147 NORTH ST - BUILDING INSPECTION (4) 1
f1*NS1Nll1ST13EfKfi94N9 APPaROVEO BY 774E
JUPWIDS!PR110R TD A.PERMIT BEING GRANTED
CITY OF_SALEM
s
Data
Wad
Zoning D1sW
Is Property Located In Location of \
aw HlatoHc oWdd? Yes No_ laildiaa
Is AoMiyl in
:- CwwentllonAna? yak--NO
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Retool, Install id , struct Dedc, Shed, Pool,
RepaiNReplace, 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 ac cordwig.to the.following
specifications:
Owner's Name 114 12
Address & Phone /y
Architect's Name
Address & Phone Z 79 y/S— 7-;7 y ( )
Mechanics Name /S� Cat ti
Address & Phone Iq cli a'44 cw. 6�ad�( i,5i� G.
Whet u ere Pupae of tnulkYrg?
MaMnal d0? n.dwaanq,for taw many tamaas7
yVlp brlldlr:7uca
to law?
Eattnlated a W&W Dana.
acm L �t
Ltc. + l `
ature of Applicant
ED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK�E BONE
L
� r
MAIL PERMIT TO:
No���-��
APPLICATION FOR
PEFWr TO
//
t/)Ly S•C�P� !l�n P 7'G/�
LOCATION
1417 zz"4 Sec
PERMIT GRANTED
310 18
AP7FD
INSPECTOR 6F BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STR[aT, SRD FLOOR
&U".MA O/S70
TILL (976)745-9595 EAT.380
FAX (file) 740.96"
STANLEY J. USOVKZ, JR.,
MAYOR
DISPOSAL OF DEBR
IS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34.I aclmowl that as a
ofconattuebon condition
llm1dig3 Permit 0
vaned delnv te8nifanS f om to
diapowl facility.as defiDed by MOL a n%S l be disposed
of in a properly licensed slid-wasoe
The debris will be disposed of at
Location ofFadUy
rg shm Permit Applicant sere
FULLY PLEASE P�l xnl�r C mfi°�'h°n`
{
N ofPamit Applicaut
Firm Name,if ate►
A%,7 O/
State
The above atstute requims that debris from the damohtla%renovation,rehab or other
alteration
itelity sa�deSn boilding M cIII,S1ucun be ��the in a�y-lid solid waste disposal
indicate the location of the faciyty. lib a licenser sm to
l.efnmonuftao[ih of n��� �
C.
boo w..�.,learee.l
jolloss t car=" &doo. Mat.Aae 4 02111
C.me..e. .
Workers' mpenudon Imamaae Af Ulwk
Pc `°�
whh.e pry pb a of badness,>c
do herebr'cerdy under t)n paiae and pensldw of perjm►, sheet '
i) Ia an emPk)w ptovldl ti workers' cotnpemadve covefate for RW Ciaplereet wpkillR on
Insurance Campaw / Policy Number
1
1 ant a sole proprietor and haw no one working fir one in any caaedq.
() 1 am a sole proprietor, general cotatm=w or henteo rner (circle one) oad hove Mrad the
contractors listed below who-haw the folbwing workers' compensation poBdeR
Contractor Insurance Company/Po Nutaber
Contractor Insurance Comp"Wiro Nembw
Conuacsor Insurance Company/Poicy Nornbw
() 1 am a hemcowner performing all the work myseff.
•1 rnawiu"VM J CM of ib AMM M"e be f rwarees / aw Oftst it inadtnoo of ON DIA/o ee.sste wrN<aiw ON On ldas 0 MOry
eewratr a resorts nwa Seewe e/PIG . 52 1620 N ow Wwo d"of alndnsr @*nays eNwint el s Am of as 041.soDAO&War eee
+ran'ieerwo~x a vs ,e.4 �r�e.!s STOP WORK ORDER see s iw of f 1C10.00 a err snit ar.
signed thls . dry of
:icerseei'Fermirtee cmi6ing Department
uccnsinf Ecart
Selectmen Office
=calth Deparmer'!
- - _-.ecCC yd : " 90e epee 405, 775