30 PERKINS ST - BUILDING INSPECTION (2) fLftN IMT-DEfR&B-*ND APPROVED BY 774E
ASPJE =PRIGR TD A.PERMIT BEING GRANTED
(� CITY OF_SALEM
No. � \ Date
s
I Ward
Zo" DIM"
Is Property Located In Location of
ftw FB mft District? Yss No._�/ BuildingILLf
k.n r ay
Is Properly Located In
Bo Gardsmallon Area? Yss�__No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
epetdReplas, , Other: nc 5�& r_k,td , 2.-A fl 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 accord4ig.to the.folkswing
specNications:
Owner's Name S a I As C h'// J v Md I n s
Address & Phone 3o R,AIW s TT. (9-)b-1 7yl -7565
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone Z/z /NvM1O2 1 Sw6 5 � g - I t t l
Whet IsftPreposeafWNdkV? hiw 6° ri` I I<• lrkL�- rt.b,,tr, 6N 20 FIX6 mxsc
Ct
rc-paure
dww of brlldrp? B a dwoffing,for how nmy famaes? 2
wa Eril V oxft m to WW? Aeeeetoe?
Ediffnated cat 2.G�a a dy U="• )31 U6 gft umw C5 6`1 `} 5 0
som improvement 41 6<414---
ature of Applicant
ED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
� kW / rr� rr bti fiti lecrrrs _gam vt`I oew k,`t "Ket
�fiYJdir VV/ i�, rPOhir SIhY cols?/ S� v�G/P
MAIL PERMIT TO
APPLICATION FOR
PERM/T TO �-
Ld
LOCATI
PERMIT GRANTED
APPROVED
i GNSPEC I OR OF BUILDINGS
.. . � �omnaorLfffa+�l� of�twachfcdeJ�d -
boo w.e�ief6e.�faed
1 uanoa.r gadva� MreJY.& 021/f
Workers' Compensssioll Inmrasm Affidavk
. . wh,-a printed Pb" of badasas as
2 s . 5mA
do bereby'cerdy under tjn paint and perasld— of perjW. then
() ��employer pmvWing workws' compematka coven fs for MY daplop M Working an
Insurance Compaq Policy Number
I am :sale proprietor and have no one working fir vice In any ooadq.
(Y lama sek propriesor, seneral contractor or hemeowmr (circle one) and baw khod drs
coatracton lined btlew who•havo the; followins workers' compenastion pollchn
3a4 STF 1y2 _ F�rC�r�C IS.
CAmdacgw insuranie Company/Po Number
&epk.i Pvmb;: +
Contra or ��� Insurance Company/Po NUm
Contractor Inawance Compsrry/Polley iIu bor
0 1 am a homeowner performing all the work myself.
.wawuawe owt a ansf of di ammo wN h Awwaro" w w Ofaa A M.adaaa.e of du M Mr cvvwan vwVkadw aw an Ubm w rat
csnrar, a rrawae ww Sacdsa 21A of MGL 13 2 can kae r w Mwsafna of aMiwa stria ewwodm al a hu of w wi i•5OD,00 rW w tact
ten'iswwwr ae a%s a del mm"in nhe ions of a STOP W ORK ORDER ar a iw of s 1COAC a an splow nL
Signed this . I S day of
ricer, i Permiuee Cu►idfng Department
censinf Ecare
Selectmen Office
e.alth Geprmen:
- - - - - - _ - - - - -.e 04 405 qpe 77!
PUBLIC PROPERTY DEPARTMENT
120 WASNINOTON WrR0AT, 3RD FL0011
&M&N,MA 01 Y70
TEL (979)74ai 995 EXT. 380
FAX (976) 740.3846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions ofMtiZ c P 40,S34,I sclmowl that ens
of Bm1dm8 Permit S .all debris resaltmg 5om the nativity
tivity ion
governed by this Building Permit shall be di8P08W Of m a
disposal facility,as defned by M(3L c nX S13M. P licensed wlid-waste
The debris will be disposed of at Ai / r���, s r�P r,f, v Fi n
Location of Facility J
Signs of Permit Applicant
FULLY complete the following infomation:
(PLEASE/PRINTJ�CLEARLY)
rn hn 7ZellhP
Name ofPermitApplicant
(A JrVUT[B h fi e!
Firm Name,if airy
Addres,City dt State
The above statute require that debris from the demolition,renovation,rebab or other
aherstion of bluldmg or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MCA.cIII,S 150A, and the building permits or liceosa are to
indicate the location of the facility.