14 POPE ST - BUILDING INSPECTION -MOST-BE f L-E D APPROVED BY T44E
=P,ECTDB PFUITR TD A.PERMIT BITING GRANTED
CITY OF SALEM
No. 19 7 ZCJO� c Nu
`� . Date -.2/-03
�s
q ()IU I 'TS PER
Is Property Located in Location of
4
the Historic District? Yes_No_ Building t
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR: j
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 i n2 k e 101r m /O�
Address & Phone 9022 �'t . �✓ D ( ��� �7�1 y- �'l�'2
Architect's Name
Address & Phone L 1
Mechanics Name
Address & Phone ( 1
What is the purpose of building?
��c C
Material of building? e-- If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost5,coo City License# N A State License # C-S 0-2 Y 9D
Noce Improvccent
Lic. t
CK izyo Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
g¢vr\Gvk �P� ll3 rL�c 61z-i
r,r l�l y x G d ec.1c:5
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MAIL PERMIT TO: AU, r �Qc �u�� CJ1 c/6U
k
t
No. 1 9 7- Zo c 5
APPLICATION FOR
PERMIT TO
ti� 2 2c�S
LOCATION,
S�
PERMIT GRANTED
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AP�OVf D
V�G
INSPECTOR OF BUILDINGS
a Y OF .5ALEM. 1Yl ia7bf+�-nv � .
• PUBLIC PROPERTY DEPARTMENT
• ° I20 WASHIHGTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT.380
FAX (918) 74(j 9846 .
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 III,�/S150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ear f 1'eCe `rh
Name of Permit Applicants/�
L. PRCC;F4- L-aks�AA4%w
Firm Name,if any
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
f
COrnm.0nlute4ahk of111a66achtde fe
s a
Jepa,lmt,al o f.7adatafria(SeeiatrtG
t 600 waa,plm S1,..l
James J.Camooes i)oalon, ///dtaaNau,aw 021/1
coy-.mrssiona
Workers' Compensation Insurance Affidavit
Z.
n (
�r�,..rt�t.r•ee1
with.a principal place of business at:
. . lcanrscaarrra
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.
C1t'rCl2 : /A5
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capadty.
() 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 Compatty/Policy Number
Contractor Insurance Company/Policy Humbec
Contractor Insurance Co Policy Number
0 1 am a homeowner performing all the work myself.
I unoeruano mat a coon of this acatemmt W R be ion aroed to the Ofrce or Imairtatrortt of the DIA for co.eratc eeriRadon and MX fairs to aaatrt
co.•erarr n rtvirec uncer Section 2SA of MGL 15 2 can kad to the onooution of crvninm oemrcm coasssunt of a rM of w tod 1.5=400&War one
years''r.+oroorwnent x ,V x tied oenaltio in the loan of a STOP WORK ORDER ano a Ere of S 100.00 a oar atfnst mt.
Signed�thiss day of
7
Litxrsec/Fcrmitcce building eparzn+ent
licensing board
Seieamens Office
Heaerh Department
t � 40° �7S
C . `i�, COJER1.Gc CALL. . ii --:-490C X4C 404, 40°,