63 PROCTOR ST - BUILDING INSPECTION (3) 22 y
fI�IIAS J VEG BY 744E 1
iiiE3N+I�IQR ,P BEING GRANTED
CITY OF SALEM
Daft
Is Nap"wmw in raeseton of
fhs a Wnrb omdd? Yes_w✓ so W"a
N FIWWW u0mm in
:• h OwswA 9n Am? Ysq_NO
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whlohwer apply) Roof Reoof, Install Siding, Construct_Ds* Shed, P"
R ep . Other•.
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROD
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a perms to build according to the folbwMlg
specillostiont
Ow wes Name
Address & Phone k n
Architect's Name
Address & Phone ( )
Madmics Name
Aftm A Phone MY I `IlkS-\1Z:113
Whet Is rM pupas of kAW
Memo or hdam? M a for now mmy ft"n?
wr t mft nonronn to*A !'
t Inslsd cal. 5�__CM umm r N A cuts
a4. Iapsv�sat _ � �.
Lie.
Signature of Appll nt
SIGNgD UNDER THE P111110"'
OF PERJURY
DESCRIPTION OF WORK TO BE DpNE
c: etc ro r0
I' MAIL PERMIT TO• \ N l J(
AL
m VP
APPLICATION FOR
PERMIT TO
_ j
LOCATION
PERMIT GRANTED
APP1
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 9RD FLOOR
SALEM,MA 01970
TEL (979)745-9595 EXT.380
r FAX (076) 740-9946 _
l STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MOL 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 MGLL c III\,\S 150A
The debris will be disposed of at
Location of Facility
� n
Signature of Permit licant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Nam?, 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
i�LE Coccmmonwaahke01 I llK.i-14U6&c gtt6
' C6 a
1Japn.leratf oI.J edeel /secia ela
600 WaJ-11m SL eel
gamesauarooa 1�e.Lti /I/..a.cluww 021 it
commastaw
®` Workers' Compensation Insurance Ada*
. . wUa-7 principal place of business at: j\
do hereby"certify under the pains and penalties of perjury. thm
() I am an employer providing workers' compensation covera=e for my einployees working on
this job.
Insurance Compuff Policy Humber
x1 am a sole proprietor and have no one working for me in any rapae$Y.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policim
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I o"oenunc nat a cool of the tuaen'er't wa pe ion+arded w trA orrce of kweakaooto of ttx 014k la co+ art+erwKaaen aak Out lairs m newt
co erarr n reovreo"noer Section 25A of MGL 1 S 2 can kad to uw iMID id't of erin'na otru d"eor�s8nt 91 a 6a of w te-g 1_%00A0 ane/ee oft
wean,irorwrr'nnt a fto z eiei .'situ in dne loan at a STOP W ORK ORDER an0 a irr of S iDOAO a ear again"e't.
Signed this . �� day of
:icenseei Fnnictee �- building Geparcr.'enL
�ccrcinf Eoard
seleetmens Office
r.c:kh Dep:r:men.
- - - - - - - - - - `r e
erne epc 0e 77r