17 PICKMAN ST - BUILDING INSPECTION f � ,
iMbi1`eE VED BY T44E
JdS A l0ui D PROF BEINQ GRANTED '?{
CITY OF SAtEM
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BUILDING PERMIT APPLICATION FOR:
Pwmk t:
(Circle whlchowr apply) Roof Road Install Siding, Construct.Dock, Shed, Pool,
IR rOther: A Pf4v-l—i'�4v-i (4 VL O�1A10 ej
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROS
TO THE INSPECTOR OF BUILDINGS:
The nda WPW hereby applies for a pwmft to build aocordhp to the folle t
Owners Name �u�. l tt rAYLA I u y L I v ,
Address & Phone Pax /yg�U Mai..13 y
Amhkect's Name �n
Address 3 Phorw )
Mectanhs Name ry/ ,4&4 LA l l e-,
Address & Phone (603) 3n3 •-d7 97
wrrr Is to p.po.r it ewurjgr 1 k FA van i y L fZ 4 S 1 )A i-
Mfww or Murano? Ry- t c K N a dwr0 for now nmy lm~ R "
Wo Murano in to aw? y -5 Aobubr? ' 3
EMnwIW cal 7.1
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um"r
ao.. IRto�at
Lfa. r .
ature of Appllcanj
SIGNqD UNDER THE P**of'
OF PERJURY
DESCRIPTION OF WORK To BE DONE
�2— 1`
';'!;. MAIL PERMIT TO: �H Me w(3 vti
AppuCATION FOR
PERWT TO
G^ Y4` d- k
3
LOCATION
PERMIT GRANTED
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APP '�D .
INSPECTOR OPSUILDINGS
S
June 16, 2004
Mr. Tom St.Pierre
Building Inspector
City of Salem
120 Washington Street
Salem, MA 01970
Dear Mr. St.Pierre,
Enclosed you will find a Permit Application for 17 Pickman Street in Salem. We
wish to renovate an apartment with a new kitchen and bathroom. 17 Pickman is a 6
family building that we have owned since 1950. 1 feel this apartment has reached a point
that it requires a bit of a facelift. We will also be installing a new roof.
Please let me know if there is any additional information that you require.
Sincerely,
/MZrk Audette v
603-891-1800
6QARCl,GF�lIILGI M131t�.4114�?dANB,,
LlpaRt $gT,RUCTIQM SUPERyiR t y
Num R� B A 7 4 t o
r
MARK L,AUDE
18 HIGH ROAD 4
NEWPYRY MA 01 , Adm�ni gfOf k
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (978)745-9595 EXT.360
FAX (078) 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 M S150A.
The debris will be disposed of at 11; 29- C O tV4
Location of Facility
L± o,-(
'Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
I�s�r�K A�v�-•'
Name of Permit Applicant
Firm Name, if any
H (GH IZmAjpr /Vew16w7µ JAA ()1C)5l
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
I
i�
COcmmonluEAk Vf Ma-U&JUaAd
6
.1J.pa,r�n.� ./J.�riaf Jfacia�s
600 eyw�.a -16 3i,osi
�amea a umood /�w1ow, ..a.dWa.w 02 111
co�(taasroa.
/Workers' Compensation Insurance Ada*
lt1
. . with.a principal place of business at:
I H 16 H {Lo N j.W V0 v v'`/ OA r 9 s r
. . 1taga..r.,uq
do hereby'certify under the pains and penolties of perjury, thM '
I am an employer providing workers' compensation covera=e for my einployees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (drde one) and have hired the
contractors listed below who-have the following workers' compensation polities:
Contractor insurance Compatry/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I uno,,,,nd out a Corry of"uatemem we be ier..aroet to O+t Offct of M.eaiCav m of the DIA fer to.sratt 11ARt8aan WA ON laatee 10 Mcwt
co.erart at(toured unot(Stcuon 15A of MGL 15 2 can katl b tut irvmMien el ak ina,vcnx t co,,,arn of a fart of as M4I.500A0 aualer out
nun'i7xwnnr,nt a va ar "rwL;a in the term I a STOP WORK ORDER ane a kw of S 100.00 a an agiwwt wL
Signed this • day of _ 0 y
.-iccrocei'Fcrrniuet Euilding Gepann.ene
uctnsing Ecare
Seitctmens Office
nc:lth Gepar'me�.