2 LARKIN LN - BUILDING INSPECTION i
No.
APPLICATION FOR
P l TO .
LOCATION
Lfwe,
PEFVAT GaANTED
4147
OF
,
� �*+w�Mr+ AP�PILovL�o sr�
:PIER 7pA:I!EJSWT�,NiKi Li11ANT�p
CITY OF SALEM
No. mb
rrra
2111"f)I�blp
f Umftdti
to MMoib n, hmdj YG No aof
16 aLL3t�
CMOUNINo1 AoW Ysl NO•�
Pafmk t0: BLNLI N IG POWAPPLJCATION POlh
(rihb whirl atlar apply) Roofer OMlarSldft C01WAU Dsok, Shad, Pool,
PLEASE M L Wr UMLY A COIAPLEMY TO AVOID DELAVS W PII X=IlIIIG
TO THE INSPECTOR OF BUILDINGS:The ,.
�qnombamm!W hereby applies for a Pam'ik to build somoigio do foNoafp
Owfars Natna
Address l Phone anti L p7�t 7s a�f�
ArchkWs Name
Address a Peon. c
Msohwd= Name Address& Phan ai r�c�ev�Na�.��s ��� . (�1ai3rn:yf97A1a '-91��9
No is to pupow it h mr e
MIroft of' w• ' — o for how awl►t�nraut
Etawlora mrl Y.Q Q2,QQ Car Uoww r
of App)iwrf
O�
oE1W%6wwnoN OF W%R K TO U opNE PrIAW
[R SSh'c Aliy S
MAIL PEffiff TO•
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
anr.eatat tmaoou.
MAroa 120 WAtamwerMSet W a LUVA MAstaastaaM01t{70
Tint ma4MM a PAX 9n 40.%4
Weillmn' Competaeadon Invirun AfQdatt Bnlldwwca
Anudeant fuhrmalbt Man Print r fSM
Names I : f.c )nr,y.
City/ShtdZIp .7�6 P 13 P� {,L� m �s. phone#
An you O emphsyer!Cheek the appreprlab hen Ty"of 1.0 1 ace.a employer with 4. ❑ 1 sm a genomi ooaaaceor and 1 Project
employ=(!hl1 sad/at pwt-dme).a have Mead the !F. ❑New eamemcda0
2.❑ 1 em a sole paapriesoe or peruser` Based as the attached sheet.t 7. ❑Remodeling
ship and bow no employe" These wb4cestracsom hew L ❑DemoBdm
working Ave me in say capacity. wmrkese'Comp insurance. g, ❑gtnldieg addition
workers'comp moosenee J. ❑ wa sm a omporadon and id
required.] officers have examined their 10.0Electrical repairs or addidCoa
3.01 em a bomeowaer doing all work right of c mtpdoa per MGL 11.13 Plumbing repnira or addir6m
myaeltL(No workers'Comp a. 112.11(41 and we have no 12.0 Roa[repaim
insurance��]t mV�DIS workers' 13.[3 Geber
cam'Womew ]
;A"appaer dire drrb bw et mind etw ea as dr ns"bdow Aratea lek wadoaa'
Itaemewama rYa reline ilia ealdara and ooks grid M dsiy d wadi and era btw aMdr MOWN =* seeretlwk d!`rit iNlaelky wdb rCoesaraae Arl dtia�ride bra mare iterclyd w eddfderl rlwt darwby Ae seas of er re drir wAea'eaq.PAW talramdoe.
fam
as aaty/oys tAiit isOrovldag wrorRare'cowpaaswfon/asarowerJw s4 aoyaa Br/oN b dYoOoBey aeafJel s41r
Jmwadaa
►ns muce Company Name - 2Fi.JJitr t fr4Ty
Policy N or Self-ina.Lie.tf N i Fspiradw Darr
lob 3iMAddreae City/Stata/Zfp:
Attach a copy of the workers'compensation Policy deeLntlea page(showing the Peary camber sad o:pks&a date)6
Failure to swum coverap as rapdred under Section 21A of MGL& 132 cm lad to the imposidoa of Criminal
fine up to f 1,300.00 and/or One-year imprisonment,as Well se civil P�d and
of I
ng
of up to 3230.00 a day apina<the violator. Be advised that a copy of t�his4gsntemeat mray be forwGuded to the Ofl1ee of a Investigations of the DU for insurance covmp veri ieada
/do lranby urd/j endp At paGrs and pana/des oJpa/nry that rho/a/aneadowOMMesf above L mw and coma
Qaw
7 oC S '9
OJyk/d rest oelp Do nod wH&in tbfe are46 to be CoarOfeted by My or toaw o lt&i
City or Town: Permlt/Lleenat tl
Issuing Authority(circle owe):
1. Board of Hesith I.Building Department 3.City/rown Clerk 4.Eleetri
d.Other al Inspector S.Plumbing inspector
Contact Person: Phone*
- I
s CITY OF SALEM
, i PUBLIC PROPRERTY
DEPARTMENT
\t-n ol; LO OVAil HNG.I ON STREET •SALFM.NIASineru.sL FI)0197C
TELL 978-745-9595 • F.,,:c:978-743.9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CIVIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of Itauler)
fhe debris will be disposed of in
(name of facility)
lnddrcss of faiilit!J)
_- -i ,raturc of permit apptican
date