5 GENEVA - BUILDING INSPECTION gPLWGMW4@E fILAB' 4ND dBP APPROVED BY 7.,7�4,�E_
Jf.C=P8=W A PEAWTBEING GRANTkD
\\c CITY OF_SALEM
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Permit to: BUILDMG PEFBIIT APPLICATION FOR:
(Cirde whichever apply) Roof. R Install Siding, Conatnict�OepC, SMd, Pool.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCEBWjG
TO THE INSPECTOR OF BUILDINGS: '
The urodecoorved hereby applies for a permit to build acoortLig.to the.followhq-
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Owners Names^
Address d Phone S 7 7S—,2P�2C
Architect's Name
Address d Phone ( 1
Mechanics Name
Address 6 Phone /� !( 0)
What Isom Vo pap of buYdY�t 2'54 z/<c e 7 /ai
MwNw of btlldnp4 M a dwrlM m,for how matt b*n?
WE bukbV=dorm to low? Mb$N=?
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Lie. f
Sighature of Applicant
SIMM UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE '
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MAIL PERMIT To:
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APPLICATION FOR
,pp PER I TO
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LOCATION
PERMIT GRANTED
19
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INSP
ECTOR' F WILDINGS .
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The Commonwealth of Massachusetts
G Department of Industrial Accidents
600 Washington Street, Ira Floor
Boston,Mass. 02111
u� Workers'Com ensation Insurance Affidavit: Buildiu lumbiB Electrical Contractors
address: d-' _<-A/
city Y P state //"'� zip,!>,���3 phone# % �� •7s'—6'y,:2
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction splemodel
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1 am a sole pro rietor and have no one working in any capacity. ❑ g Buildin Addition
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❑ 1 am an employer providing workers compensation for my employees working on this job
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❑ 1 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 - ohone •�� e , ,� +_
J
insman
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f0 a �"V*'yT,2"., `"" yY E �£` #rvn.°Y�e§ a�j3>r.^*S x
address' t i ;�"k . c.,...;` r��Yf+• :_
rdlimme
Failure to secure coverage as required under Section 25A of MGL 152 can Ind to the Imposition of criminal penalties of s fine up to.S1,500.00 and/or '
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER sort a Bat of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification.
I do hereby certify under spans and penalties of perjury that the information provided above is true and t
/correc
Signatures/(/�G%C-tiC>� Date
s
Print name Phone# 9.79 3 7J —6_Y�,?C
official use only do not write in this area to be completed by city or town official
city or town: permiLlicense a ❑Building Department
❑Llceosiog Board
❑check irimmediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone a; ❑Other
uoiuG Sept.lixtll
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
FAX (978) 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, S150A.
The debris will be disposed of at: 6— //le `/ �e /1`c/ � ✓�e �/�J
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
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, S150A, and the building permits or licenses are to
indicate the location of the facility.