137 NORTH ST - BUILDING INSPECTION I
Pill Y Y60 BY T41E
. IIQA� AEJNG GRANTED Y '
CITY OF SALEM
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BUIwwuKII PERMIT APPLICATION FOR:
Pwmk to:
(ChW whWawr apply) IndaU Skitp, C nstwot/Oral , P,,eol,
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PI NASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROD
TO THE INSPECTOR OF BUILDINGS:
The undslslpnsd hereby appUet for a palmk to hubd aocordhp to the Irvinspeamuftm
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Ownses Name
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Address A Phone �i� f�i�1 S�/3/9 .
Am~* Name
Address A Phone
Moftnkes Name y
Address a Phone o
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SIGNF,D UNDER THE P 01104-11M'
DESCRIPTION OF WORK TO BE OPHE OF PERJURY
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MAIL PERMIT TO
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PUBLIC PROPERTY DEPARTMENT
` 120 WASHINGTON STREET, aRD FLoom
SALEM,MA 01 S70
TEL(676)7454595 EXT.360
FAX (976) 740•9646
STANLEY J. USOVIC7, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(K.c 40,S34.I aclmowledge that as a condition
of Mding Permit f .aIl debris resulting fmm the cmmM ctk m activity
governed by this Building Permit shaft be disposed of in a properly licensed SoHd-waae
disposal facility.as defined by M($,c nL Sl
The debris wM be disposed of at:
Locanc®ofFaciltty .
ZDzWSignaturevcaat
FULLY complete the following m6migum
(PLEASE M Tt'CLEARLY)
A?l -ems
ame ofPemntAppfic">
Firm Name,if any
oil°Z—
Address,City dr state
The above statute that debris m9� Erom the demolition, nEtovation,rehab or other
alteration of building or sMwttme be disposed iu a properly-licensed solid-waste disposal
facility as defined by MGL cq S1S0A, and the building permits or liceoaes we to
indicate the location of the facility.
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n 600 W.1-16 31mal
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All orkers' Compensation Insurance Affidavit
. . wntsh aappriyncipal pas of business at: .
. . tunas.r✓atan
do hereby•certify under the pains and pe"ties of perjury, d=c
() I am an employer providing worker' compensation coverage for my cinployeea working as
his job.
Insurance Company PoVj number
I am a sole proprietor and have no one working for me in any tapadey.
(�I am a sole proff
eral contractor or homeowner (drde one) and have hired the
contractors listho-have t fo wing workers' co penudon pond}.
� G,f-.yrF c ��innain Lr—
Contraetor U Insurance Company/Pohq Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I vnaersHnd wt a cool of thu weemtnt..a be icn arced to &A Office el Itnesdeaaata of the DIA Ior cc 9 aft.w5icadm aW enat L'itrr m eatare
cc. rat of ttourea unow Section ISA of MGL IS 2 can kad to the irwauwon of crn:na oensti"eonestietr e1 a he"of ao and 1-$MAO muter one
tearf' 'r..prua�rnl a+vB L Glut Oena1W cnt i frn o(a STOP WORK ORDER and a ire of S 100.0o a sag 20011t we.
Si ed this , day of
ccnseei'Fcrnr
tuilcing Depamn cnt
i-icensinf Ecare
seieamens Office
"PCs ILh [1[Qar?^e^:.
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