9 OLIVER ST - BUILDING INSPECTION lrm%j 7TO A HST19E f LvES-A D APPROVED BY T44E
.WPEXTPR ,PRWfl TO A PERMIT BEING GRANTED
y`\ CITY OF SALEM
No.. 1 J\l\ /� V\ Date �_lYV\
,F
Ward
Zoning District
Is Property Located in Location of
the Historic District? Yes_No X Building 9 oo I/cC/z
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Inst I Si ing, 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 66/1
Address & Phone
Architect's Name
Address & Phone ( )
Mechanics Name oftdi3O —Dyo b LW �WkAyy-K tt*l4S C( C. ,
Address & Phone &U"0;u S i 0 3 S 0'2 89
What is the purpose of building? p LAKSc (N4
Material of building? If a dwelling, for how many families? "Z.'
Will building conform to law? Asbestos?
Estimated cost Zo 0008 City License# ztuFe\Qf
nse # CS06g0(oHome Improvement
Lic. 1 10�y0 pplicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
OIL IL 12M IM06kb
ffzLk CU�ft � �tU(,�vt> � cil�w✓�o�c.S f7�5Ct�
MAIL PERMIT TO:
No.N\ ��J�-�
APPLICATION FOR
PERMIT TO
LOCATION /
q < `L
(
i
PERMIT GRANTED
�,/3o /hJl�i 19
AP I�OVFD
INSPECTOR BUILDINGS
f
Commanweta 01 M.U."ad
� 1Ja ,4..d .11u.li.f J?tefaaala .
600 w.4111.e 31,-d
Hama 1 CaaloaM &d. , M. ." 021 11
cownsa w
Workers' Compensation Insurance AffidWk
1, DAB `ra�uX �� < �mf CLC
ta.�r..l-o
with-a principal place of business at:
6 WL(,ZA) ✓K4-pT--b12 ✓1�M.
• /tba.�a1N
do hereby'certlfy under the pains and penohies of perialya that;
1 am an employer providing workers' compensation covera#* for my employees working es
this lob.
12A c�eS lei( Uh -MUbrd
Insurance Company Policy Number
1 am a sole propriewr and have no one working fdr me in 8117 capaeiq.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' cdmpensation poncho
Contractor Insurance CompanylPolicy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I vwe.nune ens i copy of dib wamme w.be for..wo.e m Me Office e1 WMC*aewa of Ow DIA for ce.erara warlka.w MW an hum bo boot
ee.aragr a$#&Wee une.r Sn*m 25A of MGL 15 2 can kid to ow ine.aiee of airinar.Cando eorJsdm Of a sm of as W4I-UXM 0 MoPor one
rcn•:noroennrne a tat a ew owgia in the fern of a STOP WORK ORDER area low of $100.00 a an assiee aw.
Si this day of 7,P, r
Witt ' rmi ee Buildinq Departr"ent
uctnsinf Ecare
Seiectmens Office
�eslth Geyarmerc
s
PUSUC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM,MA 01970
TEL (976)745-9595 EXT. 360
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFMAVrf
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 soH&waste
disposal facility, as defined by MGL c III,S 150A
The debris will be disposed of atCot11V1
Location of Facility
6 L
rignaturb,apermat Applicant Date
FULLY complete the following information
(PLEASE PRINT CLEARLY)
�t)N t C) I D nAD ( c�
Name of Permit Applicant
Firm Name,if any
i
Sz S i �0 6L� ryy�A
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.
BOARD OF BUILDING RE
N y
License: CONSTRUCTION GULATIbNS
SUPERVISOR:
umbeC
r � 064083
Birthde�
o !T013/1549g1
EzR Tr.no: 18995
DAVID FO5WILSS6 TMDFORDE , Mq
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Medford,
MA 02155 _
udntatrater