7 HOLLY ST - BUILDING INSPECTION ' fwf��aE wr�wo Af�ovEo isv 7i+E
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CITY OF SALEM
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PNW APPUCATION FOR:
Permit t0: BUNJXOQ
(Circle Whiolmor apply) Roof• linaal SM ft OonW IOt Deok• Shed, POOL
Othaa RP L.acv(,)(4j c»-uuv Q,of.-fi
PUI ASE FLL OUr LOLLY A OOYPLUMM TO AV=ON AVS M PR00lSr10
TO THE INSPECTOR OF BU LDINGS: '
The urldsni0rred hereby applies for a pomk to build a000rditrp,to ft.1min r-n
ins: -
OwWs Nams 'S p �,�. - 1, v VN s c6, Prt
Address A Phone 14 o L Ly Si— (37 8) 3 3-1-4 0 97
AmhkWs Name
Address a Phone, ( )
mwmice Name L e, G, -b-
Address a Phoi I U Q MA w S-r Qo o h=y 07PI 1;3 k A 2 314
"m is e.Pass.it kow
momm at' 17 N a d p,for raw wen Imd and
vm OAttq owdonlr Io we
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11111MI�TIDE PONALTY1
Of POPARM
DEScR1PrIo11 OF WORK TO OE DONE
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MINI. PERMIT bo LY Cn-c,.s�
14 MA W S-T-
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-- The Conntronwealth of Massachusetts
J — Department of Industrial Accidents
0/(icaOiillLieSfigatiaRS
600 Washington Street, 7r'Floor
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y BOstoll, Mass. 02111
Workers' Com ensatlonlnsur%ceAffidavit Bmldin /Plumm bo/ElechlcalContractors
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APP11 C'8T11tY]I1�0�Na�o�'i�. W �':.ti)!y s � a 6 i�
v r. �'Ta2seWY�2°IT�''fl�Te b Yr i 'h ir���l d'r�'� 1
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name:
address'
cry att'
zip phone#
work site location Iftill address):
❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel
p 1 am a sole proprietor and have no one working m any capacity. [� Bwldm�Addition
+v rxyU.,'�'.za'svt. 11 _ _;..w' it a,� �.�:'9'{lrauli.�.J:t% .t , '.,:�' ai,..r�tt:, t _
am an employer providing woror'kers' compensation for my employees working on this job.
company name L Ly
address: -Ll Q "t ''IA. \ .✓ T
cirv: o A,b — T
h o Yl� /1 �ip phone# //9 '� $
msurance.co . . r ..1:"tLT'U �. I= 3 .� olie # .b O $7 D O ��: Q_:O �.
M i -
❑.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:
comparty name -
address: - -
ci tp: .
rihon'e#1'
insurance co.
aa; S olic i#
company names
address: - . . . .
city: hone#:
insurance.co. #
Fail@ a uncle Sect d, 2: 01 �. 152 cca to k � t�`,�� R '' � E IN Failure Years'
coverage as required under Section of of of 2 TO can lead to the Imposition of necnmina.0 enalnes of a fine up torS1,500.00 and/or
one years'imprisonment as well w civil to the
in the farm of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy o!this statement may be forwarded to the Oflce of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties ofperhiry that the information provided above is true and correct.
Signature / o — 7 /_Q_—_q
J Date f--E,�]L G,6
Print name L O,✓ ( 6_o L Y Phone# -1 r� S 3 A P\ .23 Z/
�u ti5i2aB7L^SitllEt'.f0A'3[442¢,994.ti,iY'.Nei`d'icwSNdGC.Ji24`Te ',� ''"",.�,SY ' ' 5:4Y�e 1<,vais�w76f»`3�2><i;�fNJiT�vY>aR'�,y
official use only do not write in this area to be completed by city or town official
t
city or town: permldllcense q ❑Building DepartmJ
❑Licensing Board
❑ check if Immediate response is required ❑Selectmen's Office
[]Health Departmen
contactiszdSperson: phone#; ❑Other
(a��:<a s<pL 2003)
"&`:u',3 °iE4i'A'3n-.}',-m„°•-•a•< ".=.":'giyf't.'H3iw:4> t8ilf4dk`5i?S1i"m3%i'6F&vit4:T`r:&Tulle't"a.Sb^tis3Ci)± i'3` 38CGY:°d'u"e 'A', \L4 ,.,
if
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6 . ^^ �uilDing $t�rnnrut
(Oat d.irm 6rsrn
' � 506-i4i�9595 Fxt. 360
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DISPOSAL OF DEBRIS AFFIDAVIT
In accordance vith the provisions of MCL c 4,0 , 554 , I acknowledge ttut as
conoicion of Building Permit d , all debris resulting from the
conscruetion activity governed by thi5 Building Permit shall be disposee of : 7
a properly licensed solid waste disposal facility, as defined by t1OL c
5 150A,
The debris"'vill be disposed of at ; �1_� L r ,-7 IVO i, lI -S� �o CgtiTy
location of facility
Sigaacure o �e mic plicant Data
Fully complete the folloving information;
(Please print clearly) ,
1 s
Name of Permit Applicant
Firm Naau, it any
RO A �DO fl V M� � i `i
address , Clty i Scare
The above statute requires chat debris from the demolition,. renovation , rca, r
or ocher alteration, of building; or structure be disposed of in a prope=1Y
licensed solid waste disposal facility as defined 'by, MC L cIll , 5150A and ttuc
building permits or licenses are to indicate the location of the fa a__ty ac
DESCRIPTION nr wnoar rn:oe nnaue