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29 HAWTHORNE BLVD - BUILDING INSPECTION �J r APPROVED BY T44E `.✓ T lY1VJl �TL IAI�+PI=CTi _.. PRI9R TP A.PEAMIT BEWG GRANTED . CITY OF SALEM No. �6 Date Is Property Located in Location_ of { the Historic District? Yes No_ Building ILA:ajf`lMkel /J4/0 Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) 'Roof, Joof, 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: , - Owner's Name Ck// i ✓5 L,� �4 � C Address & Phone U134Ll/ /p Architect's Name Address & Phone Mechanics Name Address & Phone G��1�,��^� J�'z'—ln Y (�� 3 r 1,7 What Is the purpose of building? 04 - i i Material of building? If a dwelling, for how many families? r Will building conform to law? Asbestos? Estimated cost 4f0, J City License n N A State license a« Bome Improvement� (f; >` Lic. i CD 3 j X gnat PP lire o A licant �P!G%1ED UNDER THE PENALTY ''OF PERJURY DESCRIPTION OF WORK TO BE DONE �e MAIL PERMIT TO: No. z u� APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED 2.0 ;F AP VfD INSPECTOR OF BUILDINGS i CITY OR SALEMv MASSACHUSETTS • PUBLIC PROPERTY DEPARTMENT 120 WASNINGTON STREET. 3010 FLOOR SALIM. MASSACHUSETTS 01970 STAMLEr J. UEOViCZ, JR. TELEPHONE: 979-745-9593 EXT. 380 MAYOR FAX: 978-740.9844 &kM Buidina D4oftW..t Debala D cra+eml j& In accordance with the visions Pm of MGL c40 S 54, a n Building Permk it is that the debris resulting from this w s shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: �Yvcy --�-- S�� —(Location of Facility) ✓i°,116bo V Sigh ' of Applicant Date The Commonwealth of Massachusetts Department of Industrid Accidents Offla offilmsd9adons 9 600 Washington Street Boston,MA 02111 www.a tessgot✓AU Workers'Compensation Insurance ABWavft Bn$ders/Contractors/EledriciansMumbers ADDItcaM Information Please Print Legibly Name ( .AVW-y Address: City/statd?ip ✓S'L '1 i ,f }. Phaae 0 5 5- �� Arty i1ai em (overt Cheek d appropriate boar' Type ofproject"Wed). L IL'I I am a empbyer with ' s. 01 an s general contractor and I o ❑New co=b=- ion employees(11A an&os par6t o4* ban bind die 2.❑ I am a sole pmprietor or partner listed on the attached abet.= 7. ❑ Remodeling ship and have no employed These sub-contractors have S. ❑ Demolition working;for toe is xe capeeity. wkai'gip.is 9. Q Bmidisg addition [No Workers'comp,insurance S. ❑ we ar''41potporawss a,14 in, olHcai Yisye `' >>uo 1&0 Electrical repairs or addition 3.❑ I am a bomeowna.doing all.wmk right of TperN.M. 11.0 Phrmbmg repairs or addition myself[No wolke s'.eon* e. 152a41(4 an vehsve`no 12,©400freyfa$e iasorasoereplvotbb t. QoDk [I`Io' kai' comp.iantaanoe r$ga$ea j 13.❑ Omer •Any Oppticsat ton chits boa)II now a.o 5g o%*mcd ow akoevi{ �1[.FaslfM' !407 polkymsoimdioa t Homo�uas oho sulodt davit mdicatlma t6sr an o bldl park sod On W6db •omr afdn t bdkathm sock tContrsebs 60 ditboi id suadod s Nuesma and Ami s as mmtirik =b.0 hW WdeWh W0&=.camp 1ONCY M&nndiod -. I err ql 0pbyerthrt bprovfdlna x/er/kse'eoaapsasedos brs4niietja urpaiiploysis allow b tlFtpsller os1Jo8 slay CompanyName L7 L� r Policy p or self-6a.Lie p /(� 3ySC7, �`S Expiration Wane I" 3j Job site Ad&=- City/Stateav: 5j lel -\ Attack a copy of the workers'eompensdloa poltey dedaratlor page(ahowhag the policy aambw and expiration date). Failure to secure coverage as requhW under Section 25A of MGL c. 152can lead to the fi position ofc&mkW penalties of a flue up to$1,500.00 and/or oUO-ywr imprisomneat,as