9 OLIVER ST - BUILDING INSPECTION (2) 1oL*M1WVSTl3EfiLAE # AfPROVE0 By T44E
.IWZCTPR PRWR TO A_PERMIT BEING GRANTED
CITY OF_SALEM
No. �� N Date o
Word
Zoning District
Is Property Located in Location of
the Historic District? Yes No_ guiyding f L2�S C
Is Property Located in °mil
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply Roof'
oof Reroof, Install Siding, Construct Deck, Shed Pool,
air/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
Architect's Name
Address & Phone f
Mechanics Name U ,
Address & Phone269
What Is the purpose of building?
Material of building? If a dwelling, for how many families?
Nil building conform to taw? Asbestos?
Estimated cost G/D O o city Licenser State License r
Raime Improvement
Llc. /
_ . Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCR ON OF WORK TO BE DONE
r o
MAIL PERMIT TO:
i
'1
1
%No A
APPLICATION FOR
PERMIT TO
LOCATION
U
PERMIT GRANTED
AP OV�D
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WA$H1NaTON STREaT, 8RD FLOOR
SALEM,MA 01 B70
TEL (676)745-9595 EXT.380
FAX (976) 740-9 6
STANLEY J. USOVIC7, JIL. 1'
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that es a condition
of Building Permit 0 .all debris resulting from the constn=01,activity
governed by this Building Permit aw be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,Sl
The debris will be disposed of at
Location of rmum y
SiSnatuh ofPeamitApplicant Date
FULLY complete the following infomration:
(PLEASE PRINT CLEARLY)
Name of Permit oWnci it
Firm Name,if any
Address,City tit state
Y � V
The above statute rexlum that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licemed solid-waste disposal
faeafity as defined by MGL cIII,S 150A, and the building permits or licensea are to
indicate the location of the facility.
r
�(I �yy
ComrA.01U arit4A Of It/.aa"fid
b •..Uepaaiaa.at of�.1rifi.f..9ua:..t,'
600 WAA.11e 31'ati
iemea 1 eaawd &d, Mus." 021 I l
cwaweaer '
. � v Workers mpe nsatioa Itwsnnce Affidavit
. . MO.a principal pbae of Am
. . � leasae✓aq ey .
do hereby•cerdfy under the pains and peniities of perjury, sham
() I am an employw providing workers' compenntkm coverage for my einpioyses working o0
this job.
Insurance Compaq Poliq Number
c
I am a sole proprietor and have ne one working fdr me in anry capadry.
() 1 am a sole proprietor, general contractor or homeowner (circle one) aad have hired the
contractors listed below who-have the folkawing workers' compensation polici m
Contractor Insurance Company/Pour Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner perforrning all the work myself.
• I aadnwoad 04.34 a caar of AL auaraws a+a be fcn riled n dr Once 87 ic.a$aaar of dw pU.for eeeerate aseiaodoa and mm Iris r"am
ca.erarr a reavree arcs Semen SSA of MGL 152 can kid wow immocen of caienec aeaoda coraedrat 01 s raceof m aai I.5M abler act
rera'inwwonrec a wit a dos oariia in the hmn of a STOP WORK ORDER am a Scw of 5'00.00a M assietrat
Signed this . 2 0 day of / Z Z5 211
/
:iccrscti Fermwet 1;U7 g Depart ent
Ljcensing Eoare
Sdectmens Office
=eslth Dep;mmer-
_--_car _ epe epc, .ee• 77r