8 PHELPS ST - BUILDING INSPECTION (2) t l+IHST'-BE ffLfl AWf APPROVED BY T44E
wi MISSAXTDO ,PFWR TP AµPERNDT.i FJNG GRANTED
q. ^9
CITY OF SALEM
No. ",
✓ ! v "� \ Date
Ward
9 °y Zoning District
Is Property Located in Location of /
the Historic District? Yes No_ Building Q�
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Con trust Peck, 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 Named
Address & Phone 8 Phe 1 n_5 S71 f )
Architect's Name
Address & Phone ( )
Mechanics Name7e
Address & Phone 091 14t1Q(0'V GlZ S/ (978) Y7 7- 3 N 6
V ,) rl,7
What is the purpose of building?
Material of building? G A2Q If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost (YSC City License# State License q
Home Improvement
?l Lie. I is 6� iiiL
S g�of Applicant
o a� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
0 7 12oo I
Gv e� S /lD�l (,yi'l/ 12e
MAIL PERMIT TO: 7"10"e 0 wh,00
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#fM,»E!14 710
�o CITY OF Si4L,,4:M9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT -
6 6,
� 120 WASH INGTON STREET, 3RD FLOOR
a SALEM, MA 01 970
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, S150A.
The debris will be disposed of at: 1,10 oral sCkE
Location of Facility ~
Sifpiature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
r
3 2
Name of Permit Applicant
1\10)2-171 &S lag L /2Uo�i i✓lf
Firm Name, if any
6?P l Ay�/w yL rz 57- �/3.V f/�S,1WI57
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
Ste\ /��
CornrnonwaaLOt 01 1 W6acLatt6
2epat"Ai 0/9, ,afs«j.rU
s l 600 " :-11m Si1,,1
.lames J.Camcod I�ostoa, qw,"acfuu.11i 021 11
cors,rss,ona
Workers' Compensation Insurance Affidavit
witka principal place of business at:
,�1027�-/ S�i�e 1Z00% f N 1
do hereby certify under the pains and penalties of perjtrty, that:
O I am an employer providing workers' compensation coverage for my cinployeu working on
this job.
S t� >�t�SusBrvc ��G73 7 951
Polity Number
Insurance Company
1 am a sole proprietor and have no one working for me in any capacity.
O 1 am a , general coraetor or homeowner (circle one) and have hired the
ole ero Tic n
contractors listed below who have the following workers' compensation policies:
A(o2Tff S,�loila jLooj;T/Jo easE �nf5v2A,ya� S cT3a73 �S/�
Insurance Company/Policy Number
Contractor
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I vnoen "wt t Cool of gWU wtvr t wo be ion+arne W the Orrct cl lnrtstitaeent of the DIA for coteratt.eiWicanon ane Ys7l lait/t b"are
cot eratc w rewtto umtr Section ZSA of MGL 1 51 can lead to the",canon of err",vct %Its Cars dnt 91 a roe of so mi 1.500M and/or one
rcan'iraruon k w vo u ci.i "t ,Ljn M tic ie of s STOP WORK ORDER no (ne e( S 100.00 eaY arainfl me.
Signed thisday of.
LiccnseciFcrritcct building P
lice:Ling boas
Seieamens Office
Dcpar-.menc