118 NORTH - BUILDING INSPECTION -PL1#PS1ftffiT-BE fiLEP-1fJfl APPROVED 8Y T44E
,W5P XT2R .PRWR TD.A_PERMIT$,SING GRANTED
CITY OF SALEM
No. 10'• 2Uo �\� . "� ai s� Date (ZI , (0 '�O I
Is Property Located in Location of t 1
the Historic District? Yes_No Building
Is Property Located in X 5�11 A
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding,Coontrnstrruct Deck, Shed, Pool,
Repair/Replace th r: 6 L2
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:
Owner's Name t JAJ 1 O —t rt (d
Address & Phone ta?g Aa-A2A ( o 5)39 1
Architect's Name
Address & Phone ( )
Mechanics Name 4
Address & Phone ( )
What is the purpose of building?
Material of building? W 00c) if a dwelling, for how many families? My
Will building conform to law? II-es Asbestos? 1�
Estimated cost 2C1C1 jo o City License a N A State License rt
Home Improvement
C.K 12-0 $1Zs°= Lic. s
X Signature of plicant
SIGNED UN R THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
I l ( (^'W�PIti I Qf-l.IL K7n S10 e-z -e-)at i�R r^Q) WI'aos
MAIL PERMIT TO: u i �n l n�shcwt N `� • I
0
No. 170-2oc"
APPLICATION FOR
PERMIT TO
LOCATION.
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
CommOnWsAk 01 /r/a6eack"646
c^� nn /
Jepa�taaaant d f,Jradmtriaf_/7eeidAAU
600 We1n11sre �t.aat
Jarnes J.f amooes Boston, /!/auad" 0.2111
Camerrassroner
Workers' Compensation Insurance Affidavit
. r
1, _ I /r�"�� MGT11✓jl S
wish.a principal place of business at:
. . Krraisr,r.ray)
do hereby certify under the pains and penalties of perjury, than:
�m an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Compan Policy plumber
i am a sole proprietor and have no one working for me in any opacity.
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoeruand wt a ceor of ehc sa,ernent all be for arded ed OR Once of(nvesctaoons of the DIA 1W co. ate vevifcadon and our facture to ware
coveranr n redssreo under Section 2SA of MGL 15 2 can lead eo the inooudon of crvnnas oenardes comsadnt of a fee of we ebi I.5M.400 and/or one
ream' 6,nww .tea as 6A oenastles in the lone of a STOP WORK ORDER and a fee of S Ioo.00 a an apirn,She.
Signed this day of
ccnsec/Pcrmiccee building Deparcr„enc
licensing board
Scieecmens Office
Health Department
?05, 409, 275
-G `dERi T CG`✓rr� G iNFC =:'.— r. i01 CAL. : _ ,
�0. OF 5P.LEM. lYIFD7na�.n.,�� • • •
PUBLIC PROPERTY DEPARTMENT
• • 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT.380
p 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# ,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 ID,S150A.
The debris will be disposed of at:
Location of Facility
Signature of P t Apphca>� D
ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
0Agr �
Name of Permit Applicant
(�/1 �'�-fv11IC Ce9't1�W���U
Firm Name,if any
OU_L kS�r
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 611I, S 150A, and the building permits or licenses are to
indicate the location of the facility.
BOARD OF BUILDIN REGULATION!$
wi r License CONSTRUCTION SUPERVISOR p,
.� Number CS 077487 '^. a Birthdate 10/13/1966 `
... Expires 10/13/2003 r.rt- 77487, i
a Restricted To:,,,00
tk
DANIEL E
76 GROVERS AVE MCINNIS � „ _ kF
WINTHROP, MA 02162 Administrator.
6i