84 MOFFATT - BUILDING INSPECTION � 3 •oo , a , .
1 L*W1Ab6T13Ef4Lf94AO APPROVED BY 774E
ASPECM8 PRIOR TD A:PERMIT WING GRANTED
CITY OF_SALEM
NOM
,i'o ward
Zmft Diem«
Is HWori Located In Location of D
tffa Hletotic Dbtrkkt?? Ysa No
0
Is Property located In /
the Carranadon Ante? Yas
Permit to: Non
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, roof, I awl Siding, Construct 1)edc,,Shed, Pool,
Repair ce, Other: 5f^se /A .tea(( �
j PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSMKi
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accorcLig.to the following
spedHcetions:
Owners Name 'Q,(-64LlZ 101I L
Address & Phone 21 /�'JOY��/d 1� t9A 7�q )�W
Architect's Name
Address & Phone
Mechanics Name GS-I\) NVAP,J�
Address & Phone 6 CJ4��11 Y� 5v � 021 S22-E3Z�
WMt Is su prapoea a ftWldW r,iJ.l� 0 w• �i Y
mdWW of t>WWW "0 1 a dwaarg,for how many famaes?
Wa bdcbv oordorm to law? AeDaelos?
Edmatad wO00 (� qty Uo a ZQo $fete umm M 12TO-f 3
s� / 63 s �
Signature of Applicant
SIGNED UNDER THE PENALTY`
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
f }Qe D C)�
MAIL PERMIT TO:
'1
No. ���
APPLICATION FOR
PERW T TO
LOCATION
PERMIT GRANTED
19
AP ROYFD
INSPECTOA OFBUILDINGS--
i
i PUBUC PROPERTY DEPARTMENT
,,•� 120 WASNINCTON VMKST, 3RDFLOOR .
&MAN.MA O 1970
TEL (979)743-MOS FAT. 360
FAX (979) 740-98"
STANLEY J. USOVICZ, JR.
MAYOR .
DISPOSAL OF DEBRIS AFFIDAVIT
In mordance with the provWcm Of M(N c 40,S34.I aclmowledp that ea a ca adm
of Mding Permit S .all debars resulting from the conshuctian admty
govaned by, this Building Permit shall be disposed of in a properly licensed soli&wsate
disposal facility.as defied by MGL c D;S150A.
The debris will be disposed of at L( yv LJ `- 4
L6cadw ofFacil ty
k Si
goa Pe�rit ApplfcaotData
FULLY complete the following f dmud ;
(PLEASE PRWP CLEARLY)
GLC,),j /� ��aNuR „o
Name of pmmk Apphcaot
� vut?y-j /PoorwN jE' �y of, ,.��
Firm Name,a any
o)qo �
Address,City&State
The above statute requires that debris from the demolition6 recovadM mbA or other
alteration of bulk mg or smwtum be disposed in a properly-lionised soli&waste disposal
facility as defined by MGL ca S 150A, aid the building pamita or Hce are to
indicate the location of the facility.
G l.,an►mOatsYal6iLt; o� !I/a``s.9ac��d .
�, 1JaPaalwaaf a��avfrdria[�ailiafa' .
600
ewa.d g dry Mussai-A 02111
c..ara,A,asr
Workers' Compenssdn lourance Affldsyk
. . wkb4 prbtcw place of bmiuu.(a'n )
S(0}�C'
do heeby'certly under t)n palga and penihhe of pof.w ►, thm
U Ia an employer providing workers' compemaden corers#@ for nw emploreea workbg M
Insurance Conww P Number
1 awl :oak proprietor and haw no one wwkbtg fir me h1 any oosdey.
() 1 am a sek proprietor, general contractor or hennowner (drde owe) and have heed do
concrocson listed below who•baw the following workers' eompaissdoa poschn
Coesraaor Insurande Company/po Nuanbw
Contractor Insurance Compasry/po Humbw
Contraaor Insurance Compaq/RN-7 H mib@r
0 1 am a homeowner performing all the work nMel.
vrhrwaa ew a Carp of db aamom.e k forwaraa a at Olin ii war of ow M ka trees".aAlaadw ar on bars r
k+.edt aawra
cr.rgp at MAWN.ours Sacdra SSA of MGl 15 2 can kad w ar Wwiim d ariniaa reseda cowdat d a I N of A wi IJCGM aW ar or
+rare':arao,r,.aa a s akr in me kvw of a STOP WORK ORDER w a ins of s ioOMa an apbaeaaa
Signed this •. dad• of
l
:icerseeiFermiuss ouildinf Department
ucsnsinf Eoare
Seiectmen Office
=eslth Geprmer:
-.eeCC eOe 405 40e, 175