195 NORTH ST - BUILDING INSPECTION -PL-*MIdOST Ef+L4--P� APPROVED BY T+IE
IAl�SPECTpR ,PRWR TpA.PERNMT.BIrWG GRANTED
CITY OF SALEM
- 2ooC�No. �I7 I Date
\, J
Is Property Located In Location of
the Historic District? Yes_No Building lye
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroc , Sidi Construct Deck, Shed, Pool,
epaidReplace 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 ZaL
Address & Phone 1�� r�/7 ,C'Zi
Architect's Name �-S� ��IL9;1� n/
Address & Phone J6-2-7Q 61
L 1
Mechanics Nam �7zn'Yl n i d mil/ ��77 4
Address & Phone . ,,I d7��J�� f-291 y Z 2 -.S5-ZZ
What is the purpose of building? l ! \, =2 f lot4 r
Material of building? Z(1 /1 U7� If a dwelling, for how many families? C�2 -
Will building conform to law? AsbesAgs? N �
// �6K/i
Estimated cost/ � License # _State License # Q •�
Home Improvement
Lie.
Signature of Applic
Lk ZI�� /� 3 9f SIGNED UNDER ��E PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
1
/N � /� r
J 0 � j
L6 G !.(/VYI i t 4 /— i
. J
MAIL PERMIT T0.
i
No. 1 1 -7 - zoo
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
AP OVFD
7
tir2
1 SPECTQ OF 1 DINGS
€� COrrmOnWaafik 01M0,6eacLUU6
tw
,_� �epa�Irasanl dI..7�w ..lrial�eeiaanla
600 eWdla:rgr _31<aa1
James I Camooel �s�� ///Yaaad/at .ib 02111
eormrssoew
Workers' Compensation Insurance Affidavit
with.a principal pla of business at:
a ,?
do hereby' ertify under the pains and penalties of perjury, that:
( 1 am an employer providing workers' compensation.coverage for my employees working on
this job.
Innsur ct Company Policy Number
I am a sole proprietor and have no one working for me in any c2paeitY•
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I wndefscand at a cony of this aatemtnt wg be for aroed W the Ofrce of 1n ciraoons of the DIA for coeerate werAcadon asad wit Wore 'a secure
co. art as ttviree under Section 25A of MGL 152 can lead to the rnocs tjon of crvrirsa oenaities corsadnt of a rant of w M41.500.00 and/or one
year,, vsoraa, a Kra a civ9 txiuldo in the lorn+of a STOP WORK ORDER and a lint of 5100.00 a dar ataro`t�sne.
Signe this , S day of T
w
nsee/ ermitzee Building Department
Licensing board
Seieamens Office
Health Department
TO VERIFY COVERAGE INFORTiATION CALL: 61 7-727-4400 X401 , 404, 405, 409, 17S
�oxnr OF SALEM. MASSACHUSETTS
vE� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
3
SALEM, MA 01970
TEL. (978)745-9595 EXT.380
�gfnra FAX (978) 740-9646 .
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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�50A.
The debris will be disposed of at: S
ation of Facility l
Signature of Applic ate
FULLY comp a the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Fix—Name/ 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.