11 OCEAN AVE - BUILDING INSPECTION (2) .,i r J
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WPFXT—R FMCIR TP A`.P.ERMIT 13EING GRANTED
CITY OF SALEM
No. � .� qp\,' Date C//>
Ward
\q�cnrmrcA�D Zoning District
Is Property Located in Location of
the Historic District? Yes No Buildingr
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Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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
Address & Phone F-- R-D .57 SA,I 22
Architect's Name
Address & Phone )
Mechanics Name
Address & Phone
What is the purpose of building? &'.i
Material of building? i tarty-- 9 If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated co [ ri DD City license # State L'cense # /
Home Improvement
Lic. i �
i ture of Ap icant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: &41-)
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Carmrssrona
Workers' Compensation Insurance Affidavit
favaeva.r.�••ef
with.a principal place of business at:
. . 19earsaat✓saq
do hereby'certify under the pains and penalties of perjury, that'
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() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
G��r7�t✓ t77��-� _ CUC.� 7yds�_�
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capaoty.
() I am a sole proprietor, general contractor or homeowner (circle oast) 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/Polity Number
() I am a homeowner performing all the work myself.
I unoerwne wt a CM of the atatnemt" bt i,arno to the Orfct of InwiKawn! of the DIA for tolerate+erwKadm am am hire to sacwt
co. art at reevrec under Section 2SA of MCL 1 52 on lean to the irrooamon of cranrtm otmmgks corsa6nt of a fine of no toi 1.sw=andor one
yeah"r:.xuommtnt v aso at Cmi ""Wes in the iorrn of a $TOP W ORK ORDER ano a firs of 5100.00 a an angst mt.
Sirned this �� day of
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errn 11tt Euilcing G p:rtr* ent
Uccn ing Eoard
S tic cRmens Office
-ie<Ith Geparment
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT -
e •120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
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 III, S 150A.
The debris will be disposed of at: `%l��fl�o��Yi/ %7/lft'/L
Location of Facility
r lure of Pen t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Kr Av C,6-exL3
4�
Name of Permit Applicant
X-6 C A_161yepS _;�uC ,
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.