20 NAPLES RD - BUILDING INSPECTION n:.
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JWWMG GRANTED s`
CITY OF SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Root, sroof Install Siding, Construct Deck. Shed, Pool,
Repair as, Other."
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCBtI
TO THE INSPECTOR OF BUILDINGS.
The undersigned hereby applies for a permit to build according to the following
speciHcatlons:
Ownses Name 61A�4v I
Address A Phone 197?1 7W-- 1Y61-1
ArchReas Name
Address 3 Phone ( 1
Mechenic:a Name
Address S Phone f 1 is
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Signature of Applicant �;..
SIGNF,D UNDER THE 1,6
OF PERJURY
DESCRIPTION OF/WORK TO BE DONE
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MAIL PERMIT T D. _G����( &AIh�v
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APPLICATION FOR
PERMIT TO /
LOCATION
00
PERMIT GRANTED
AP OvFo 2
SPECTOR OF BUILDINGS
s
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
i SALEM,MA O1970
TEL (978)745-9595 EXT.380- j FAX (978) 740-9646
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 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 M S150A 11
The debris will be disposed of at ��g�ei^L �Luwtf� �Sl kk A01M s L-ow/.
Location of Facility /
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
106j/c, �i etr �vtS�
Firm Name,if any
i0Fjmmk If ti Sf- 5 o)bkj
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 clII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
;,�� Commonlue:a� o�r 1.11aF�at�a�
6
JJepasletea�o f�ad�ial�eeie als-
n 600 ryw��..�-11m Stmel
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ism"J.camwel Uoc!«y uaAeeaelb 02111
Workers' Compensation Insurance AMdayit
. . wicha principal place of business ax
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. . lGgaawrare)
do hcreby'ccrzify under the pairs and penalties of perjury, thug
() 1 am an employer providing workers' compensation coverage for my cinployees working ens
this job.
Insurance Company Policy Number
1)6 am a sole proprietor and have no one working for me in any npaeky.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation polieks:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
1 vnaerftand dm a every of" a'r nc et we bt is�aro.d ev ow Once el leerodtaeeoett of ow DlA for cv+ ate terirraden used out lent m IePCa
cce are as rtwrea unoa Steeon 25A of MGL 15 2 can kao to Ow inddeeteon of e'*"^at cooed"eor�"dM of a h"of se vs-S 1.500:00 aue/st vet
rtan'ir..yooremtnt as % a err ci.i ocnAri" in the form of a STOP WORK ORDER and a bet df S 100.00 a Oa/ ogling set.
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Signed this t� day oftu
L
iccnseei Fcrmmtt ilding Dep;Zr�-z n
iScensinq Ewrd
Seiectmens Office
^e:lth Dep2r-:men-..