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36 NAUMKEAG ST - BUILDING INSPECTION C -im $ ffL+_ N{ APPROVED BY •T44E U�SP CJ� i ,PF.iJL1R Tp;A_PERMIT.BfWG GRANTED CITY OF SALEM g 3 No. Z Z "Z©O�� et° �4\ Date 'S Is Property Located in Location of the Historic District? Yes_No—Z Building 3 i1/Q LCm�fQa-� i 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: rub Owner's Name rn, Address & Phone 9 69- 913 q Architect's Name Address & Phone Mechanics Name �S 4 Address & Phone3 What is the purpose of building? S/ — cnty, /S Material of building? If a dwelling, for how many families? Will building conform to law? Asbestos? C-,12, 7 d Estimated cost/�/ `� a�J IC ty License# N P' State—License # a V A_a? _ Home Improvement 1 �S Lie. I /d 3 Signature of Applic t ,7-Zq -Zo© �1 SIGNED UNDER THE PENALTY C-V— Z55q OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: c�D ✓\�9 No. LZq APPLICATION FOR PERMIT TO A � LOCATION. 74 �� ke�� PERM TT GRANTED A ROVD INSPECTOR OF BUILDINGS r co " ' OF SALEM. MASSACHUSETT5 ' s PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR •, A SALEM,MA 01970 TEL. (976)745-9595 EXT. 380 Grua FAX (978) 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 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 III, S150A. The debris will be disposed of at: �GL Location of Facility 4r'e of P plicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) 1 Name of Permit Applic Firm Name,if any 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 cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. iw —� fommonwr:akk 01 Ma»acltweffi � n s 2.pll"nl e/91+Ls GL,-icciasnll James J.camooen /IlmmcLwfb 0.21 /1 carmraspna Workers' Compensation insurance Affidavit - (ascuwraeaa+aae) with.a principal place of business at: orT do hereby certify under the pains and penalties of pedM. Ye that: () 1 am an employer providing workers' compensation coverage for my employees working an this job. lnsur ce Company Policy dumber 1 am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor or homeowner (cirde one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor insurance Company/Poliq Number Contractor Insurance Company/Policy Number Contractor insurance Company/Policy Number () I am a homeowner performing all the work myself. I unoencand wt a coot of this tutenn m.o be ion 3rotd to the Office 07 Imodtavons of the DIA for coe arc eeri4caden ana tlut laiurt to wave co.•eratc n rtourco uncer Section 2SA of MGL 15 2 can lead to the:noovtion of criminar oerwtta corsudnt of a 6m of eo to-4 I.5M.00 anohar one ygm iaaruonmmt v tet as cir9 xnaIdts in the io n of a STOP WORK ORDER ano a 6"of s too.00 a oaY ataiaot me. Signed this , day of J� Lice nsce/Fcrtniutt building Depann+ent Ucensing board Seleccm ens Office Health Department _ v i 4500 X4C= , 404, 40S, 40°, 375 C VEnit COVE;-AGUE iNrG=�— � illy CALL: