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184 OCEAN AVE W - BUILDING INSPECTION 13L-A"S MWST-Sf ffL-ED--A!!O APPROVED BY T44E INSP XT-03 ,PRWR Tp A PERMIT BEING GRANTED CITY OF SALEM N " ;? ,L ��\ Date o2 ,H h � r Ward Neo�° Zoning District Is Property Located in Location of , the Historic District? Yes_No_ Building Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) R of,-9e f Install Siding, Construct Deck, Shed, Pool, Re air/Replace, then: 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 J� e. AtGa ©�-7D Address & Phone Q � (�r�52 '7Ys lo,;? -- Architect's Name Address & Phone Mechanics Name R NI {�FE� IL OXD 7 Address & Phone (t 1A What is the purpose of building? 2 l— Material of building? If a dwelling, for how many fam'ies? Will building conforrn to law? Asbestos? Estimated cost City License# Lice # i Home Improvement V Lit. f 'gn ure of XPRcant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE Y13 - I n1�,m t�l MAIL PERMIT TO: OYICY��` 1 No. APPLICATION FOR PERMIT TO 1-7 u ��cera�r,� LOCATION PERMIT GRANTED 7 19 APP�GV INSPECTOR 6F B ILDING Comm.oemciahl of /l/aesachws�a � �lJaPe.Za.al.�.�.�f.�uio a1a• . 600 wsAiylm Jfa ad iatatea 1 Cammas &d, ///iaaee" 02111 Caaanasoear ;' Workers' Camp ensa ' Insurance Affidavit i, G r� f . . wkh-a principal place I business at: 7do he by'ccrttfy under the pains and penildes of perjury, thm ' Fly i am an employer providing workers' compensation coverait for my employees working and this job. GVI Insurance Company P umbq L I am a sole proprietor and have no one working fdr,me In any capacity- () 1 am a sole proprietor, general commicsor or homeowner (circle one) and haw hired the contractors Pined below who-ha" the following workers' compensation pekoes: Contractor Insurance Compatry/Polity Number Contractor Insurance Comparry/policy Number Contractor insurance Company/Policy Number O I am a homeowner performing all the work myself. ' I anarvane ant cool of th'o auttae,+r W fon+aoed to d" Ofke el In.adtn m of do DM 1W ce..•ate.alacadm aM ran LAM 0 rave co.erart Al refund enoer A of 2 can kao to UK irwoud"of erW inn veranda tof"dM of a neat d w w41.SOO=an"t eat racers' :aarronnent a a w of a STOP WORK RD SA-aee s it of $100A0 a ass atirtt.ea Signed 3U- 'J C.,✓�- o2D .iccrscti Fcrmhttt euilcing Depsrsr►.ent Licensing Eoare Seiectmens Office �e.-tth Gepar-mere - - - -- C.c _ cna eye, _pe, 77c * PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM,MA 01970 TEL. (976)745-9595 EXT.380 -UU' FAX (978) 740-9646 STANLEY J. USOVICZ, JR. MAYOR i 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,S150A! The debris will be disposed of at: f �f71i V Location of Facility a 4.1 �3 sure of emut Applicant bate FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant (AMA-�Dq G ,SJicS 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 cM S 150A, and the building permits or licenses are to indicate the location of the facility.