131 NORTH ST - BUILDING INSPECTION -PLAM lAli6t-OE fK.+G-AND 'APPROVED 8Y T44E
.WSPZCTDB,PRIOR TD.A.PEWT BEING GRANTED
CITY OF SALEM
No'3 Q� v "y Date
s.'
Is Property Located in / Location of
the Historic District? Yes_No
Is Property Located in
the conservation Area? Yes No S
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof Install Siding, Construct Deck, Shed, Pool,
Repa lace, 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 �� /Uae X� . �f /�- . (lam)
Architect's Name
Address & Phone ( )
Mechanics Name //
Address & Phone s r.��`w e,41bC fy�L) �C� c��31
What Is the purpose of building?
Material of building? If a dwelling, for how many famlies?
Will building conform to law? Asbestos?
Estimated cost city License r N A state License 0 6J/�7
Home Lzproveaant
G
. r Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No. 3s8 I>
APPLICATION FOR
PERDMR TO
LOCATION
PERMIT GRANTED
APR VFD
IN PECTOR OF BUILDINGS
Y.
fp The Commonwealth of Massachusetts
Department of Industrial Accidents
y office Oflm ugauons
600 Washington Street, 7 h Floor
Boston, Mass. 01111
Workers' Compensation Insurance Affidavit: Buildin /PlumbinefElectrical Contractors
ad ess:
r � fn LLB
city .�� I_�/��j, state . zip' Cl/�G phone#
work site location(full address)-
1 am a homeowner performing all work myself. Project Type: ❑New Construction [-]Remodel
❑ 1 am a sole ro rietor and have no one workialLany ca am puntry. Buildin Addition
providing Pe y employees working on this fob.
am an employer rovtdin/�workers' rpm nsation form em to ees
a L /lam .. .
comp
address;,
city: it"a ilI
❑ I am a sole proprietor,general contractor,or homeow (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comoanv name:
address:
cim, Rhope-illRPM
oollcv M, M , .
company name: -
address• ..
city: - 3..
R
Failure to secure coverage at required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to SI,500.00 and/or
one years'imprisonment n well as civil penalties In the form of a STOP WORK ORDER as
a flue of SI00.00 a day against me. 1 understand tbat s
copy or this statement maybe forwarded to the Once of luvestigatioos of the DIA for coverage verification.
/do hereby certify under�an[�enies of perjury that the information provided above is true and c rrect.
Signature Date
Print name / C 1,-e+ -Phone#
official use only do not write in this area to be completed by city or town official
city or town: rmittlicense#
� Pe ❑Building Department
❑Licensing Board
❑check if immediate response isrequired ❑Selectmen's office
contact person: hone#; ❑health Department
na��sat s.r, :wn P ____[]Other—
f
CITY OF SALEM9 MASSACHUSETTS
SoLliwir
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MAO 1970
TEL. (978)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, S 150A. l
The debris will be disposed of at: IV S �4 /< ,I 5�,O"? '1slG
Location of Fad �y e—;,Ii
Signature of P t Applicant at
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.