1D GRISWOLD DR - BUILDING INSPECTION (2) "ANSIRtWq@EfRA94AD Afr'PROVED By T4IE
JMBPJEQB-PWR TO A PEBW AI[ING GRAND
CITY OF_SALEM
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is PmWty l noted In Location of /BN 2 Mm DMrM? Yet No >< ln!]dlaa
Is PWmmy Lacsfad in
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Cirde whichever apply) R , Install Siding, Construct Deck, Shed, Pool,
RepaiNReplaq Other:
PLEASE FILL OUT LEMBLY i COMPLETELY TO AVOID DELAYS IN PROCBSSMM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accor&ig.to the.following'
speoNloatione:
Owners Name PZ�7 AAO C; 9tAJCHA(V
Add1hm d Phone A-D (fW,,73y1o0 b/Z (R7gt -74q- 27 5�
Architect's Name
Address d Phone I ( 1
Mechanics Name
Address A Phone last u3 oo4lW,J p3 54-
Whot is 10 wean it k*W A Q A a
AA NN ar bdldhq? 1 n n D N a dlrelYq,for how mmly lapin?
Wa 4iY"conform to law? �/ S AMNMoa? Al n
EftmW om S?0o 0.°° Clly boar«,r aft Uoalaa r C 8" d-.v�P of�7^�41
Yawn Iaf�t c� � n.�� (1 , . ICC
i 3 a� 0 9 3 Signature of Applicant
V SIMD UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF VMK.TO BE DONE '
Rsp�acE Fucis � ��5 R x I `12E13 rl. ►� c k ��1. .
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The Commonwealth of Massachusetts
r f - Department of Industrial Accidents
u _ BIBg'III/YY�tl/Ellt
600 Washington Street, >a Floor
Boston,Mass 02111
Workers'Co eosation Insurance Affidavit: Buildiu lumbin lectrical Contractors
r -
name: I,, C V 4- E fl_�
Au, YJ S .
address: l a I t.� o o I '�-
city ky AJ o) state: M(nA in- /ICCJ `ip Li nh e 7 P I .F'i 3 3
work site location(full address)' i J G ill S 4y 0 J l�C I) R A 1 b IK MA
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction®Remodel
1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers compensation for my employees workin on thisLob
couusmayxm , p Y t
sE LL
'xddreAOL
yZ,�.
citr
{T`r�
❑ 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:
"i
oddrew. -
c act
. ....rkvttatari.,rk,eti',«ut'4�. ad3i 7+ 'rgy +a is sir,sir ' - n- i „w
Failure to man coverage n required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to s1,54)0.00 and/or
one years'imprisonment as well an civil penalties in the form of a STOP WORK ORDER nod a fin of$100.00 a day aping me. I understand that a
copy of this statement may be forwarded to the Omca of Investiptbm of the DIA for coverage verification.
l do hereby certify under the pains and penalties of perjury that the in urination provided above Is true and correct
Signature � rr l �t + ` Date tl ' 'o( 0 — D r
Print name T I1,D INA W ,5 C.A h 6 CYL4 Phone tl c! 3 3 to 4 y
onkial uae only do not write In this arm to be completed by city or town ofikiol
city or Iowa: permit/liceme N ❑Budding Depart ntal
❑cheek If immediate rrsponre is required ❑Lkenlog Board
❑seleet 's Omer
contact person: phone o; ❑Hplth Department
conga t person:
❑Other
L
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
00 FAX (978) 7409846
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: a w M W
Location of Facility v, q g iL 1 Z Z t) ,s p o s A f
Zo— os
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY) I
wl. C o-WL EvLT'
Name of Permit Applicant
Firm Name,if any
9'1 L0001> (dwPJ Ma
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 ckII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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