16-21 FREEDOM HOLW - BUILDING INSPECTION C 77yo
jRj* IS*"T-qE f&Eq-I 9 AfMOVE0 BY T44E
J SPF.=DB PRW Tp.A.PEF1SlfIT BEING GRANTED
CITY OF SALEM 2
NA Date J GS —
s:
Is Property Locawd in Location of
Me Historic District? Yes No�� &&Ming
Is Property I ocated in
Me Cormervetion Area? Yes No=�
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo eroof, Install Siding, Construct Deck, Shed, Pool,
Repair/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:
Owners Name
Address & Phone f cJT z' ��,.1f �� L_ (��) -)y/ ado
' Architect's Name
Address & Phone
Mechanics Name d17 '{r'1
Address & Phone eeJl i e-7
What Is the purpose of braiding?
Material of Wikft? / fl a dwelft, for how many families? 47
Wig Wildhp conform to law? ✓ Asbestos? �—
Ed meted coat CUy Ucerme r N A state I.Icarme r
Bone Isproverant
tic. e� Signature of Appicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
� 7` c/
C
MAIL PERMIT TO: Z-I
No. U
APPLICATION FOR
/PERWT TO
LOCATION
PERMIT GRANTED
APPR
Qp 4
L ' . , c-;,72
INSPECTOR OF BUILDINGS
.r 1
r�
The Commonwealth of Massachusetts
G� T Department of Industrial Accidents
-- - i?1tl000IIBYBStlg8tl00S
600 Washington Street, 7 h Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name
Cvo /9
city state: zio: Cl 9,)Gohone#
work site location(full address),
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction model
❑ "t am a-sole`proprietor and have no one working in any capacity. ❑ Building Addition
[-ktfian employer providing workers'ccompensati n for my employees working on this job.
company name:
addr
-r--�-,--7 ishout 7�1 f
^` M.
J
❑ 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:
ennsurniny
address:
city; phone k
ycr-.h.,t c
ins ranceeo. nolicv8 ,.
com s e•
address:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal pens ties of a floe up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of is STOP WORK ORDER and a fine of S100.00 a day against me. I understand that s
copy of this statement maybe forwarded to the Office of loy mligistions of the DIA for coverage verification.
l do hereby certify under the pains a Id p /lies off r)n that the information provided above is true and correct. C
Signature Date ✓ C —
Print name L' : Phone#
r[3,h,",ck
e only do not write in this area to be completed by oily or town official
": permit/license# ❑Building Department
❑Licensing Board
if immediate response is required ❑selectmen's Office❑Health Departmenterson: phone#; ❑Other
L