well a.civil penalties in die form of a STOP WORK ORDER and a tine of up to$250.00 a dry against the violator. Be advised that a Dopy of this statement may be forwarded to the Office of Investigation of the DIA for insmaoce coverage verification. I a hff*car*�tAspabis end pendUbr ojpalwy that for lajo Ovation provided above b taw and correct C/_ �_"""�1 D.W. j Phtme T S=/) C 6 o lerl au e* Deno Wd&bf A&any MAN cowpbted by ciy ortraw Q8@id City or Town: Pram N Issuing Authority(drde one): 1.Board of Health L Building Department 3.Clty/I'ows Clerk 4.Electrical inspector !.Plumbing Inspector 6 Other Contact Person: Phone 0: s.P/AOS'SSs[II'AA" sO9l-5 Pon all 64LL-LZL-L19#ye3 HjySSVW-LL8-i 1090b W 006t-LZL-LI9#'ta.L IIiZO vw` WOE[ PWS u03HUWM O09 nop4pPAaj p o*Mo wuwp v pWiPIIido pmuldba gwnlgaess wp vmtAUOMMD OU saj po auoq(bin 4UW s,luam mft ou pea s so a"t8 at a oP aZ 'saageanb Am aneq gnogs pos u)peadooa mod IT aaaeAM m WA>loegt a'ulg Ploob 1a0ptft mwo Xwo ou VANW SM oM mw oW pwnbu JAN a nosed p..M("off saAeat amq a Vm"d io osuaaq fop a•a1) OMMA P.MMMW m UM"nq Am a VMW toa Am»d so mwq s fo}m W st WaPP to P"o*aouds�gdde tiara too M[[B p4>! +8�!sPWg! y .sasmaq io mmad uoigl m3 al9 ao f<tcnePgde p!R"s se�pj oqi apop!Awd dent ubat m + °� po.00q > c,a�aso!cao�v.«tom ,o&P) . m s&.aopgM V.a ptnogs tasagdde aqt„ssa�WS qM'„�p�"(dassaa�a3F)nopeaz►a3m� to ilia S=CMM t,mMg am t►mqu dtao p='aad MASS das�suogeagdde !��� t ►gdde a�' pps a ,��.I'i a a Wo a4 Mm W.%,*"Fm am"q/gmrad� pg WA c pe, as seq eao¢eSUsanaijo o a*toaaa OV m tno p9 av '�tt"WMI M jo ,a aae amrasa= a:,a dmou A,,,,ePy�e a*oV am of maatoq weds a po Aosd seq M2Cwdaa*u •AI�I pm . pas Mal s gnuo WWL ao AD ;MIjd y am•mw Am ampmwomedataoWmam'�'S Aso�agp�!t sgl�t aaBIIsa_ �gm¢oaVlo! ,sra oAs s soago a paiLMbU an dad,p w AW,�i nm vb&O onsgtad WIM jo tea aw 3w'Paasaobas�q a aeoaaq m>�a*xs gdde 2%M�so a p aqL 'i4►sPl1R mp atop pas Ap al am l d4 ow �wAoa aouemem;o �el�V plmls B demgdtW m[►m poste aH •aunbu a dagod s'wadot psq:np 11 jo daa*W at pottmtges*4 ton on %amid w sragmaa oAsg saop dT I+o.�'YI as 3I oonuosa[°a►ssao�.atmµo+� p poltobat Owuum am to�o dan oa (d PI)edtgstaa�ed dt. qe<'I pa 110�'PI)pmedmoJ dgpQet I pol°m<'I , ao(.)sega I► soots Cs � �sPOP�(s�o)`a° 01* 3no as VU stOWmn m"ta didde M* xoqoo A4 ,kmg dmW swhnd� node4a�j°quamamibb, „'R1�R►os lm�sq a@ a pond�4 W4 An Mu!AM*dmoo jo a�P!Aa a�alsidaaae ip m�agQ to io3 °� gRtl VW WO aq► s.jo duo taa ggsamuDmmoo aq1+WAL.sotels(Lbn4%51 UadsR�'L`N4t AUMM. pegs saotswpgns Imo![ d too Mq a!1A taoapdds ..Vulobas dsom"oa s+as Wwq MP nW eaoe�dmoa to aaaaptAa / Po" ascaap o jo IsA>aai 6s mj ggsaruasumoa sqt q�q boa of"o spupoq o ap redo a tP ,o aassnq aft t�9s Laoaso sapgM pilot Ia Mp LOAa„XV MW oste toeaamddc>�a�'4'9D m »dqdaa is aq a p V a4 dcld®9ans jo asonoq pops afar aas o asnoq'up"+4 osoaq 8o$u'4 gnus°°#iob m souogangsuoa'aoaeaytal.w�W a saassad sdgdma o9A+ fmPMP s jo""o jo tasdnaao asg io'maom sagsu otim pas a sagt amm too sa�Ao4 sm jo oasoa m nA»au ogi'Yonai+sog podotdma 3mdo�dma-bw plat 0*0 so aogs�+a>e'd!gspo@3�!"iPaf daa sad"agtjo . oqi ao ho.totdma pip s3° Ps+I aq►lmpW.Poo`asudsnaa m4°(sac map . omai so w dos io'Amw ICI mo m u*s000 5sagotaosss*pod"'POa aV paagap st r „ so Iuo'Pa Iduq Za ssWO o am duo»Pam sMOw jb utA»s M m nosr+d Nana „se rdsldrro as 'attusls spasngaesss➢Q 113 aonesaaduwa.>� ►�a tradotdma ne eanmbw ZSI=dgga SA WJ Is19 u18 QOi guI.IO II suot�an��s�I p .� 3 I