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19 PHILLIPS ST - BUILDING INSPECTION fit_ Q$idkfS* £ffLf94+0 APPROVED BY T44E Ipi7( IIAA TP AT B,EWG GRANTED CITY OF SALEM 1 /Io zr� AEI No. �` �Z-©o� 4:>• � 'p� �/, Date Is Property Located In Location ofthe Historic District? Yes_No Building I'LttL�V S Is Property Located In the Conservation Area? Yes,_No,_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) 4 Roo 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: Owner's Name �►HI RPoPI.1�_ Address & Phone 19 PHP1 P-S -Si, Architect's Name Address & Phone ( 1 Mechanics Name U n0.(trc Fml ca,, i�TtfC'�s Address & Phone W__11—.RIO 4, MN What is the purpose of building? 5�17EAf1 llkL Materiel of building? or If a dwelling,for how�many families? I Nil building co form to law? Asbestos? /uG Estimated cost • J City License k N A State License # ' I Home Imprt ` Lie. i /14 '- ovem�epX L� I �q 3'1 Sig azure of Ap li nt SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE ��P �xt�1�10 �(Li` ��► h1Qi� �F � o`s�os� �F DE�s. MAILPERMITTO: �� 9l�t(CL�SllYlf�• i s X , No '3q -z oo1� APPLICATION FOR p PERMIT TO LOCATION: PERMIT GRANTED APPROVFD INSPECTOR OF BUILDINGS CommonwaaAk o/ V&6-iachwef[3 � �:Jepa,•Im.,tl a/.7�Iriaf�ccia nla 600 ,yLlla,L.1Lon-31r..I James J.Camooes 4� L. , ///itaaehta,.1b 0211 J corrmrsstoaar Workers' Compensation Insurance Affidavit wich.a principal place of business at: �l M44-Cni'ii�,, a <rhr/SUW3M) do hereby certify under the pains and penalties of perjury, that: 1 am an employer providing workers' compensation coverage for my employees working on ��this job. Insurance Company Policy Number I am a sole proprietor and have no one working for me in any opacity. () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I understand tnat a coot of this wternent wa be fon.aroed to the Office of Inwdtavom of the DIA for coV ate Verification and chat bawt to"cure corerate as rcoureo under Section 1SA of HGL 15 2 can lead" the inoomion of criminal ot"ties corsotint of a fine of uo to-S 1.500.00 and/or one Veers' .wwomm t as.rr_u as chi nnasdts in the Iomr of a STOP WORK ORDER into,fine of S 100-00 a der at"t me. Signe IS , day of - Licens a/Fermittee Building Depamra,ent Licensing Board Seleamens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375 co OF SALEM, MASSACHUSETTS 6 ' PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR - a� qp a SALEM, MA O 1970 s TEL. (978)745-9595 EXT. 380 �pm�a FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34,I aclmowledge 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: Location ation of Facility Alt Si tune of P t Oplicant FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit plicant � G 'T (1t�d,L6r i_ Firm Name,if any e-r O)W,III4,vAX 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.