198 LORING - BUILDING INSPECTION 'f1>�N6~49Ef♦A94N9 APPROVED BY TW
JNBPZC=,PQ= TD A'PERWT BEING GRANTID
CITY OF SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof. Install Siding, Construct Deck, Shed, Pool,
r`RepeiilRplaw, other:
PLEASE FIL40UT LEMLY A COMPLETELY TO AVOID DELAYS IN PROCESSIM
TO THE INSPECTOR OF BUILDINGS: '•
Thee
uM hereby applies for a permit to build accordGig.to the following'
Owners Name X Jan G�
Address d Phone l7 —
Architect's Name
Address & Phone
Mechanics Name 6,-/(, /�✓��P
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Address 6 Phone 3)
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SNUM UNDER THE PENALTY.
OR PERJURY
DESCRWnON OF WORK TO BE DONE
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MAIL PERMIT TO: r o s f
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No.
APPLICATION FOR
PERIIff TO
LOCATION
PERMIT /GRANTED
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AF"MVFD
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INSPECTOR OF BUILDINGS
The Commonwealth of Massachusetts
a — Department of Industrial Accidents
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600 Washington Street, 7f1 Floor
Boston,Mass. 02111
9}Workers'Comilensation Insurance Affidavit: Buildia lumbi rical Contractors
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/name: lif/1'L7K4 04LAI!S74
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Y work site location(full address/: /gf- c u a oN — All 6 . J nk G in /
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction Meimodel
f�(] I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers eomQertsatron for mY employees workin on this'ob h,
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❑ 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:
COMMIRV MINIMM. -
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Failure to more covemp a required under Section SSA of MGL 153 an Ind to the Imposltloa of criminal Pennines of a flue up to$1,500.00 and/or
one yeah'imprlwnment an well as civil penalties In the form of a STOP WORK ORDER and a flue of S100.00 a day against me I understand that a
copy of this statement may be forwarded to the Oma of Investigations of the DIA for average verification.
l do hereby cerl, m e ainr and -alder of perjury that the information provided above is true and correct
- SSignature h Date l / J
Phone tl `�J.�/) (y 4f
oRkial use only do not write in thin arm to be completed by city or town official
city or town; permmleeae a CIBullding Department
❑ ard
check if immediate response Is required ostiect e s Oft
QSeketmah Olfiee
014alth Department
contact person: phone a;
costa p,.mot Other
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (976)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 1{5,0A.
/V o The debris will be disposed of at: , �s d, r" /'��
Location of Facility
SiVQ6 ermit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
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 cM S150A, and the building permits or licenses are to
indicate the location of the facility.