147-149 NORTH ST - BUILDING INSPECTION VEo BY T44E
P ,t3 MQ GRANTED h
CITY OF SALEM
Dab
h Mlar unam DNAilal'1� ioeatioa of
OWNW Spn AIM? Yak.No
SULLDM PERMIT APPLICATION FOR:
Pomrk Ur
Pdo whWWW apply) Roof. Remof, Inowll Sld ft �DWK Shad. Pool.
R@paWRoplaoe. Odurr
PLEASE FILL OUT LEGIBLY•COMPLETELY TO AVOID DELAYS 111111110011911111110
TO THE INSPECTOR OF BUILDINGS;
The urdwWpW hereby aPPbs for a pwmk to WW acmdinp to the leis....
speonadom
Owner's Name ,1 �h ✓ i S
Address A Phan V 7 _/ Y� /!/�r� [ ► 7�/S 7 2 ,2
AmhkaWs Name
Address a Phone p 7 ( 1
Modunics Name
Address a Phone ( 1
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f AAWd d blat Ill pa g for now wmq taI111M?
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SKiN�D UNBSR THE
OF PERJURY
DEBCRIPi1/0N OP WORK TO BE apa /
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600 U "L-11ax 369
Jame:,,,=, Bale. //le.aeeleee•tf102111
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11 Workers' Compensation Insurance Affidavit
. . witha principal place of business a1M
do hereby'certify under the pains and pensihim of pujory. thm
() I am an employer providing workers' compensation coverage for my employees working an
this job.
Insurance Company Policy Number
L�f am a sole proprietor and have no one working for me In any capadty.
() I am a sole proprietor, general contractor or homeowner (cirde one) and have hired the
ontractors listed below who-have the following workers' compensation policies:
Contractor Inslranit Company/Policy Number
Contractor Insurance Comparry/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoerwne cut a coot of the wtx a wa be to roes the Once el In. kaeom of the VIA for cc C ate r"Waden arse VAX1AW9 b"core
co.eratt at reosrrro enoa Sec' /.0 2 ca ae" tnr:r+oowion of cn*inai ocnxdn cociatint of a swe of w =41.50090"W r am
rear :avnonrwnt a.ye cws a t eta STOP WORK ORDER arse a fine of S 100 00 a ear apltat aK
Signed this ay of -
._iccnstt/FtrmiEct cuilcing Geparcn+ent
jctnsinf Ecarc
Stieamens Office
r:c:lth
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RDFL.00n
SALEM,MA O 1970
TEL (978)7434595 EXT.380
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge that ss a conditim
of BuildnS Permit M .all debris resulting from the constnu km activity
governed by, this Building Permit shaft be diapOaed Of in a properly licensed solid-waate
disposal facility,as defined by MGL c DL S150A.
The debris Wl Of ��
Location Of Fatality
v�G G/� ZIZ
Sigoatlae ormit Applicaod D
FVLLY
(PLEASE PPRRINTT (.
Name ofP ' Applicant
Fnin Name,if any
Address.City k State
The above statute regwrea that debris from the demolition, renovation,rebab or other
alteration of building or structum be disposed in a properly-licensed solid-waste disposal
fatality as de red by MGL ca S 150A, and the building permit,or licenses are to
MOO the location of the facility.
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