34 ORD ST - BUILDING INSPECTION �L�tfitS�VH T-BE f4L-E� APPROVED BY T44E
INSPECTOR ,PFWfl TO A PERMIT BfMG GRANTED
CITY OF SALEM
No. Date /
J y
Oct
I##
�ay� I.' 'rl) Ward
'\rFcimNrcoj° Zoning District
Is Property Located in Location of "/
the Historic District? Yes_No Building 37 0nl7
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: p
Owner's Name
Address & Phone 3 Of2a (91cl -7 �j f 3 3 7S
Architect's Name
Address & Phone
Mechanics Name G z-66 tin'l•1J R R-c2� 4
Address & Phone �3 4 1K�Wt ST E,���� (2 �22 What is the purpose of building? v t
Material of building? wow If a dwelling, for how many families?
Will building conform to law? �ZA Asbestos? ki O
Estimated cost�5500 v City License # State License # D`/'Z 8 7-7
�T Home Improvement
W Lic. / 7 t7 1 g
i a ur of Applicant
as_�7 SIGN UNDER T PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
e,/r�
t;'z�-v ��� G8 A/X /b6 s �
MAIL PERMIT TO: 3 0&0
No.
APPLICATION FOR
PERMIT TO
LOCATION «I
PERMIT (GRANTED
ze!z ,9
APWOV�p
INSPECTOR OF BUILDING
PUBLIC PROPERTY DEPARTMENT
120 WASNIN=om STREET, 3RO FLOOR
{ . 1 SALEM,MA 01970
TEL (978)745-9595 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 defned by MGL c III,S150A.
The debris will be disposed of at: rPJ A)L e S PUS 4-F 4/420r
Location of Facility
i z _
i of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
6a 6 /yl vra2,e-�
Name of Permit Applicant
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
� Commcneu�:a� 8E llla�acl�a%fd ,
6
600 ryW.111.31mal
games 1 Caaaooas ///�wc�wlb 02111
Corrmssm w
Workers' Compensation Insurance Aff1dapis
1, �2 r✓G �y 22 /�-t
. . witha principal place of business at:
y Altoq
do hereby•certify under the pairs and penolties of perjmya thalr
() 1 am an employer providing workers' compensation ccverafe for my einployees woritiag cm
this job.
Insurance Company Policy Humber
1 am a sole proprietor and have no one working for me in any opadey.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation polida.
Contractor Insurance Company/Policy Humber
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
. 1 uaoe ad wt,can of chi we me%w+e br icn arwo m &K OBcr S7 brradeavem of du DM fa cererate r"Vicaden arse an War m a.dare
co.sratt ar reawro unew SwRion 2SA of MGL 1 S 2 cm kad ga eax i++veviee of crinmar oertadea corwdnt of s far oi w aei I,SODAO and/or one
rcaa••rneroor t b wA a eivi oenma a it thr form of a STOP WORK ORDER arse i W of s 100A0 a On again"eae.
Signed this • 12 Lk day of
&:
:ic r cei rittct
cuilcing Departn+ent
jcclvinf Ecar�
Seiec%mens Office
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