194 OCEAN AVE W - BUILDING INSPECTION f1.�N6iNtl6i 9E 4%eWMD APPROVED BY 774E
JOISP C=PFWR TD A PERMIT BEING GRANTED
11\`\ `�\_ CITY OF_SALEM
�
No\y y \ r (�
))) A \ Data 15 d I
wom
Zoning owed
Is WoMiy LocaEad to Location of
ea Historic Didrkl? Yea No I/ Building
Is Property Localed in
Bn Corrervallon Ana? YN No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, nstall Sidin Construct Deck, Shed, Pool,
Repaid'Replace, Other:
PLEASE FILL OUT LEGIBLY dr COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '.
The undersigned hereby applies for a permit to build accortLiq to the following
specifications:
Owners Name
Address A Phone AN• G (TV) "Itih6 �7i9�
Architect's Name
Address d Phone
Mechanics Name
Address A Phone f�., �L�� (� (9 ) 17 YS 76,�-4
Wbu Is ft P.PM a bwbprg? a a vet c�
MdrW or buMnino? 'W c B a darning.for row many famom?
WIN boot cordam to law? Asbestos?
Edmatad craft . CRY t CK"e T
so.a Improve t
Lie. I
C S tr8(,Z3 o Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Sv l� v� i VmNIA-0
MAIL PERMIT TO:
No.���
APPLICATION FOR
PERMIT TO
LOCATION 1�
PERMIT GRANTED
AP
.9
INSPECT OF EKJWNGS
A
l.onfnfonaaualt/t of !//ewae�ueeffd .
µ JJ.p.c�.aaatit a�,7aderf,id�a�' . .
Si+lwti M...d.& 0.21/f
Workers', mpensadm lmuramn Affidayk
. . w101.a prb"*W phlae at, ��, qq•
`3
do hereby'cer* undo t* pains and peruil" at pM*ya the
O I am an employer peovidIng workers' eompewtteo covepge for my siuployiari working on
this
iaaaumnigs.C�Wapaa7f� - P wumbo
I an atask proprietor and have ne ons werkhfg iM me V any opadq -
0 1 am a sole proprietor, general wmramo► or homeowner (drde ogle) and have hid d a
contractors listed below who•bove tbi following workers' compensation po9dm '
Conaaaer Inturs"" Compatry/Po Number
Contractor Insurance Compatry/Po ADumber
Contrauor Insurance Company/Polig number
O 1 am a homeowner performing all she work myself.
1 eeaeluwe ew a Carl of di aeae0ee e a be fa+.arob r am Office A H.e#aeo d dot M k ce.wafe werlikeden am as lire•rare
cowrge a renew sea Sweden 2SA of WU 152 can 4N w at bwoeeve of abw*oeaada cawing d a do of a wi I.fOD.AO abler are �
ream'%weeneent a yt add earads in du lone of a STOP WORK ORDER a inr d S ICCAC a oaf apha na.
11r
SIS}Ie t� day of U'S r 0o
l -
:icerlic'0F ermifcee iilnidfnt Department
'- ucensint Ecare
Selectmen Office
-ealth Depammenc
t
- —_ceCC ye 404 <Qe.:405 T JS
PUBLIC PROPERTY DEPARTMENT
120 WASHJN6TON 9T11aa:T, 2RD FLOOR '
SALaM,MA 01970
TEL (970)74"595 ENT.3e0
FAX (979) 74""0
STANLEY A UWV1Cz, .)R.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with ft proviaiom Of MGL c 40,S34,I aclmowladge that es a eondidan
of BufldinS Permit N_ .all debris resulting iiom the conaor wdm activity
govemad by this Building Pemrit shaft be disposed of in a properly licensed solid-
waste
disposal facility.as defmad by MGL c IIL S150A.
The be dispaad I.e 04ZT�S Cyr
Locadon of Fmity
siglutlma of Pa>mit Applicaat Da
FULLY complde the following iaform sane
(PLEASE PRM CIBARLY)
Name ofPaamftApphcent
-,� 0,-z C,, 7
um Name,if any
Addnw.crty tit Sara
The above statute requires that debris firm the demolition,renovation,r"or other
alteration of building or structure be disposed in it properly-hcemed solid-waste disposal
facility m defined by MCM all,S150A, and the building pamits or 1jew are to
indicate the location of the fatuity.
N
I