14 PRESTON RD - BUILDING INSPECTION (2) IN &111 10 APPROVED BY THE
II& CIDA PWR TD A PERMIT BEING GRANTED
2 _ CITY OF SALEM
�)�No. � Dab
rid° Wwd
Zwft Dis hl
Is PmPwty located in Location of
the Miatoric DWdct'1 Yas No Handing 1 wl �Y
Is P OMIY LocNad in
Nu Conawwdbn Area? Yak__No
Permit to: —
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Install Siding, Construct Deck, Shed, Pool,
Repair epla . Other: k,,-.? i w A, G
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned herby applies for a permit to build accordwig.to the following
specifications:
Owner's Name �G���� 1/Lo
Address & Phone L/ Y P Cvz 78 7 VLJ
Architect's Name
Address & Phone / f
Mechanics Name
Address & Phone
IuorceS'4-ew, /J74_ C) cy-j
What Is Me PwPo"of WHdkgl
Mdwld of W~ N a dwef V,for how mmy farrow?
WN bAdlrq conform to law? Aabaatoa?
Edtfnated cod cry Ucw"a Stab Umm a
Hawn Dwrovawaat
Lis. a I-P-[o k�3
ignature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF VMRK,,M BE DONE
MAIL PERMIT TO: &o4 r,121 14 o
y
lry h9 5 �v�o lea o IS -79
No.v
APPLICATION FOR
nn P/ERIRT TO
LOCATION
PERM��IT GRANTED
19
APpROVfD
l//IrtJ`1��,J
INSPECT OF BUILDINGS
'°' l,.DrriAipailYalsitfA 0��a:�.1CCnLi0iar0
•.1Jep..lw.al a�.7a4dria[,�reeiisa4-
wo w.A40.Sfead
a.na t G.md B-dies. ///sarel .6 02111
Workers' Compensadon Imurarla AffUlwk
. . wirh.a prindpel place of baslAeu an
do hereby'cer* under t)a paW and penildes of pv}ryo thou
() 1811180 emplo/V1ss Finwiding W"kis s' compensation covep fe for my eiaploreer workL�op
Insurance Cenap.q Fo9tv Number
L ,
I an a sok proprietor and hove no one working fdr an in amr capecky.
0 1 am a sok proprksora general contractor or homeowner (dreie ens) sad hove hired the
coausaors listed below who-haw the following workers' compensation poBdaR
Conmager Insurancs Compstry/popgr Nuedrer
Contactor Insurance Comparry/Fo Nu"W
Contractor Insurance Company/Poky Numhor
() 1 am a homeowner performing all the work myself.
•I rearaine ON a call of db aure.es.e N for warned as der Office A 4redtaeae of dr DIA fer coverage eerlaodeo ar an Whet ce wom
Cosner a frown.aoer Secdae SfA W MGL 15 2 can kid r ow Worsodee of v6pbue aeeaie curedne of a for of A 041,NO muter eee
trap'iweef.netl a!f/a add pewees in the kme o!a STOP WORK ORDER aee a br of S 10GA0 a an anise ar.
Signed this . / day of
'icer'se enfarie 6ud6rrlg DeparcrWint
Licensing, Ecarc
Selectmen Office
=ealch Dtpsrsmefr.
apa apc qpe M
PUaUC PROPERTY DEPARTMENT
1 120 WASMINQTON STRaaT,aRDFLOOR
VIAL&N.MA 01 S70
TEL. (S76)748-nog E)rr.360
FAX (976) 740.96"
STANL.EY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In sccmdanee with the provisions of MGL c 40,S34,I acknowledge that as a condition
ofMding Permit S_ all debris resulting fmm dw conoucbm mWigy
governed by this Building Permit shd be disposed of in a properly licemed sOlid-w"W
ficilitY.L defied by MGL c III SIMA.
The debris will be disposed of at 3 L/S � h w urn U� C/vv rcp S-►-U !M,
Laced=0fFacility
Signaaue of Permit App i Date
FULLY complete the following mb matm
(PLEASE PRINT CLEARLY)
& 4-1 C��.
Name OfPermrt App
7-Cp
4 Y o —�
Fain Nang if my
�lC0 / -Cot-, 0d 5-tl-, 61�-)p✓Ce s-/G- 1,1114G 0 CL `rJ
Address,City k Sterne '"—
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or stnlctute be disposed in a properly-licensed solid-waste disposal
f cility as defined by WEL cIff,SI50A, and the building permits or iiamsa are to
indic the locadon of the facility.