57 REAR GROVE ST - BUILDING INSPECTION joJA Si"T-BEfH E�11 APPROVEOByT+IETED
JN:+I'F.t IL1H PI?IIDR TD.A.PERMIT BEING
CITY OF SALEM
Date:S 1 306
IS Property Lowtad in Location of n .
NW Hletoric District? Yas auwing Y�«cr lS✓o
is Propwty Localad In `�1 b
a*Cammallon Am? Yas too=
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace. Other:=(:�Isk0a,rm a b-mri.- Z� Pk LS
PLEASE FILL OUT LEGIBLY A 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 %C V\ �Vf y)y)e'n
Address aPhone 105 hjaSbn 5j
Architect's Name
Address & Phone L
Mechanics Name
Address & Phone !
what is NW purpose of txtildinp?
Ma1wW of bidkv ? N a dwellfn9,for how many fambes?
wN1 bi dIdUW cordorm to law?� Asbestos? w"
Estimated coat a 5U� cuy Ucem a N A Stow Licwtsa a CS 0 b9 3
Some zaerovda �
a dC
Lie. / M 531 Sign lure of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
14ns � 5ee nF s
MAIL PERMIT TO: 1 ti 5
S-.let• Yvw bl�f?�
No.
APPLICATION FOR
PERMMT TOO
LOCATION
,p
-5 7
PERMIT GRANTED
PROV�D
INSPECTOR OF BUILDINGS
�Po y �rn
s + JOB
IAOBBS ENDEAVOUR CORPORAIION f
. 34'Rockland Street - SHEET NO. OF
Swampscott,Massachusetts 01907 w//ti Dn� /9 rr14T
781.581.2454 978.744.4646 c^�C�aTEB By
CHECKED BY DATE
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HOBBS ENDEAVOUR.CORPORATION JOB
34'Roddand Street SHEET NO. /
OF '
Swampscott,Massachusetts 01907 /
781.581.2454 978.744.4646 CALCULATED BY t_ DATE 19 m4Y 0.6
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HOBBS ENDEAVOUR CORPORATION JOB
34 Rockland Street - SHEET NO. f
OF
Swampscott,Massachusetts 01907 CALCULATED By �� 9 r>r4y �b 781.581.2464 978.744.4646 c
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CHECKED BY, DATE '
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The Commaxwtalth ofM4sswhuseft
Department oflndusWd Aaldenb
6"Wasunston Street
Bostons MA Mill
wwwaraassowag
Workers'Compensadon Insurance Affidavit Basdees/Contradora/Ekdi kbn*Mumbers
ADDlltn�infernratlon Please PrhA 10C21my
Name b
!! / io�w, A`T1-'tnAb�
Adtlzma: l pp L Ol oy� 1a l l SJ1p
Cityamea* Phaoe 1417
Are you so emote?C1eek ttE pproprb"boa' Type of project Crequirefk
1. I am a eagkryer with �2 a t. Q I zm a Small connector and I 6; ❑New oontEeoe6On
emQbym(f6n and/or pmFthwi* Lava Lied ba rnblaeuracws
2.0 I am a sole r r prielor or partner- bane at the asoodkd sheet.= y 0 Remodeling
ship and have to employed These wb-oonnum have S. ❑ Demolition
woddm IN me in saw cape46. t coup i 1003a a 9. �Bta>dlOg addition
(No WOE.� inavraoee 3. 0 we ate s oo psuo%md is'
offieess uLL'" lap Elasieal repasts or additions
regnhed Y. WIAT i.,,a
3.0 I am a homwwnw.domg ap work *!errs of P MGZ' 11.0 PkeebLg repairs err addition
atyself Via wadrm'.coup a 1.1 aail�rehage`no 12.0Roofrcpaur
inssraooa regokad:]t. 'j, 13.0 Otbcl
COMFimmatie
•:my Vphcaa,er clam bm:/1 mwt 4a se oosdip a ctko below a.tw r compm�aoa policy idumgtor
t Homsowm a wyo mt=$sk a®a.vit Mdkwho eft as doing err abmn a am attldsvit iodfmeins sock
tCawacmma wAMsbin'rase ameawatoddiimadodsbowisasrs btsw mam..lenadesrwafts•coop yor bdbmmdm
lxfwwudwL
rawgr�eerplayerdtetbprwi�x�erltna'eoatpswJdlotb:are�erjwar�suprjrrfs Bda.brkepellSyestlfolaid
77 bormanca CompasyNatne: V-�l �
Policy M or Sehl:iss.I! N ? ('
Expfradon Dale:
Job Site Addrtsa City/Statdlip:
Attack a copy of the workeM cosolwadon polity dedwatles pale(showing the polity number and eiplratloa date).
