15 MAPLE ST - BUILDING INSPECTION f1-MtSMWV:-BE FE M146W APPROVED BY T44E
W✓Z=0B PWOR TDA.PEMT BEING GRANTED
CITY OF_SALEM
No.ZY—O
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Is Ply Located in Building of V
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is ftopwly t oraatad in
to CgwrvaYpn Area? Yw No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install SicMg, Con�stru�t Deckle, Shed, Pool,
Repair/Replace, Other: (1 C
Y&COMPLETELY TO AVOID DELAYS IN PROCESSING
PLEASE FILL OUT LEGIBLY
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name S�e�IV- oh
Address & Phone l I/' '�� e s 7—
Architect's Name
Address & Phone /�
Mechanics Name C� e° r�e l5 N 'v eS —
Address & Phone CJr TG i,C
wm is VW Pwpow of fxrlldtrg? Q e4 i 2 i fi/ 7yt
mmoraf of buYm ? G✓on d n a dw*Mq.for row many fami m?
wo buHding CWorm to law?�� �S AWW"?
Eafraatad col"�6m o. a- Cay Lamm r N fa suw r ok 2 Z 3 V
aa.. LProse.gd
ignatur of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0:
No.
APPLICATION FOR
PERLffr TO
t�e�LR� leis G', ,371.0 7S
LOCATION
PERMIT GRANTED
2� 200
AP ROVED
77OR OF UILDINGS
Tl to Conuaoaw Afth qIM4uschusdts
DepwMeat ofIx&i*f f AecMwW
6"Wa khts"blWd
BostOM6 MA &1111
wwwMeasswas
Workers'Compmadou insurance A®dr& BWMal'ContnCtOm ledrldans/Plumbers
Applicant hfi rmatka Plats P"Lettlbly
Name Goo r OL C- ..� y ry e r (r-,O F1 r'
Address:
Cityttlipe �i9'/eir PW Q/f/W Phase*: / �6;2- o v s; 2 2 9.
Are u ens jer!Cfeet tkd ii�propriw bars' Type orprew*0411dre
1.❑ I am a employe vvitA I am a tamed aoaYsetor and I 4 ❑New
employm(usodtarpssftime}• Lavebtadtarsektiedestsekass
2X I am a sob pmpr*I or pattsa6 Had as on Ausrhed skeat t 7. ❑
ship sad have so employees Bete Lave S. ❑Demolition
wadft(No vwsirea'crosy mmr 3• w i oompp ' , I ❑ sddidoa
oEoai liiye Mwwcal' s
or addtions
3.0 I amshomwwsdoing apwed
11.0 Pkmft g*8 or addidam
�Rk�sw compa 152,11( aa�i ebtveao 12 0 Rootnpan'
iossrsaaeregsirstd]t. .:•. ' .r . 13.[3Omer
•Any app&aa*dAubboarsmumW o�wl4c�b1�'+�se•kwwamq!ao.paler
t Iron wum po oak*MW s®dwh�mar m 4dy.A sok ad an bi�'sstddi omaiesonmirt,abab s om M'ntt�s�
tCanna�ottylskra4isbot'�mstmsrasd sddkkeotthatdgw6rsosstifs►siaeeb�o4asdslorwbwie amp poftyismnnod .
