91 MASON ST - BUILDING INSPECTION i L-*NS-MOST-BE fiL-EG—ANO APPROVED 8Y T44E
UaSPZGJpA PF.WR Tp A .P.ERMIT BEING GRANTED
CITY OF SALEM
-0�J
r
No. �l rll , / r a. qqq ••��//// ��
� l�`� ..�. '*\ Date
Is Property Located in Location of /
the Historic District? Yes_No l Building J
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, nstall Sidin Construct Deck, Shed, Pool,
Repair/Replace, Ot er:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name �� • - of'&cgilf" &, t
Address & Phone q/
Architect's Name
Address & Phone L
Mechanics Name z&"
Address & Phone Z (Tkl 7 Y 7
What is the purpose of building? /� s
Material of building? In)d O GO If a dwelling, for how many
�f �
families? —
Will building conform to law? 5- Asbestos? , y D
Estimated costCity License # N A State License # ®/O �� D
Lic• 1
X
Sig-nature of kpplicant
Cl�- 15 to co SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK/TO BE DONE
MAIL PERMIT TO:7/ A'02,o r d r gieuaZ f/o c0 i•< 't"7 r ✓ _` '
L
y
No. (o -ZooG
APPLICATION FOR
]] '' PERMIT TO
LOCATION
,�i�
PERMIT GRANTED
�1a5./fl3 ,s
APP70VED
INSPECTOR CW BUILDINGS
` porn OF SALEM,- !MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
t SALEM,MA O1970
TEL. (978)745-9595 EXT.380
�G7nu FAX (978) 740-9646
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 Ill,S150A.
The debris will be disposed of at Tz �,1-r r Y 71�- -
Location of Facility
nature of ernut, plica�r► a�
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address, Ciffy & 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 cIII, S 150A, and the building permits Or licenses are to
indicate the location of the facility.
Commonutoahk of /4a6eacL6efL6
n I
= � � rat /.9rtdullriaf�ccipfenla,y .par raga o
n 600 LUd, 3Ireel
James J.Camobell Uoilon, /!laaaac/aataett! 02111
Carmrssltaner
Workers' Compensation Insurance Affidavit
I,
with.a principal place of business at:
tonrsowta)
do hereby certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company olicy Number
I am a sole proprietor and have no one working for me in any opacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have she following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I understand eat a copy of did susement wa be fw arao to the Office of Imesdgauom of the DIA for coverage.eeiRndon and sew Wuee to secure
coverage at reword under Section 25A of MGL 152 can lead to the inposnidn of cr6nirrat oenmtiet corsudnt of a fine of ttp to-S 1.500.00 minor one
Years'imoruonment as.cep as cm analdes in the form of a STOP WORK ORDER and a fine of S 1o0.00 a day apina OR.
Signed this , day of L)
Lice see/Permit Building De(pTartne�ent
Licensing Board
Selectmen Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375