6v
Ne
APPLICATION FOR
�n PERKY TO
LOCATION.
PERMIT GRANTED
�AQ Sf 2006
APP OVfD
I P OR OF BUI DINGS
CITY OR SALEMq MASSACHUSIgTTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINOTON 8MAT. 399 FLOOR
9ALSM. MASSACHUSCM 61970
TSLSPNONS: 979.749-9699 W. 390
FAA: 979-740.9"4
Salem Bait �w.n...4.....__•
rm
In accordance with the provision of MGL c40 S 549 a condition of your
Building Perant is that the debris resulting from this work shall be disposed
Of in a properly licensed solid waste disposal facility as defined by MGL
Chapter HL S 150 A.
The debris win be disposed of in:
114 (Location of Facility) SC J
Signature of Applicant
The Coruaomred"of%sochum tta
Dcpa MUM of Indrrs&W AaUmft
On'Ief dlta
6"washl»r"Sh*d
Bosim MA 9L11
wwwasnagaVAW
Worker'Compentadon Insarmee AffidrA t Bv2ders/ContradOrs/Elecbdda>Wftimben
Anoficmd Irma&& Place Print I.es;lbly
Name P (',mf t-wcb h
Are you an ao".. rf Ct+v. t>t6`ippeeoriate Gorr' _ Type Gf~��
1.❑ I am a employer wit► R 13I am a gmerd oautraetor aed I ❑x�
employees(hMand/orput-dowNe boveliredtleati aatactoe
2 I am a tale pmprielor Of patoatr6 listed an the ammw meat 1 7. ❑ RemodeffeS
slip and have no employees M=mb-OM*aelm lave 3. ❑Demolidaa
waddofWamieaa,�apeft. wodoWcon96'att 9, q admanS. We am a�pOc 'Al to., • ]0 0 FJecdial sepaQa or addid�
ngabed.}_� o8feat>iiynaee ttidr
3.❑ Iamaiomeowaar.doiogap.ao� Sig6tofeiiQ.xerM( 11.QP1mabieBrgnbaaradditbaa
C 0 132,fl(� ae�"lawno 12❑Rooftepaie
iaaasaaaerequited:]t. Eby LI'b .0 . 13.0 Other
•w,q�pptlr�,Ytdwbb=01=adds®wl4c•Ai WOW+wieae.t. ao�..tlo�vexarietbim�elo�
}lOmtOMD�� Ot�telV at6arvlt p d d) �a�bpatitt adhlp�etirt�abma sA.ma.�a iedtatiq acL
�CO�Ofcba n�If�Ca�bOa'fl�YOldt/a��aad00a�R Abe d DA�r��COm�{'�I�/�+�IIOI� Om� DOVC)�O�lfflfrtOL
lear sompkydrLwlrpwviAWS wrderr'eowpommiidbtndattorfa►Spahr Ai;f* BdvwitdrpoBeyeradma&#
hO
immures Compmyxat�
Policy to or Self ins.l ic.tr Eapitation Dace
Job site Addtat (fty/S
Attack a copy of the werkera'compeessilm Polley declaration pap Gkowing the policy number and eViratlo■date}
Win to Secure ooveta ti err tegtwed under Section 23A ofMGL e. 132 can lad to do imposition ofe:�mal penalties of a
fine up to f 1,J00.0o aod/ar one yew ,swell ar cid pwalBer fade form of a STOP WORK ORDER and a fin
of ap to 3230.00 s dry aphW me violator. Be advised do a copy ofah sWC10M maybe fixwatded to ge OM"of
Investigation of the DIA for maaraa coverage vai}fatios.
