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10 MONROE ST - BUILDING INSPECTIONi MHST-BE fiL-Ea N .APPROVED By T44E 11 P1=C7 R .PWRTP.A.PERNDT.B,EWGGRANTED CITY OF SALEM No. Date C—lJ - 3 .\ `s.i .. ii a Is Property Located In / Location of / the Historic District?. Yes ttt///_No_ Building Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, 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: Dy-. 1Z . MP<V q $> ?XC� Owner's Name S C �1 ����re /j e �— Address & Phone f© xo g p©'e Architect's Name Address & Phone �n L ) Mechanics Name �CntS �P�Q 1�f r t Address & Phone '� Lt t reS i 4e f , &/r,6 (9h11 An l T-4 2 3 What is the purpose of building? Material of building? UJ(!>o r If a dwelling, for how many families? Will building conform to law? 015 Asbestos?—,& D o Estimated cost 60.�v City License # N P' State License # (2 S 06-S14 p Home° Improvement Lic. : X gnature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE / C-G.0 V l vLP It � (z- C nyvy , zoOS MAIL PERMIT TO: No. 2 APPLICATION FOR n PERMIT TO LOCATION PERMITIGRANTED / � ► APP VfD INSPECTOR OF BUILDINGS 4 �— forn/nanWi.'a L ol lllaaeacketb 6 Jepa,Itataatl o/.J , "rL boo W Im-31,111 James J.CaataoDN dare 02111 Cormtsstona Workers' Cc Lion Insurance Affidavit with.a principal place of business at: . . ltatr�swdalr) do hereby'cercify 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 Policy Number I am a sole proprietor and have no one working for me in any capacity. I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: T 6e-- af�ocefl Contractor Insurance Company/Policy Number Contracoor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I onoetxanc mat a coon of Na ua,e t wW bt f,aroee ro the Offtct of Imvegawom of the DIA for car ate eefWKadaet and out Is➢an to ttcwt coY arc as teootec unoer Section 2SA of HCL 15 2 on lead to the jr n jion of creriroi Ocnatem conazont of a fee of me=4I.500t00 amla_tt^t rears'i:aruormxnt v ws0 at tiei "naltic in the loan of a $TOP WORK ORDER ano a ftee of S 100.00 a oat against nK. Signed this day of �icersee/Perrr�ilcee building Gepartn+ent i.iccnsing board Seieeamens Office l=catth Department - - �o OF SALEM,, MASSAQK1=r- i I PUBLIC PROPERTY DEPARTMENT c ' 120 WASHINGTON STREET, 3RD FLOOR e SALEM,MA O1970 a } TEL. (978)745-9595 EXT.380 �G FAX (978) 740-9B46 . iTANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT that as a condition In accordance with the provisions of MGL c 40,S34,I acknowledge of Building Permit# all debris resulting from the construction activity govemed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c lII,S1550A. n The debris will be disposed of at: Location of Facility Date i tore of Permit Applicant FULLY complete the following information: LEASE PRINT CLEARLY) Dye \ �—(� Name of Permit Applicant Firm Name,if any 11 nn 3 tl c, �-es PA 2 i� t� 1/� cUe� 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 permits or licenses are to . . building erml facility as defined by MGL clll, S150A, and the g P indicate the location of the facility. - BOARD OF BUILDING REGULATIONS License CONSTRUCTION.SUPERVISO_R Number-CS _ 063148 A,Li. r _ £xpiies.01f13T2004 -ir.no 2847?g ' � ,:. Res�Icted I ' JOSEPH MCCARTHY 1 I' 34BATES PARK F3 :. BE\/ RLY,'MA.171906 Administrator �- s . b