112 NORTH ST - BUILDING INSPECTION (2) I
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J JNSP.Jr DB 1D AWP EIEINCs GRANTED
CITY OF SAItEM
\A Date
s• �
Is Property Located In Location of �/� /r Ul�• 7
the Hlstodo DWdct? Yak_No_ Building
Is Properly Located in
Me Coruamatlgn Ame? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidin Construct,Deck, Shed, Pool,
Repair/Replace, Other•.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCE$IMNG
TO THE INSPECTOR OF BUILDINGS: `
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name ���1�� C't U/��'►�
�y /�'� S (q?A --74CG
Address & Phone /
Architect's Name te* C �rR"mil
Address & Phone �Z r �7�11 ',32
Mechanics Name
Address & Phone L 1 is
IS!!1
What Is the purpose of b mng?
Matedal of WNdhg? B a dwel ft for how many familes? rq
WIN bulding cordormto llow?'� Asbestos? i
Eatlnuded cost.,/-i CRY Llcanw a N A State IJcer"M
Rome Imp2w!"at
Signature of Applicant
SIGNED UNDER THE 100j ^If j
!
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
y��' Gr�"�A �C�����"� ��' f'1/I'�S�T1 G��✓�Sim
4,
MAIL PERMIT TO: C'C1 /t /,P
��Ey�I
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2-6
AP ROVFD
INSPECTOR OF BUILDINGS
Board of Building Rngutatloos and Standards
j NOME IK+ROVEMENT CONTRACTOR
it Reps b1m0fc 128680
6cp11
iratlon. 7(612004
Type Supplement Card
B&C WINDOW CORP:a 1
BILL YOU
12 EVERETT ST
MALDEN,MA 02148 .4dministntor
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boo W.16floo Jl,.el
JIM"i.Caanood �,loti /!/aaanck+uaW 02111
conymsmow
Workers' Compensation Insurance Affldapit
. . with.a principal place of business at:
/unseaa✓str)
do hereby•ccrtify under the pains and penalties of pedj ,Ya doc
() I am an employer providing workers' compensation coverage for my einployees working oa
this job.
6�AMe1 G l �7-�-
Insurance Company Po1'Icy Number
I am a sole proprietor and have no one working for me In any capaeky.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors list d below who have the following workers' compensation policies:
GO
Contractor Insurance Company/Poliq Number
Contractor Insurance Company/Polity Number
Contractor Insurance Cornpasry/Policy Number
() I am a homeowner performing all the work myself.
..S be for arose to ON Offce of Itrvotitataaro of the D1A for co.erare'�a°on WA out taaurt to aeatre
I utaoenunC we cc" et tl+o weemetn _ "Wer Omco.erart err noarro unaa Section ISA el MGL 1 5 2 can kao to tM i*aoeantoa of crvnnat oetwaes corsaunt 01 7 bet d w lai 1.500A0
rean•kserrerment a ft a t:irG ot"ILM in t tor+++of STOP W ORK ORDER ano a fine of s 100=a oar attteot tag.
Signed this • day of ���—�
.iccnscci Fcrrtiitct "tuilcing Depamn cat
licensing Eoarc
Seleetmens Office
rie:kh Depat-tnen'
- - - — _�c
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O1970
TEL. (976)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. LISOVICZ, 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:
LLocation of Facility
'/�-/ '2
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
woa-P Ul*�:'To- C114- t�
Name of Permit Applicant
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 I:MI S 150A, and the building permits or licenses are to
indicate the location of the facility.