1 MESSERVY ST - BUILDING INSPECTION (2) ` , ..�
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� � .�����/ 1a�A 7I '�tJ��P T B�iNG GRANTED
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\, m a ; Zoning Dlstrict
Is Property Located In Location of
the Hisioric pistrict? Yes_No� Building � ��55 �
Is.Rroperty Locatad in
ifi'e Conservatlon Area? Yee_No�
BUILDING PERMIT APPUCATION FOR: '
'Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construet� Shed, Pool,
, Repair/Replace, Other:
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 /�'G! 'T_�/Uh,j'��Y
Address & Phone ,��.f�za�s�_ (�/�1 ��/����.�
Architeet's Name
Addcess & Phone ( )
Mechanics Name iil�/y1�CS,�'� fil/�i%" o7.�i`—G���l� /�ia��/��l /�4•
/ dl�}'S
Address & Phone (�� �7%`���
What Is the purpose ot building?�/lp%7?i°/�� OT '�/�GeA?f GQ/2"�L_
Matedel ot bullding? If a dwelling, for how many familles? aZ.
WIII building coniortn to law9 yPs Asbestos? �(/fJ
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Eatlma;ed cost __�j�.�City licenae r State Licenss d O 7��'�,(
O� 9 GC�7 � �r� ���.f�..��Ju,c.
Signatu[e of Appticant
SI(iNED UNDER THE PENALTY
� �C� OF PERJURY
DESCRIP'TION OF WORK TO BE DONE
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MAIL PERMIT TO:�` /ylc�f,I�P�/,f� fC�/�/y� /�G1 • ol�'/'p
No.y i -
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APFUCATION FOR
PERMIT' TO
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Workers' Compensation Insurance Affidavit
1,
.. with.a principal place of business at:
do hcreby'ccrtify under she pains and penalties of perjmya thiM
1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor
Contractor
() I am a homeowner performing all the work myself.
Insurance Company/Policy Number
insurance Company/Polity Number
I Ur4e,t " wt a coon of tlio weemem wit be ior,•araa m the Orrce of Imeadratr of the DIA Ion coeerate veri4cadon an. enat bkxe to asevre
co. arr at reairec unoa Section 25A of MCL 15 2 an kad w the inooYdCn of erimhgi oawwdn corstadnt of a #ne of in =4 I.500M MW we one
rcary' iraruonmrne v W M M 6-i oena160 r the loan of a STOP WORK ORDER ano a frac of S loo.00 a oar ap+nt mt'
Signed this , day of
/.fir 66y,,
liccnstti Ftrmiiite
builcing Departn+ent
Licensing board
Seieetmens Office
lzh� Department
n � "
STANLEY J. LISOVICZ, JR.
MAYOR
CITY, F SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
TEL. (978) 745-9595 EXT. 380
FAX(978)740-9846
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 150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
;Z, ezf ' s�r/r
Name of Permit Applicant
� ��A & i��&-0/,P
Firm Name, if any
Address, City & State
!G c!r_ o2,c,7of
Date
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.