5 PICKMAN ST - BUILDING INSPECTION (3) IaT r t G I PF�FI01
OVED BY T44E
y` p PFT BEWG GRANTED
i
I ?PITY OF SA�LEM
ter . f � iT
No..I Z_Z_00 Lf i y� �. Date �� -�� - (�3
Ward
s \�amn r T Zoning District
Is Property Located in notation of
the-Historic District? Yes_No_ Building- S P c m fir✓ ST
Is Property Located in
the Conservation Area? Yes No _
BUILDING PERMIT APPLICATIO FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, FOR:
DeckShed, Pool,
Repair a lace .Other: f:LJ r, c.. /
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 J ' A tiC XA" YG f1 f1-
Address & Phone S P S7 )7 4 S vc-Z C. q
Architect's Name
Address & Phone 1
Mechanics Name
Address & Phone
What Is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cosy¢,-qF/3 0 o ..- city License r q 32 state ucense n 1 O 2 1
U q°" Gib 9 7 Rome �tn.� r3
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
R� b L,4c4 r 0 D o��
MAIL PERMIT TO: 1 to. i Q r 1-r I
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Zaaarimant o1J1ad Vial_7tctaaraL
600 VVwhinylon'.�trrei
• James J.Camooell lv.acnuaatt! 02111
Commissioner
Workers' Compensation insurance`Affidavit.
1, � �NGfb � LY
• 1
with a principal place of business at:
A iN S'-r P.o o 1 9 (zo
(CLry/4uae/dlnj
do hereby ccrsify,under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy.:Nu'mber
O 1 ant a sole proprietor and have no one working for me in arty capacity, .
11 0 1 am a sole-proprietor, general contractor or homeowner.(circle one) and have hired the
contr2mors,.iisted below who have the following workers' compensation poilcless
Contractor Insurance Company/Policy Ntmrbe!
Contractor Insurance Company/Policy Number
y
Contractor Insurance Company/Policy Nutaber.
O 1 am a homeowner performing all the work myself.
I underua w MR a coon of Mis tuumem w14 be forr,aroeb w the Orrice of inv ugaum of the DIA for covemse ven6cxm VW Nat U&NO tb.eeOfe
corarm u rtbueta under Secoon 2SA of MGL 152 can kao to the enoo wn of mmmat oenaiuea'eonauanr of a fvq O uo W s I.S00=w6/e'r eve
rears' entxuom,ent u wewnarave ocnaiva w the form o!a STOP WORK ORDER ano a fine of'f Ibo.00 a oav na m me.
Signed this / day of
Licensee/Permittee Building Department
Licensing Board
5electmens Offlee'
Hulth Department
TO VERIFY COVERAGE INFORMATION CALL: d 17.727.4900 X403,. 404, 405, 409, 373
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50H=r-15.9595 c'si. 390
DI5POSA1 OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40 , 554 , I achnovledge that as a
condition of Building Permit tl , all debris resulting froti the
core trueticn activity governed by this Building Permit shall be disposed of :n
a properly licensed solid vaste disposal (acilicy, as defined by MGL c III ,
S 150A.
The debris will be disposed of at :
location of f dility
- k
Signature of Permit plicant Date
Fully complete the folloving information:
(Please print clearly)
Name of Permit Applicant
Firm Name, if any
�--i 9 M a a S T �� �� Y M o
Address : City 6 Scare
The above statute reauires that debris from the demolition_ renovation , rthul
or ocher alteration, of building or structure be disposed of in a prepu'ly
licensed solid vasce disposdl facility as defined 'by FGL cIII,' S1504 rnd that
building permits or license's are to indicate the location of zhe facility at