4 HAYWOOD STREET - BPA-05-826 4PL'ONBMM,BEfIL4B#N9 APPROVED BY Re
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CITY 0F_SALEM
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Permit to: BUILDING PERMIT APPLICATION POW
(Circe whichever apply) Roof. Re000f, Instal Siding, Carpa Deck, Shed, Pool,
Repair/Replace, Odw. k A L.,
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undereVied hereby applies for a permit to build accortLig.to the following
� ..
Owners Name SA]-ellL OL' .
Address& Phone _`(— N � wu S� (99) 7 N/
Arcdhitect's Name
Address & Phone
Mechanics Name cJ sy S c Ai-R/a JN u� , a .� -C
Address & Phone ox C.SS/ ZZ (9>c zso 9)TI
M ,�d '7rM , vbta oiS4-�
wow is ft pumm of b~ .: ,i cl.4.. 2L�Cj L. ' j>1A
L%WW of bulldlno'+ M a dwNY g,for how many hndim?
wa bum*caronn to low? S Alf 14.
Esmead ooa D on c� soy Uc r KC-0 S sow Uo r CS
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Lie+ o z a g Soidure of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTJON OF TO BE DONE
,
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MAIL PERMIT TO:
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Iffraw
WA NOELVOrlddV
J&S carpentry
P.O.Box 655
Middleton,MA 01949
(978) 750-9741 Fax:(978) 750-8892
Mass Construction Supervisor License#CS 073424 - H1C License#112278
Letter of Agent
To Whom It May Concern:
I hereby authorize J&S Carpentry and Construction, Inc., represented by Jeffrey Schultz,
to act as our agent and to make application for a building and related permits.
Address: 4 Hayward Street
Salem, MA 01970
Signed: WJUAIZ Date
John or Shelly Matthews
t i
The Commonwealth of Massachusetts
Department of Industrial Accidents
nmeee►►nw�sn®es
600 Washington Street, 7rh Floor
Boston,Mass. 01111
Workers' Compensation Insurance Affidavit: Buildin lumbin lectrical Contractors
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addre 2
city ap7 O htfi phone#
work site location(Poll address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole ro rietor and have no one workingin an capacity. ❑Buildin Addition
6=
1 am an employer providing workers compensation for my employees working on this fob Company Q
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city: - q ; T'. " .1• d,"6'Y'S� �iFuh� `` � +�3N`^l�'�'ui �� gu�"y
01'1 T °'q`e��r tt'J,' +3s'cxx F"'� "�/ ,y,/ •� d.+ E,
insurance co. .f� -rl7 .R aullev/J^- !t
❑ 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:
company name
address:
city: -
w 3+<.: y� z ,xt rt Cv a a •� r xY ''�a x t ' ' r;NM
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n i•Ym" H""�t m , errg
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omlAAY name '�•,+'f",�tis�` ,°.✓�}r.M".f-'Qx,^"w},*4�t'�,§S,x}
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� �S L +4 5•ME t '.t ,
address:
clillp
777 '7„ �`� � e!+, ��Sr�" r'"�l'�e✓i4`�''3"�� �"�a ,`Y'r�r�,f� �7!£i' *'k"'N
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification.
t do hereby certify Ander the pains and pen ofi jury N ar the information provided above is true and correct
Signature T Date 3^�•3d '�
Printname SG ✓ Phone# y7g 7So 9 / t'( '
official use only do not write in Ibis area to be completed by city or town official
city or town: permittlicense# Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
e<,e«r s<vi.asm
c
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASH INGTON STREET, 3RD FLOOR
SALEM, MA O1970
- 0 TEL. (978)743-9595 EXT. 380
FAX (978) 7409846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVrr
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: `�l _ 6t �D IJ►S?o S ' e, &�I
Location of Facility
3
Si o ermit AppWdut Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
T9` S CA- AA�,jcc tsl-iuJ 4tiC
Firm Name,if any
0
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, S 150A, and the building permits or licenses are to
indicate the location of the facility.