39-41 HARBOR ST - BUILDING INSPECTION •.y
IS1AUSreEfILABkwD Af�MVGD BY T44E
=PECIOB.PWR TA)A:PEBWTBEING GRANTED
l 1 CITY OF_SALEM
NO.
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Permit to:
BUILDING PERMIT APPUCATION FOR:
(Circle whichever apply) Flow woof, Install Sidirtp, Construct Dock, Shed, Pool,
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The urrde►siprted herby applies for a permit to build accorcLig.to the following
specifications: (
0~2 Narrle t c�I ,a /-Cl e r 1�jt
Address 6 Phone t yc
Architect's Name N��
Address a Phone f
Mechenice Name �L✓RJ^/ p
Address a Phone y/�T 1� I l V
wn.I Is II►.Purport ar arrarga l6 [I�l f C.tirl o
mdeft of a~ lI�S ra ll n.a1rhlMq,ro►now m.ty t.rMl.s7 /C
wa bLe"canton.to w&? AbMros9
/Gas,• mum Im"viumt
�" �� SipnaWre of Applicant
SNUM LtIIWER THE PENALTY'
OF PEPLWRY
DESCRWrlON OF WORK TO BE DONE
oar„ - �, j
r/ln �(C'l � (;�Ovt
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1
MAIL PERMIT TO: �c � A (11 , 4 '� OM2 3
4 �
No.
APPLICATION FOR
/J PERIf lr/TO
A leadf — Ag' /k e- /Yq r(¢enAS t� CJ4 ThI -
.�
LOCATION
'r
PERMIT GRANTED
APFI
ROVPD
OR OF MOLDINGS.
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASH INGTON STREET, 3RD FLOOR
SALEM, MA O1970
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,S 150A.
The debris will be disposed of at: cjc✓y5 ( t 1/ 144
I
1 Location of Facility
Signature of Permit Applicant D e
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
��vj A/J Oct V/!@ 1
Name of Permit Applicant
Firm Name,if any
¢.)
Address, City& tau
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
office offevesti OU=
600 Washington Street, 7th Floor
h Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Buildin lumbin lectrical Contractors
rA �f�Iorm((a��i n �1� ;. `s P1 eR 21 I . ti M -
address: V
city ^t✓�� state Mf i zip' O' ) phone#
work site location(full address)'
❑ am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing orkers' compertsation f r my employees working on this job
ii
com an name:�` MC`A N P ll2 2 �Md ^`' `�,"."sM„:',aa
�r �address: 4 t, ,, .. d". `
�
insurance co. li
4.; . .. ._ -„- w., — .:.. ..� .. - .._ _ ,.:- _ . . _.. ... ., a - .._ •-�-.
❑ 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:
_ .O
company name:
address:
city: phone
k w 4e., 6 n• - � r# �er3
insurance eo. a0 a`, r,a f ;;x _ o�,•.: °rr°..,td`:.- a.;l°, ' i ^, s. .,
' ;.a a 1"v."-?:}+ .�{ e a � ,t,=."�'2•,�U F' m ,f `,ri 4—
company name:
address: .f � t,�� i; ' >���" a� s#.�-�� -e �3 RA
n o rc
city:: - ' phonehl -
insurance co. _ ,.c.. . . a.. .ti= . . . .,e,h..xs_sM _xA.=cr,1, ., he # ,,. _.k .-4 ozay , s , ,.�.,.
�$L.mlditiomish ff .; _ . .,.,_ �.:::... , ar*-• :.;,.w �.:. :. -.,. . .
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine upto$1,500.00 and/or
one years'imprisonment a well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this smtemen a e a d to the Office of Investigations of the DIA for coverage verification.
/do hereby certi n r t pa a d e allies of perjury that the information provided above is true m come . r
Signature / Date i2 �~J
Print name VD, "' Phone# _?0
o
ffic
ialt write in this area to be completed by city or town official
permit/license# ❑Building Department
❑Licensing Board
onse a required ❑Selectmen's Office
❑Health Department
phone#; ❑Other
BOARDS pp U LDII;{C,�'�a �
License: CONSTRUCTIONSUPERATION
Number CS. VISOR
083886
n BIrtildat 9/Y.?/7965• -
�t.
_� ^Explresi 09l1�/2006 Tr.no: 83888
RestNeteft pp +
EDWARD W
35 DOTy AVE
DOFiERTY d > A+
DANVERS Mq
Administrator