Fat7me to scare eoveraipe ere retpmed Sider Secdon 2JA ofMtll,a 132 cm lead io the figmidon ofaiminalpenaltim oft
fine up to$1,500.00 and/or one-year imprsaooment,as well ere civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a oopy ofdtb statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage veti8tation.
r w hereby into'under the pahm w4penaMw ofpwitry elect tke ltfartaadon prov1*d above b trw and correct
sionatum -` � �. Date ')I ")) CA
Phose N CY 14 (2� '2)-V<ti
O,aJdd w,rt oetp De waf:vriYt br ddt art,N lot rowpfetsl by e4p M Asrvlr anlrleL
City or Town: lermWLtxase 0
Issuing Authority(drde ode):
1.Board of Health L Building Department 3.Cityfrowe Clerk L Electrical Inspector &Plumbing Inspector
&Other
Contact Person: Phone S•
Information and Instructions
�their emvlcyw.'
M Gcaaal Laws chapter 152 tegafres all amplaprOW�vv*.wQd* off
��� � is defined as ...every person _
AD awpfe!"a! defined as"tea individual,writtee
Paws .�0 'Op1pdeti°'dr Other amp
of the rani is i joie;eater anti including iegal a 4fa demo" i q
gsl entity,mpioYnt, i emPloYaes the
Meava or"M W_I of an h&j"pamaship,association Of otber k
owner of a dwelling borne baviog not morn than three*w mmts and who raids therei•,or>b�° °fps
dweHIDg bonne of anther who mp*s pins to do mansumaooev oomtmenon or�h we* boom
ter as the g orbw78iag appmtessm jhwo shall notbeamse of ae&mpleymeatbe deemed io be an WMIO
mGL chapter 152,125C(6)also states that"evert Wte or toed lieendK fteneytu the or
to a badness or to eaaserm buildings for aq
renewal of a D IM or permit s wdh the insurance Coverage regd�d•"
applicant wM his nsa prnd1 nt bls a"Nei,ide ca die cu gs nes any of ils pow shA
Additionally,Mt3L�p�13Z.�����"Neidter floe aoamoonwealtb
ea We any con>ad Aw the paw ofpublie wodt and amcptable evidence of aompliz=wA the imaraoos
ter
Lequkcmm of this chapter bttve bean peaented tat floe aanatsieg> "
situation and.if
Pkase fill out the wwkea•oompensat�affidavit couple$*,by Applicalift the bola that appbrb y�
neoasatyy,anppb (s)namc(s) dd a =Kee)an¢phone munbes(s)along with their cadfiate(s)of
imarsaca: Limited Liabrbty Compasaias Qj Q or Limited Liablby Parmeribips%M with m employees other than ins
members or paeoers,are not required to cagywmimW cosupeassidon fiisaranoo. If an LLC or LLP does have
mployces,a pommy is required. Be advised that this affidavit may be submitted m the Department of bidustcial
of honunce covaape. Alm be�se to dp said date the dfldav]L The affidavit dwell
bAccidents fte returned qw�91010dIn"that the appliad n far floe pemthor license fan being requested,not the Deparmvmt of
rrialpceidem. Sltoald you bave say gnettioas regarding de law or if you are rIqutaed to obtain a waskCre
1poft pbasa aaB tun es the mmaber 1{atod below. Self unmated 6ompaoies shonid cafes their
congensadoaself-hwxv!m finesse ttsaiba oa tba biro
city or Town Of adds
Pkase nine this affidavit it complete and printed legibly. The Department bas provided a space at the bottom
of the affidavit for you o fifi out in the event the Office of Iwvestigstions bag to contact you regatdmg the appHcaot
please be sure m fin in the permitNceme number which will be used as a reference number. In addition,as appl1effi
that most submit naltipk pamitlHceosn aPP in any given year,need only submit one affidavit indicating Current
ppllcy ipSOImanOn(if necessary).and, "Job Site Addrese the applicant should write badons is
of tuwn may be;novided1b Cif Of
the he
town)."A dopy ofthe sgktwit dm bus bom officisily tttamp4 oL by_. . cit—
appHesut s ynootd W a valid affidavit is os tik for a=e pamits or hccwm A new affidavit moltbe filled Ott each
year.Where a home owner or eithm is obtaining a Hem"or pansk not related o any busioas or Omnu=vW varmre
(ie.a dog Seem or permit to bun kaves em)said panne is NOT requited N complete this affidaviL
The Office of investigation would Ilse to thank you in advance for your coopaation and should you have any questions,
please do not bcdtde to give us a call.
The Departmem•s address6 telephone and firs mamba
The Commonwealth of Massachusetts
Department of Industrial Accidents
office o(Invesdpdons
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-03 www.mass.gov/dia
CITY OF SALKNo MASSACNUSRTTS
PUBLIC PROPERTY DEPARTMENT
"a WASH'"4"84 STRUCT. 340 FLwn
SAL[M. MASSAGNYSSTTS 01970
TULS►MONt: 97&745-9095 Off. 380
FAM 9791-740.9"G
Salem
iJCbrb i kowd
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit 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 M, S 150 A.
The debris will be disposed of in:
_(Location of Facility)
Signature of Appli ant
77/ t0) a
Date