99 PROCTOR ST - BUILDING INSPECTION IMIST13E ffL-E� APPROVED BY T44E
WSPE.CTPFa PFUDS TP A.PERMIT.B,EWG GRANTED
_ CITY OF SALEM y/
\ t\ UN' I /
Date � �J F
a�iys ' lrl! Ward
'\°ncimNrW'� Zoning District
Is Property Located in Location of
the Historic District? Yes_No_ Building G�—
Is Property Located in /
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Insta Siding, onstruct 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 r-t�1n�rnti�
Address & Phone U�7 �s a �,�r�- 71, 09 3 },,�)
Architect's Name
Address & Phone
Mechanics Name oz/
Address & Phone - G) 9_2 2— S:5-7
What is the purpose of building? �_ S/ — T-/-!/YYJ
Material of building? (tf 6F If a dwelling, for how many families? '/zjJ U \Z
Will building conform to law? 4z-o j Asbestos? 1-11/U
Estimated cost
700 City License# State License G 3 3
L / Home Improvement
�J Idc. / /O
Signature of Applicant
SIGNED UNDER THE PE TY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE _
To 2 d7LTi1 6� A� Grin ��✓
MAIL PERMIT TO: T z / `6r G��
.L
i
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
19
APP�PiOV�D
INSPECTO. OF BUILDIf S
I
I_
PUBLIC PROPERTY DEPARTMENT
-,. 120 WASHINGTON STREET, SRI)FLOOR
SALEM, MA O 1970
TEL (978)745-9595 EaT. 880
FAx (976) 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 III,S 50A.
The debris will be disposed of at C „p�YyJ 727,1
.��
Location of Facility
Signature of P t Applicant Date
FULLY compl the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
4l AIGI�- Ze- s cam_C .
Firm Name,if any �r
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.
� COmmonfNaa� Of �O.IDaChu3sat0 •
600 W"L.11 s Stmot
Hama.l.Canvas &.1., M..J 6 02111
c
Workers' Compensation Insurance Aff1dayit
1, /Utz 1 �
1
. . wiih.a principal place of business as:
do hemby'certify under the pains and penihties of perj.w than:
(� 1 sin an employer providing workers' compensation coverage for my employees working an
this job.
2hr r r1/ Gy c . - 3/ s �3 �4yrr Gy G/.3
Insurance Ca - Policy Number
I am a sole proprietor and have no one working fdr me In any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired d a
contractors listed below who-hsve the following workers' compensation pe5cles:
Contractor Irtsuranie Companry/Pollw Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I UftowHee ace a coy of ill's wemmm wen be foe woes a On Oaks el LWC* sees of ON OIX ke ce..rare eerillco ten ace an gam w were
eo.eeare Al>eftwea saes Seeder 2SA of MGL 15 2 can kaa to OW irasoaaiee Of ees'ina vends Coeeaodeet e1 a toe Of•eat I.So*=never on
rear-ianroeeae>eea a fto as ew sesame in one term of a STOP WORK ORD ER arse a Am of S 100.00 a an atdec sae.
Si s , day of
:,cerseei F:rmittee iiuiiding Deparcn,ent
�cen:in{ Eeard
Seiectmens Office
^c:lth Geparmer�
Z.
OF, i7c
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