125 NORTH ST - BUILDING INSPECTION (4) I SIIINS1011STIBEff'LqE9-AN9 APPROVED 8Y T44E
JhISPF.CTDR PFWFI TO A PEAAIIIT BEING GRANTED
CITY OF_SALEM
No. Date
i
Ward
Zoning District
Is Property Located In Location of I _
the Historic District? Yes No_ Building d c� o, S/�
Is Property Located in
the Conservation Area? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(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:
Owner's Name
Address & Phone
Architect's Name
Address & Phoneme /J f
Mechanics Name �
Address & Phone Lid �-T//
What is the purpose of building? // Ot/ffY7G/7
Material of building? tr/r� �/ If a dwelling,for how many families? J
Nit building conform to law? Y v0 ; Asbestos?
Estimated cost O C9 `� city License M state u GS 0 8 K 5
Rom Laproveaent
Lit. 14 40 /
Signature of Appi ant
SIGNED UNDER THE PENA
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
!�Leh �'�
MAIL PERMIT TO: Cbh7�i�. r
APPLICATION FOR
(� PERMIT TO
pp I112n q o Ap 311-/;' t—�ioo v
C�`z� CrzGC Ci
LOCATION
o5 orA 5-�eta-�
PERMIT GRANTED
19
AP,PROV�D _
INSPECT R OF BUILDINGS
�I I
' CofrtnaOfw/aaafiJt of�a�ac�iwstte
ISMboo Sr..al
�anrs 1 uaea+ 8vadw M.&A .6 02111
cowsa slaw
Workers' Compenssthm Insoranm ABidayk
. . wich.s principal place of business ac
. . l •S
do hereby•cercly under the paint and penifde of pw*ya thm
() 1 am an employer providing workers' compensation coverage for my employee working on
:Ns far.
Insurance CempsxW Poligr Number
/I am a�sole propriesar and haw no one workbag fdr nee in any capsdey.
() 1 am ��Proepdezr
�general contrseaor or homeowner (drde one) aad have bind the
contrawho-ha" the following workers' compensation po6dest
Contractor Insurance Company/Polly Numbw
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
•1 weaww"me a ca.r of ft wawnww wo be forwarasd a w Oran ie Iwaer Mww of w DIA for corwala•saeindm aeea an bare a wean
c~atr r rrawrd a SSA of MGl 152 can ksa as w irrwwd.a sf c o i is.eaada eerradnt eta awe eel w mi 1 NO ansfor ne
roan':e awl.wrni a.us d.i aua.iw w d+e ena of a STOP WORK ORDER a a a iw of s 100A0 a aar apbot aaa.
Signed this • day of _
JCcrseei Fcrmitcet Euila of Departrkenc
�ictnsinf Eoare
Selectmen Office
-�e.slth Deparmer*
PU84-JC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 9RD FLOOR
> SALEM.MA 01970
TEL (976)745-9595 EXT. SSO
STANLEI/ J. USOVICZ, JR. FAX (979) 740-9a4e
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
Ia accordance with the provisions of MQ,c 40.S34,I aclmowledge that as a condition
of Building Permit N_ .all debris resulting from the c o=uucdm activity
govened by. this Building Permit shall be disposed of in a pmperly licensed solid-woe
dtaposal may. as defmned by MOL c M S150A.
The debris will be disposed of alt: C -Z,' � )/1�Jo f��
LocaIIon ofFaaallfy
a�Z(9
mgnatme of P Applicant
FULLY complete the following information;
(PLEASE PRINT CLEARLY)
�. 01,
s��f'
Name ofPesmmtApplicant
Fan N uame,if aay
Address,City dt state
The above statamte 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 ss defined by MU cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.