r.w.r..ylsf..rA.rbp.rr8ns+wrdn,'eowp�aaa8esaio.+re,I«ageart� a.�.bwpBq.�fojslw
Insurance Compasyxasne
Policy 0 or Sdf-IOL Lie N: Dar
Job site Address (yly
Attach a cafe of the wwkwe eo WOudos pocky dedarsdu pap OUwls6 the potley sssnbsr sid eaphutlos date}
Psm7me b sesste covenp at requQod under section 25A otMGL a 152 can lead in an imposition ofaimmsl
fi=up b S1,SGaOD mdlor one-year s wells civil pessaltin of g
of up b S250.00 a day spho the violim Be advised mist a P is ne may of a STOP wtin CjjU@ and s tbse
Invadgadmw et the DU for fiamaoce covetase vaiftths. otWi sfaxmmt may be linvvasded b tba OtBce of
I4 Aa+sbp cool MWA#Avf asl pasaltlat oJpw/sq Aw AN 6sjammrlos p vW*d abow is aw and arrns
phone _
Ojkld Mace oatp Do ad IN 46 any to ba cowpktad by c*or*Mw oaktd
Clty or Towns pauklucesse 0
Inning Autharky(circle one):
1.Board of Hakk L Building Department I Cky/rown Clerk 4.Eleehiesl inspector I Plumbing Inspector
is Other
Costad Person: Phone P
Information and Instructions
crews Lass d*w 152 raglim an ea�pkwmp PA R of�
Cant b this sramt4 m1 F�';t
a defined at"...every pasoQ is me,suite ge
prpesa m kvii d,oral or writ m
�dgti er say taro err more
$de8td an"a iadivi�Pam►��eap°aii°a or od� empiaya;a tde
As ayl�, fir i joist eataptist;sand ischtd�t��
oiins ibt ° °� a:tociatian or otba kpl eatitX w0wag estowa ' HoMavq'S°
taxiver or trmoes dust � ssrae aPatm°°r and afio raids&ad%or than a�
owner of a dwcums eontruc a a nptdr artuk a,inch darelHs�bome
dwepin{house of ttotiee wbo employs i&a wJ cmpbymeaba d�b be m emPlOW
or a the s�abnr'Wios apputtaraot
MGL cWw 152,125a)2W stm twat"every state er hod ateades aWe7 Am wkhhdd the isanaaoe or
reaewai of a llreass or Per"a�e a bdaar or b toaslrad battdlop V tie oomanoaweabh for tm7
with the bsannaa awerw require&»
aPP�� + avldenua[ nor ofit><yoHttalid �d Y
i states"Neidw the 000mMwa>m , �otaomP'Wa wdt the ittsoranee
Cum into anyeo Iola fix do perfotmanoe ofpubHe wort mtfS aoeepotbb evtdawce
m9s&CMs of this dtapoa bave bean praenled b ties G=kuc&gAppliesuft
•"
afBdavk=Vjej*,by theborus that aDpb b ytsr tiaudos ands>t
aeoaeeey,mpP y mbcomraclot(s a1 addraf(a)s+t�> tmtnba(s) iw� s)no eggplaym�than the
i Limimd LiOAw Comp>w alQ orLimbdLiabt�t pDiP'
are not reggired b any wodow°p° 06�0es°e° Han ILC or U2 does have
crap regoired: Be adviaad that aw VO n b dr a ttM a �sboold
dw
Aaadmm for cm*maaos of bumanee ' or H=w s berm w*wOedt apt the Departmeat of
be r of tows that lbe aPPliatiw ibr the p�
� Sbgnld you bsw Ow 4aatian�f me law err if you are rammed to ob��woes teir
aa�po�g phase caII the D at the ttomibet l{ W Delos,.
Shc-ionued
COUVO
selFimttra►oa Hams ywOer oa the
C"or Tow,Olsdad
Please be Lane&tt hits affidavit it complete and printed le�bly. The Department but lamed a sP z<the H room
eprilig
of the affidavit for you b®out in dw event than Office of Juvcsdp iom but b contact you Ian
of to be ruse oo iM in the per°rumba wbkh will be used w a reference,amber. indicating��
ass Mplicad
pk �y�y �"�������p bcad m is any e'en year,Wad only submit one affidavit
yam.rmtt submit m kwlg!-'-- M WW or
poHey in".dou(if secetsery)and.wda"Job Sine Address"the applicant a�����,�b�
ro"r A mPY oftbe a�dnvit tirt hss bsea o®cial4r» aL» bK-. �'..
s that a valid a0davit it oa Sla in iipme painter a Hama A new a®davit or o valswe
VpVcwS Where a of owner or dthm is oba dot a Hama a pamu mg rdsoed,to asy busiow
y b bum leaves ere.)raid Mum is NOT regsaed b eomPhtte this a®davit
(La a sod Hants a pe®t
The OffiCe otlavanpWW would JflW to thank you in advance for your coopcadoa and sbould you bin any q
m a aLL
please do mehaitab itYe
'Iba DcparmtenYs addrw.telephone and in nnmba:
The Commonwealth of Massachusetts
Departinent of badushial Accidents
Office of Invesdpdons
600 washingtoa Street
Bog^MA 02111
TeL #617-7274900 art 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-O5 www.man.gov/dia
I.
CITY OF $ALXNq MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON 3TR[9T• 3119 ROOM
9ALEM. MAf9ACHUSaTT9 01970
TCLEPHONs: 979.749-9999 0M. 300
FAX: 979-740.9949
D
Debris lsoess,
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
Of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
Mw debris will be disposed of in:
r / ' f (Location of Facility) S9 lell�
I
Si of Applicant
y
Date