f lr hereby aaJpenad:Ja oJpfffiW that Ad Jajanaa kx prov1*d above k tress and carro"
77�
Shmaum
O,�Jelal axes onlp 1>,ad»rbe u,rhb any b ba roaeptdedby eldaibaw o,�rli
City or Town Permbucesae 0
faaleg Authority(cirde one):
1.Bond of Halo i Building Department 3.City/rown Clerk 4.Electrical Impeetor i Plumbing Inspector
ti.Other
Contact Person: none fh
Information and Instructions
: .... .. _.., . .._. Sur deir emPbsyM
� en Geral L.awa dapter 152 ngoi m ad emplo wo"-wow
ender"eras comnd of�ite,
Nnaaat b&b stalaw. as dMAYM is defined>s ...every person 4
�a imPHed,od a wrates'
it od o ICO Co"air Say two or mace
of thaaca foreW�s° °� anocia"a a�gid Ca empla M®Vl°9°a' Ho�raMAS
receiver or ttostee off and wfa raid"Saak or tl a occupant olydw
owns of a dwelmK =NO a do maibta nw%con nuctbaor�wor#m sad dwellin bome
4 OR di boase otatotba who a NICAM 1�"mtbecame Of=&cmpby �be d0E°�b be m emPlaYes:"
or oz the��erbaildinf���
M,c�1s2,1�6)'lao sister that-everq state err beer).deaaln{atWc7*4 wkbbdd tie Maeo' a or
rencwai of a deem or PQu*to operate a Dada""err to caratrad bull"b the temmaawalM fW my
sppilent wYe hm rat psodred am at'M.M aticomOSS"wen the bo raaoa eonrap rW _
AdtHtiooady,MM d VIM 15Z 1Kl):nteo"Neichat*0 ounuoswaLh�at��widt
�nr�aee
��tiCM
�ab mbsvebeayae�k�d the6> -
APP§cow thsbossa cost appt)r byom situation and,if
affidavit eomplettly.by
new snPPb' oe�(' s).addtaf(eS)era¢pbow�ba(f)aiwg wi&their eati>ie"K0 odka f tbm the
MonumsMdM( er Limited I.iabtl$Ir Pa<masbiPa(LLih wib no cogfteea
membese aP �b butum If aau c a LLY do"have
mipioyea,s PaIiLY s!04°II0d �'dOf industrial
V-d� `71flalwaucecoverap � to me Devarmtaat t3a affidavit sboald
b and date the amdavit.
Accidens be nuunabeOO itkCcity tw Sit the petmit�� x no uked a obad i of
�ialAaideota� Sbpaid yttabave any Q ski . should ester theft
poH X pleas&eat).the Depe Mxd at the nmibet below. Set[ittamed'ao®paeire
ionter on the Hoer
(ay err Two°fodder
u late and printed legibly. The Dcpamnest bus provided a span at the bottom
please be me that the affidavit con4Aling
of the affidavit fa you b IM out m the event the Offioe of imvatigatiom has to contact Yoe ht sddidoe,�ad
comber which will be used n a refaencc mmba.
applicant
that roost submit aM*le P fe appficadens is any gives year,need only submit one affidavit h dicatimi current
poky; manna(if nocwary)and nader"Jab Site Address"the applicant sbu w���tiONS be P n b y Of
town)."A c6O ofthe a that hmbass otfieiagpstamped aL»!!bod bX eih!..
as that a valid affidavit is os ffla for NOM pamas a Hcentea A acw aflidwit mostbe filed eat aid
yew. " . a of a Hance a patbrt not related to any Dumb""a a n maeial veabre
pr.Where a home Owner or dtttxa is obtaiaioi b lqp>bi•affidavit.
(La a dos Hama or Puma b barn laves etc.)said pricer is NOT ngaaed comp
The office of luvatipboaa.
would Mw to dank yet in advance for your caopaaaon ad sboald You have any 4u�oM
please do not baihse b Pure as a ca0.
The DepaMeds address.tc=Phone and fa comber:
The Commonwealth of Massachusetts
Depaftmaut of Industrial Accideob
omct of InY Wpdons
600 Washington Strut
Boston,MA 02111
TeL 617-7274900 ext 406 of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-O5 www.mass.gov/dia