8 PHELPS ST - BUILDING INSPECTION Mid T-Ff ffLfB-4&M APPROVED By T44E
WPXTD13 ,PifWfl TP.A .PERMIT BEING GRANTED
CITY OF SALEM
No. SOD—ZQO kA Date
h
�q�YNING
Is Property Located in / Location of t
the Historic District? Yes_No 1/ / Building
Is Property Located in
the Conservation Area? Yes No_✓✓✓
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Cgn tr ict Deck, Shed, Poola
Repair/Replace, Other: V;At)41 ��c�yr 1 ru �a�(/off
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: 1
Owner's Name `l c3/�/V + 4 ke �Ge fo -cP Iv
Address & Phone (4-3) -? Vq 9a XG
Architect's Name
Address & Phone /� // )
Mechanics Name rc,ry 're/L), ,Z, z
Address & Phone ZSV " J�/I°�^ (177) WJ d 2 h;
What Is the purpose of building? e C t Aj 1q
Material of building? If a dwelling, for how many families?
Will building c fo to law? V44 )
Asbestos? N y
Estlmated cos% rm�� City License # N�A State License p
J Home improvement Y a ,en : b
?J5 Lie. if S /t ,L
I 1 Signatu Applicant
3/, o� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
1 1 YX L64V
c-7 U
MAIL PERMIT TO: (9�i_�r
Sal�ir� ✓�r�� anti >v
1
No. 30� 2ooy
APPLICATION FOR
PERMIT TO nn
LOCATION
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
4
'-'_""' OF SALEM, MASSACMU:ci I
{0� PUBLIC PROFiEP.TY;EPARTMENT
• '. 120 WASHINGTON STREET, 3RD FLOOR
9 SALEM,MA 01970
TEL. (978)745-9595 EXT.380
FAX (976) 740-9846
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA 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 114 S150A.
The debris will be disposed of at: Loc�
ati t C�
on of Facility � u. �'"', / " ✓�
Signs of t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of P t Applicant
Firm Name,if any
70,
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 clll, S 150A, and the building permits or licenses are to
indicate the location of the facility.
CCn1,rn0nLVaUZ k of Ma66ac L effi
a• cc'^'y�� Q / F
�CJeparGataatl e f..Jadu.s4i61 SeCi"AU
a 600 ryL(faa{t;a9fat.�fr.at
dames I Camood 02111
Cornmrssroaa
Workers' compensation Insurance Affidavit (c�
I, — Lt Imo\ l°/Va i vv
-- (ia..eeert+erere)
with-2 principal place of business at:
del7 ,0
do hereby'certify under the pairs and penalties of perjary, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
%kIll'am a.sole proprietor and have no one working for me in any opacity.
0 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation Pericles:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Poliay Number
O I am a homeowner performing all the work myself.
I vndentand that a dour of the suty n n ww De ion arcee to the Office el 1 4 titavons of the DIA la co.erate verthatien deb& faatrrt m teNre
cos art m rewreed under Section 2SA of MGL 15 2 on lead to the ineeylion of erinini oennties eorJudet, of a fie of W to-B I.5=00 altafa wK
r<an'i:aruonment v.esu as cir3 xnalritl i+ the lone of a STOP WORK ORDER and a fie of S ioo=a am araintt ase.
Signed this day of
ccnscc/F tcf builatng Departrent
licensing board
Seleamens Office
Health Department
--�000 X= G 40e, e �0° Z-7