10 NORMAN ST - BUILDING INSPECTION (2) VEO By DBE d
�iW REING MUNTED
,t�IQA D P
_ CITY OF SALEM
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SUILDMG PERMIT APPLICATION FOR: '
Permit to
(Clyde whloha er a") Roof Reroof. Install Siding, Construct.De* Shed, Pail,
Repak/Replace. Other.
PLEASE FILL OUT LEOIBLY i COMPLETELY TO AVOID DELAYS IN PROONWM
TO THE INSPECTOR OF BUILOIN13&
The undersignedhereby applies for a pwmk to build according to the bilmo 1p
Owner's Name
V
Address A Phan /Q ,I/meat, s4. 5&6A / Mj 1 L<3g-ncc3Z
Architect's Name
Address 3 Phone Pore'
�
CMednnlcs Name L t t�.-: l 0 o r e;r�
Address a Phone Ifn /�I�A`,.M!' 1
VNIM r HM p apm d OIINuk1g!
fAlle W M a ch, far how rawly lm~
v-wirrr::: i
WE aAft omift. label
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Scom t X
Lie. t
Signature of cant ".
SIGNqD UNDER THE
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
,;A&nn 2r
^1
MAIL PERMIT TO•
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49-.
F7 .
No
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED ;
AP
.t
INSPECTOR OF BUILDINGS
�afff..r
(fornnionwaa& 01 /r 6ac"af
,1 � �. 1J.parioa.al a/�.6�Gial�ccia.aLs
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boo w.�:.�►�.��.�
James a Camooas Qedow. //I..aor/uww 021 11
cormarssaw
Workers' Compensation Insurance MUM*
f�° e i do
, s'4 ric 11rOy1
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. . wiihaQprincipal place of business at:
ac�a N! 21260
. . ftanuear✓aM) -
d ereby'certify under she pains and penalties of periorya Thm
lam an employer providing workers' compensation coverage for my employees working OR
this job. A)-J-
Xtr au4r :.L/L
Insurance Company Policy Plumber
1 am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation poneks:
Contractor Insurance Company/Policy Plumber
Contractor insurance Comparry/Policy Humber
Contractor insurance Company/Policy Plumber
() I am a homeowner performing all the work myself.
I vn4erUar4 we a coer of"Aaermrar Ni be ion aroed so the Olf2e of imasdtaoosa of the DIA for co. are w"WKadon arced Wn laiare 0 weave
co.erarr as rewaro under Section ISA of MGL I S 2 can kad to ene inoorwen of crvr.nas we d,rwon eorsarint of a G of w edi 1.50000 aawor one
roan,rror.onneenr v .ter as ci.i mnalcw in the Ivan of a $TOR W ORK ORDER and a far of S I00A0 a ear apirot roe.
Signed this . r` day of �
e,/� ,
iccnscciFcrnittee -tuilding Gep:rtn+ent
1cen5ing E.oarc
Seiectmens Office
j. nr . Ge=, -C� , 77r
f
PUBLIC PROPERTY DEPARTMENT
• 120 WASHINGTON STREET, aRD FLOOR
SALEM,MA O 1970
TEL (976)74"595 EXT. 880
FAX (976) 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# . th
all debris resulting from e construction activity
govemed by this Building Permit shall be disposed of in a properly licensed solid-waft
disposal facility,as dellned by M(3L c M,//S��15ft
the debris will be disposed of at: C ,�r
a�
Location ofFacrTrty J
Signature ofPa=it Applicant Date
FULLY complete the following mfo:mawn;
(PLEASE PRDU CLEARLY)
Name of Permit Applicant
L _ j2re f r�. �o�x}rt,�rfi�•
Firm Name,if ally
Address,City&State
The above statute requires dust debris ftm the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MG,cIII,S 150A,and the building permits or licenses are to
indicate the location of the facility.
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