134 MARLBOROUGH RD - BUILDING INSPECTION gP1iAMiMtlST9E f&19 019 APPROVED BY 774E
ASPIMLIA PFWR TD A PEBW BFJNG GRANTED
CITY OF_SALEM
N � _ �
of � � � \ Dab
q : i Ward
ZW" Dishiot
Is Pmpwly Loeabd in Location of
ft HWodc DWfict? Yes No\r—'
Is Pmpwty Locayd In
• Bn Corlservatlon Area? Yee No\
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof,(R� Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other
PLEASE FILL OUT LEGIBLY 3 COMPLETELY TO AVOID DELAYS IN PROCESW40
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accordwig•to the following
specifications: //
Owner's Name 4l17 olo P)n pip )
Address 6 Phone `3(/ ( 7W—
Architect's Name Sro(
Address & Phone
Mechanics Name
Address & Phone ( I
What is sla pwpoea of WWW 5e/; Ao/lxJrl--
Mdww of tallldirq? S K(rLS IP S B a dwaft ,for raw many lamaae?
w9 bMi av ow"',l to law? Aebeaos7
Eetinated coat Ca-). Qo CRY Lkw"s tSo"Lloalea s
Ha Iapso�mat yt
Lie. If / o ("
Signature of plicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
f/.P_/dn� of •S-hif 51e_
MAIL PERMIT TO: b 15 6 o
J
No.
APPLICATION FOR
PERW TO
LOCATION
PERMIT GRANTED ')
19
ovFo .
INSPECTOR OF BUILDINGS
Puauc PROPERTY DEPARTMENT
120 WAsmimaTON !TREAT, !RD FLOOR
SALEM,MA O1 S70
TEL (270)745-95EE EXT.aao
FAX (976) 740.96"
STANLEY A USOViCZ, JR..
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the pmviaiom of MGL c 4%SA I aclmowWV that as a amwiaoa
of Bm'lda1S Permit 0 ,aR debris res aft Rom the cozaractkm acdytY
Sovaaed by this BvildiDS Permit shaft be disposed of in a properly licensed soli&waa
dulposal facility.as de$oed by MGL c D%S150A..1
The debris will be disposed of at:
Location ofFa tty
Sig nV=Of Permit AppHlatot Date
(PLEASE PRW CLBAR mtso on.
t5(V1 ( �oo4i n s ( C
Nam ofPamk AppHow
Firm Name,if my
Ad&*City&State
The above statute requires that debris fi+om the demolition,reaovsdM reW or other
alteration of buNing or Anwoue be disposed in a pmperly_licensed soH&waste disposal
facility as defined by MQ,cl% S I50A,and the building permits or heaoses an to
indicate the locavon of the LciHty.
. � �' • lwf►s»softivaf� a f�assachttdsJ�d .
600 .A616Skied
n..l Ga+me1 Saal.m. M".ei m& 021/1
Comm"Mar
Workers' Compensation romance AffMavk
'rf>uh-a principal place of bminess an
t •S
do liereby•terdy under i))n pal
sss�and peasides d pw)Wg thm
() 1a an employer Providing works, Compensation Co"Fade for my etA� week on .
Imo• y
Insurers" Compaq po "Umber
r ,
I am a sok proprietor and haw no am working fir me is aW capadq.
() 1 am a sek proprietor, general contractor or homeowner (drds one) and have hired tM
contractors listed below who•heve that foikswing workers' compensashm Poldw
Conwaeter Insu»nes ComPMrv/Po Number
Contractor Insurance CompaW/Po Nervier
Contraaer Insurance Conspany/Policy Number
() I am a homeowner performing all the wont myself.
eeeaxs"net a Cur+N"wawew.e be fon.areed a sr Ofke s1 Savedraaom N do DNA is covers""Vikedes aN SU Idba a a ="
Ceram aC"wires«rs Swim 2fA N NCL 152 Can kad at am ataxia CSCueinc N a Amiga aai i•fMM aNfer w
teaq•iesrssnerw a�A a CM aaaeie w dCe awm N a STOP WORK ORDER sore a ba N S 100.00 a asr ata4t era,
Signed this • dap of ,
:icerseei'Fcrmittte euiWing Department
L.icertsinf Eoarc
selectmen Office
=eslth Gepsrmer,:
7 - -=eeC.r Yet _ ace epe qpe 77!