19 NAPLES RD - BUILDING INSPECTION I
iM.*1161Ml16T9E fKA9 019 APPROVED BY TWE
imsp=m PMOR TD A PERMIT WMG GRANTED
CITY OF SALEM
No \ Dab 1 0
I' r�\ d
f Ward
Zorkq Dlatrki
Is mp tic wty ocmd in Yw No Location of
aaimins a L S
Is Property LonNd In
ft Cotwtvatlon Am? Yee No
Permit to:
BUILDING PERMIT APPLICATION FOR:
�
(Circle whichever apply) Roof, eroof nstall Siding, Construct Deck, Shed, Pool,
Repair ce, Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVO
ID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accor&g,to the following
specifications: �n I
Owner's Name lreo�P, 60LAV)
Address & Phone
Architect's Name
Address & Phone 1 0c, ( l
2\� Mechanics Name CeVa�,c'1 // �Vicl-
i Address & Phone l0
Whd Is the purpose of buikJkq?
�\ Mabft of bull W W o o I I a dwaft for how awry fammm?
1 W N buk kq cm ft., to law? YLJ' AsbMm? 146
EdmsWconk 0000- 0'C- kflyU0a a slawLic t CC1000
aoar rarpso..raeut
Lie. p LICas-o
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
S
MAIL PERMIT TO:
12WO
No���
APPLICATION FOR
PERINT TO
LOCATION
14,41ei Age/
PERMIT GRANTED
7�D�t 19
APP,ROVFD
INSPECTOA OF BUILDINGS
I
PUBLIC PROPERTY DEPARTMENT
` 120 WASHINaMN $TREK, aRD FLOOR
SALEM,MA 01870
TEL (979)743-MOS EXT.Sao
FAX (076) 740.94"
STAMLEY J. Usov1CZ. JR-,
MAYOR
DISPOSAL OF DEBRm AFFIDAVIT
In accordance with the provisions of M( L c 4%&Up I aclmowle*do as a
of Bmldbng Permit# .all debms r=uhig fim the dam aeftyty
pvamed by this Buihding Permit dM be disposed of in a peopaly liceoaed so"watats
disposah facility,as defined by MUL c 1%S1SQA.
The debris will be disposed of st; N rikcr�l h L S <i�l ova
Lo wan of Fatality
Sigoitme of PeamitApplicaot Dom
(PLEASE PRINT CLEARLY) kosma>ion.
N,,annme ofP=MApphems
GAS f l
Fnm Name, if any
Address,City dt Statue
The above stalArte map*u that debns fi+nm the demolitim reDovation,rehab or other
alienation of braking or structure be disposed in a properly-Incased solid-waute diRmw
falaality as defined by MM cIII,S 130A, and the building p=is or lieeaea we to
indicate the location of the futility.
• l.or�.r�iaonuraaa{i/to��a�ac�J�d
' �, JJaPas/waa��.7�rifriel�ai�..�•
boo waAia16 S'be.l
1 esa+oeet Boni e. //SeamA..A 021//
e.eaaena�.
Workers' Compensadn Intnrance Af Wayk
- • w1*4 prirldpal place of kniness asc
f %
do hereby'cer* under t)w pains and peril" of pwl.wy, tines
0 1a empkf'er providbW workers' compemadon coveraie for my eiaploreu wpideR on
11111116
Insurance Cenapatn r Policy Number
x1 am :sek proprIe w and haw*no one working fdr an In any wysdcy.
0 \ 1 am a aele proprietor, general contractor or homeowner (drde one) and how hind the
conmicson lined below who-be" thi following workers* compensation po$cku
Centracter Insumnu Company/Policy Numier
Conaactor Insurance Company/Po NUMW
Contractor In atrance Company/Policy Nunaior
0 I am a homeowner performing all the work mrsdf.
•I.eape+y W.0 s caaq d ei^WNW M be fen.aeN e M Oface A b.eitaeae of ON au b COMM*.ealacoise ane on h5m o mm"
'owns a rreorte saver Sacian 1SA W FILL 15 I can lase r er irrreaaie of- I i eeeaie+uiseiae et air of w 04 IJC0M aearer er
Tenn'iaarermim a Sys a der,mania in &he Ia+e e!a STOP WORK ORDER ans a har of s icoAc s an atsiw aaa.
Sirned this • day of
.iccraceiFcrmittee Building Geparsn.ent
!icenjinf Ecare
Selectmen Office
�nith Geprmer,�
epe epc rpe T;rc