22 NICHOLS ST - BUILDING INSPECTION t
r
"PLA"6ilAg6TISE11%11! IND APPROVED By T41E
JdSMUTA PWR TD A PERMIT BANG GRANTED
CITY OF_SALEM
No. �� \ oats �3
Ward
Is Pm Pwty Located In / LwAtion of
ma Historic obtdd? Yes No �! wing
Is Proparly Located In
rre Corroanabon Ana? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) R QRwnatal) Siding, Construct Deck, Shed, pool,
Repai , 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 accor&Aq to the following
specifications:
Owner's Name
Address & Phone a 1 )d!'W_4 S7- f S 0'o
Architect's Name
Address & Phone If
Mechanics Name #qR �/V�S
Address & Phone 3� tJ�� L% 1 ,5-35-
Wfa t Is fha purpcaa of tadldW
Mstedd d h AdIng? N a dwawg,for how malty famaee?
WIN fa6ft corrloem to law? Asbestos?
EdNWed cost !�d-dz%�" CNy umm r State ucerrw r d l S-/3 7
now I"ro.dnt
�W rte. IL)6-233
GIVIliture of-Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
a
.t.
No. �
APPLICATION FOR
PERNT TO
LOCATION
PERMIT GRANTED
PROVED
INSPECTOA OF BUILDINGS
• �o?;�rloiyunt6(� of///�at��d
b •�.[Jepaclwae��.l.L.t,�l�axiieela•
eooUyJ.,�r.,,Sa.ei -
n.a f1�.a.J.ae,l 021/1
eaaaseMW
Workers' Compensation Insurance AffUlo d
. . W104 p►laeloai place of btohtess 8C
do bereby'cer* under the pains and pesaldos of perry, tbaa
I am an CMP oysr providing workers' conWeatadon covgate for my siapioreoa workbag am
this
Insueanp Con"NOW Policy Number
1 am a sok proprketnr and haw no one workbag fir me `aq caoedge
() 1 am a sole proprietor, general contractor or homeowner (circles one) and haw hired tho
contractors listed below who-have the, following workers' compensst3os po6d=
C WSCI*r Insuranis Compavvylpollcy Number
Contractor Insurance ComPARY/Folicy Humbw
Contractor insurance Compaq/Policy Humber
0 1 am a homeowner performing all the work myself.
•1 VOSWWM sue J ref of Oda A MWIM WE et fer+.reN M dM Ofire A iMaeraeae of ON DIA 4 Cove/ono voukedee we sae ham r.aaan
cowrap V wwrrs wow Scden 2SA d MGL 152 can kid row irweis of ak imm stawk;euuebat of a aec et ee asi 1•SODAO aWec er
+cm•:sreeamn a a dd wards in L%c kale*is STOP WORK ORDER aM a iw N S 10CAD a an Raiw sea.
Signed this . day of Ad dot Y
,s iFermittee euiWing Department
Jetnsinf Ecart
Seiectmens Office
rieslch Depammerc
a
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STRaaT, 3RD FLOOR
�. BA1.a14.MA 01 S70
T[L. (970)74D-D995 MIT.360
FAX (970) 740.96"
STANLEY J. USOVICZ,
MAYO JR.
R
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the Pmviaiow of MGL c 40,S34,I aclmowledp that as a condition
of BmUng Pamit N -all debris resaltmg¢Dm the CmMmcbm w"
SDvanW by this Building Pamit sW be disposed of in a pr paly licaleed solid w"M
disPOsal facility.as defmad by MGL cc DL S150A.
The debris wn71 be disposed of at:
Location of Facllty
OfP & 3 Ll
Applicant Date
FULLY(PLEASE P�RIINr CLE d1c�ARL owing meson`
U�
Name ofPenait Appficaot
Film Name,if my
Address,City&State
The above StRUft requires that debris fi+om the demolition,renovation,rehab or other
altaadm of building or savctm be disposed in a properly-licensed solid-Waste disposal
facility as defined by M(X ca S 150A, and the building pamits of licenm ere to
indicate the location of the facility.