39 OCEAN AVE - BUILDING INSPECTION f11t1�81M1l6T'9Ef�Lf$�►i1D PWOVED BY r�
1USAECILiH �JD BB1NO GRANTED `
CITY OF SALEM
DaW
le top"L.ocaWd In Location of q n,
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N Prapaity Located In
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) f Install Siding, Construct.Deck, Shed, Pool,
RepaidReptace, ther.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCIIIN0Ii'i
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the folW*"
specifications:
Owners Name IA a olt.4
Address & Phoned
Architect's Name
Address & Phone j 1
Mechanics Name �� u a 10
Address & Phone S IIW d,,ie C L 211��
what W Iw pupm at tatNdNq?l2 k" ! L 4
MdmW or rxNd W l t )d I a dwe Mq,for how many IamMin? �--- r
WN buk"oontmm W Im? Asbaaos?
N.
Eatlrnatad coat. .J r pty Lka,ra• N p► SWW M C S
.,`
Bor Lpraweqq t t
Lie. I( '�y�
11Signature of Applicant
SIGNED UNDER THE PII „1 Ii i
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
FiLtovy't �DZa�S/ �dutd//� /�iy0 � /�� (�� pqyq e
LOLL
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MAIL PERMIT TO.2e[ �✓�,� �c Ci/yc S'/ ��u/,rii'�cc �d
Q
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APPLICATION FOR
PERMIT TO _
.!/`1�j�6r•'i- �'�� /moo °��
LOCATION
Ike
PERMIT GRANTED
G / 0 2b
APff J�''OVFD
INSPECTO OF BUILDINGS
s
Wa ) PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL. (978)745-9598 EXT. 360
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
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 �r/lta(,1 rl h/
Location of Facility
� � L
Signature of ermit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
c --/L Ll0 L D M
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.
Cocr''yfi,�.monwr:aLiheo1r M Fmoac"U3
`' �1JeparlanesSl ol.J:d�al�ccicsaG•
/ boo eywaajw,fre.�iaaal
Jamesi.Camtod (Jwlow. J//aaae 02111
Coermssaw
%Workers' Compensation Insurance Affidii0t
12 Ir-I 4'�
Saom..e.crrssr�S)
. . with.a principal place of business at:
do hercby'ccrtify under the pains and penolties of palm, that:
() I am an employer providing workers' compensation coverage for my employees working as
this job.
;
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capaeisy.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' co ti
mpensaon policies: .
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I uneeuane alas a Coss of sus ataeesnere WIN be ion aroee max Office og(snositawra of aK DIA for co.erare eelsiscsdees and We faaare m"Core
co ware as reourco under Swoon 2SA of MGL 1 52 can kid So esx iesooswen of ervn'na oenaedes eohs ont of a some of ssa aei 1.500AD MWW one
roan, iprMn,nrnt x a as ciri e.nawes in the loan of a $TOP WORK ORDER and a 6x of S 100.00 a ear J926M sax.
Signed t r / day of
�7
liccnstri F ermntct cuilding Gep:rtr. ent
liccnsinf Ecar[
Seiectmens Office
nc;lth Lep;�mer.*
J a
BOARD OF BUILDING REGULATION'
eerlse: CONSTRUCTION SUPERVISOR
3 Number CS:` 028460
Blodate 0$12611993
Enpirea 08/2612005 Tr.no: 4588
ResMcted ,Op -
RICHARD A CERUOLO . _
51 KIMBALL AVE
- REVERE, MA 02151 Atlmmietrator
_ �: - ✓% �1O�ARAC
ier/uwelld.
' Board of Building Regtandards
"i
HOME IMPROVEMETOR
Registration: 1104 .10%2Type PartnERUOLO REMODELINGRICHAR .CERUOL6
KIMBALL AVEERE h1A 02,451 .y-