19 ORD ST - BUILDING INSPECTION `r \
{ rMi {t1
S t OVER BY T44E
�;. I:. T .B,EING GRANTED
It
f
;PIT ' OF S EM
Date
s' p Want
\ Zoning District
Is Rropelty Located In Location of (} \ &
thq HIs�OHc District? Yes_No Building ^/ J
Frgpwty Located In
this conservation Area? Yak—No
BUILDING PERMIT APPLICATION FOR:
Permit to:
'(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, P ol,
Repair/Replace, Other:— �s9faf�/�/ . G' I
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 ��mn-
Address & Phone 9f (T78-) 71/Y e170
Architect's Name
Address & Phone I
Mechanics Name i,TA .A J /��l j✓ /�� /� _/G Tnu�
Address & Phone ri , d9 LLi1S
What is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated coat! 1 City License I State Uc n d 0c) A Jy
liau Improvement
,lV " Lie. i / D Y'
Sign re of Icant
UN D R TH E ALTY
OF T E'RJURY,
DESCRIPTION OF WORK TO BE DONE
(MAIL PERMIT TO: to/I 1A . e4
4 .
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g
of C7E'B;Erao,j at
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ns9 gRvlzi CMU'lll"R 01 %RV'AJ it C`UOV A OT d_��1":r ,�� ti+::s � f F«:i� ab"Mt.) I'7.0 ..UP4 lSAllJq
if;l t,,o}j°ry` cft1 C t1 tf'C' .9,.xi"i ;D7k, C," : ✓t..noi
�!aBlfrn�'. ,ri�:rer; n+�r 'trJi .�Yrfrnw•a� e �'. "j rst or.h; _. ,:.a�u�Wi,�'r
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— _ C0rf1=n1U4:6L1 of Ma.6eacku. 9tb
� _:Jepa.tratael or.Jrad+iflriaf.i eeiwnlf
600 w1,11m Simal
hmesJ.Caanooea [�oslea, /Ilayae�i,u.1L02111
CorrRu7saoaa
Workers' Compensation Insurance Affidavit
I,
with.a principal place of business at:
. . Icana
do llcreby'certify under she pains and penalties of perjury, than:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity
fA� I am a Solt proprietor, g neral contneto or homeowner (circle one) and have hired the
contractors listed below whb--Vaave the following workers' compensation
nnpollCIO:
4'Y�'y za1 ,
Contractor 1 unnde Company/Policy Number
Contractor Insur ce Company/Polepr Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I unoera:ano"t a cony of the W ttTen[wR bt foMwoed 0 the orfxt of jh a&eavotat of the Mk for corerare verWKadon and GM U&09 o faevre
co.erase sae rtairto unoer Section 25A of MGL 1 S 2 on Itad to the inooyion of cr'vninai otnufm cornatint of a fame of w edi I.MQ0 mWor one
.00 a clan ata+tat ame.
ycan' kwoommnt x ,u a citi ""16v in the loan of a $TOP WORK ORDER a/ne a fine of S 1000
Signed this day of
p cn ee/Fe ,i a Building Depanrt,cni
Uccrising Eoare
Selearnens Office
r;r<Ith Depar:men!
_ter
CITY bF S3LLEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
e 120 WASH INGTON STREET, 3 R D FLOOR
7a SALEM, MA O1 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 1 50A.
The debris will be disposed of at: &�k s'e1:e 6"14,
/ Location of Facility
G� f
ILYlgnature o ermit A$ i ant Date
complete the following information:
(PLEASE PRINT CLEARLY)
k" T a
Name of Permit Applican
Firm N e, if any
Address, City & State C T
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, S150A, and the building permits or licenses are to
indicate the location of the facility.