52 MOFFATT RD - BUILDING INSPECTION flliN6iNlf6f�6E f�L $�►HD OVED BY T44E
JNSi EtrIbJ3 IpB IYTII#.P. FMG GRANTED
CITY OF SALEM
No. J Date
1 ,
S r
Is Properly Located in Location of �C�
the I•Ilatorto Dlstdot? Yak_No /C Building L2 Z/Lu� LL
Is FimpeAy,Located In
No Con mki gn Area? Yak_No
BUILDING PERMIT APPLICATION FOR:
Pe.nnit to:
(C9rcle whichever apply) Roof, eroof Install SI jn Construct Deck, Shed, Pool,
Repair/Replace, or.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCBBII NG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name
Address & Phone `745'
Architect's Name
Address & Phone
Mechanics Name
Address & Phone Z4 Zl� %���
uu What Is the purpose cf brdld4rpt
r Matedal of trulldlrg7 i��r .�.n U a dwi0m,for how many IamYNs? ,, . ..
WN 6 kbv conform to law? Asbestos?
Ektlrnated cost. 'core e N A state IJcaeke M
Some ImprovementLie. — i!
� � Signature ofA6plicaht
SIGNED UNDER THE P19NA 'i
OF PERJURY (il
DESCRIPTION OF WORK TO BE DONE
it
tl
I i
•�/ Div.::
III '
'+4. . .LiuST.., // GY2T.o,r..Trc/J: . o�$�/s� 31.0�✓ .O�,d�.nUG j � i '
i , -
"''il lei MAIL PERMIT T0:
Q �• I
I ' Ilfu,
.1*
No��`�
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT'GRANTED
APPRpVFD
INSPECTOR OF iUZILDAINGLS
AMPS'° -L£
W36 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (978)745-9595 EXT. 380
FAX (976) 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 Pemrit# ,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 a S150A.
The debris will be disposed of at
Location of Facility
Signature of P t licant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
l_,oA, e6:54
Firm Name,if any
/G/S- ���� s%e �f'.11.✓/GEC/ G/9 3�
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 cIlL S150A, and the building permits or licenses are to
indicate the location of the facility.
' Commonulaa1hk 01 `ma:,6aCLa�
sl
boo w.rLj1-SL v J
.amen a s ... ?V..r.eLr.et, 02111
coranssnoat
Workers' Compensation insurance Mdavit
. . witha principal place of business at:
. . . itrw..r✓aa,
do hereby'certify under she pains and penalties of peritrty. tha1C
() I am an employer providing workers' compensation coverate for my employees working cm
this job.
In ranee Company Policy plumber
�/ I am a sole proprietor and have no one workbag for me in any capacity.
red the
I am a sole proprietor, general contractor or homeowner (cirde one) and have hi
/ h contractors listed below who-have the following workers' cornpensrtion policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Tlumber
Contractor Insurance Company/Pol'Scy Number
O I am a homeowner performing all the work myself.
I unorrWnC ,,t a coon of the l,jrmm wa bt for armd to the Office of tnbKa"o of the DIA lot corer""e"Mcabon arse out blur to WWI
eo.erart as rewrro Omer Section ISA of MCL 1 52 can kao to the irnDOMiOn of crir ul oenanks eorustit+t rd a fine of w w41.SDDAO rands ow
yeah,imoruorrnent a vu of chi or1121tw in the form of; STOP WORK ORDER anc a f+r of S 100=a sat apeot me-
Signed this �� day of /✓II,2 C) — -
iiccrseei F t et building Depart ent
ucensing Ewre
Seiectmens Office
LQG . r,0