4 PERSHING RD - BUILDING INSPECTION t
� 1
Ck a� 75a ,
f+. tisls fl ovEfl $Y r+lE �r ,'
IJ»ECxl�R, LD P ,EING GRANTED
IV
CITY OF S. EM
No.\\A l\ \ w Data
Is Property Located In 2/ Location of y I
tiw Historic District? Yee_No— Building
Is Property Located In
;. the Conwrvati9n Area? Yes_No �!
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, iionstru Deck, Shed, Prool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCi[SO NG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name l�� 1nn Itu
Address & Phone 14P Sl,i� 'S d • >�1 > �/ �3 Z
Architect's Name
Address & Phone II l
Mechanics Name
h Address & Phone Q l�• l s t`� (>�l ) s`�3 ��3 ;-;: .:.
' Ilw�l
r
� I what Is the propose of butidirq?
Material or buk1W a dwsfty,for tow many families? �,tl
i ;
I� Will brrlany conform to law? 'ft-�5 Asbestos?
Estimated colt 2j�City Umm e N A State ucense ar 03 2
:Ili 1.
None laprommant
i /o i 7 y3 gnatur of Applicant ;;;
SIGNED UNDER THE P N�IIIII�' I
OF PERJURY I (4
DESCRIPTION OF WORK TO BE DONE
Gl � K
I \✓� 11. � I��l 4I
v , nir nigllpll� �
I
J, >Fllf
1 9q
MAIL PERMIT TO:
$"L I
s r:
_ —j
NO.'
APPLICATION FOR
PERMIT VTO JJ
�opff
LOCATION Q
PERMIT GRANTED
20
AP vfD
INSPECTOR OF BUILDINGS
s ,
4
- 7
IR
PUBLIC PROPERTY DEPARTMENT
:• 120 WASHINGTON STREET, 3RD FLOOR '
SALEM,MA O1970
TEL. (978)745-9595 EAT. 380
FAx (978) 740-9646
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,S150A.
The debris will be disposed of at: "I S I) C�
Location of Facility
/
of-Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
LI Mr ►. M. 1���►
Name of Permit Applicant
Firm Name, if any
YP�' 1)IPS �' . s1,) ��S' -�
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.
Coc ymmanlul aeeo1' au¢ta3
S1J.Pa,{uua� o/.Jam«ice a�t
boo W"L-,,1m Jfns1
jams l camood l�.lele /!/.,aacLrwW 02111
Cmrnvssaw
Workers' Compensation Insurance AffidwAt
. . witha principal place of business at:
do hereby'certify under the pains and penalties of perjm o thas:
() 1 am an employer providing workers' compensation coverage for my employees working op
this job.
Insurance Company Policy Humber
a sole proprietor and have no one working for me in airy capacity
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policks:
Contractor insurance Company/Policy Number
Contractor Insurance Company/Policy Numb"
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoenunc we coo,o!the avemrem rai D: fon+aroec eo the Offc<e1 k.fsctawru of ft DIA for co.<ratf radon aee wt Mere m feewe
fs coraauM of a trot of w 10-51,500fl0 amela one
cO. nr U rtPJleO enof(SKeion ZSA DI MCrL 15 Z can kael eo L"c inoow!on of cekniaar oenard
yeah•i aroonmenl W vu of d'i nrwriel in the form of; STOP
WORK ORDER ana a W of S 100.00 a eat apketc we.
Signed t
ccnsceiFrrrriuet cuilding Depa en[
licensinf Ecare
Sciemmens Office
,e.lth Dep2mmem'
- - - or Y - enc aCE, =05 , 77r