18 PICKMAN ST - BUILDING INSPECTION U s;, t;
OVEfl BY i'+iE
" T R OI . P T BEING GRANTED
IT1 OF S, LEM
No. Date, _
na'
Ward
l\A Zoning District
14,Rrpparty Located In Location of
tF®Historic District? Yes_No_ Building / a t w�
I,i►,Property Located In
the Consanratlon Area? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, 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 ov r f//Ur
Address & Phone / q Pe/
Architect's Name
Address & Phone { 1
Mechanics Name �ZnAL04
//_ elcIz / h
Address & Phone -2A wd,4 e, -,1- ( 1) 72Y 2193
What Is the purpose of building? a�A RMd16 ze
Material of building? Le If a dwelling,for how many families? I
Will building conform to law? Asbestos?
Estimated cost 1�city License r J1 state License # � 7�
Bma imp nt
�( Lie. / j�
Signature of Applicant IJ
—
SIGaNEO UNDER THE PENALTY
0F'0ERJU4Y
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
..........
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James J.camooel Uofloat, ///aauc�uwW 02111
corwys,ioner
IlWorkers' Compensation insurance Affidavit
L '�n�•ms �K���f't.oiYl
with.a principal place of business at:
do hereby'certify 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 Number
1 am a sole proprietor and have no one working for me in any capacity-
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 policies:
Contractor Insuranee Company/Policy dumber
Contractor Insurance Company/Policy Number
Contractor
insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I anoentanc wt t cool of thh we<rmnt wo be iorwaroee w the orrcr el lmctiiauons of the DIA for corarare rer;ht&on MW VM(aixre w retire
co.:rne as reovrec unorr Section 25A of MCL 1 52 on Ieao to the inooytion of cranium o<tutue6 corsatini of a fiat of w =41.50000 anoler one
r<an' ir..xuanmmt a trn m chi o<nalua n the lortn of; STOP WORK ORDER ano a/r+u�of S 100.00 a aaT arairtA mt•
Signed this c day of QM/U
r PrYJ �/J
�iccnsecr Ferrniuee building Geparr*+ent
ucensinr Eo2r0
Seiectmens Office
",t2jrh Department
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
® 120 WASHINGTON STREET, 3RD FLOOR
1.
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 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/IIII, S150yA.
The debris will be disposed of at: / i / /15
cation of Facility
Signature of Pem. t App c t Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
2J L"y
Name of Permit Applicant
Firm Name, if an
Y
/6� u4
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.