14 PURITAN RD - BUILDING INSPECTION (2) II ?£CTLIR ,PRTp :P ITT BEWG GRANTED
'; CITY OF SALEM
I i fD I 4.
No. tib q L, Date '03
Ward
\A6crrrmr Zoning District
Is Property Located In ✓' Location of
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
I Permit to:
j (Circle whichever apply) Roof to stall Siding, Construct Deck, Shed, Pool,
Repair eplace, 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: p�
Owner's Name �T-CA
Address & Phone ��M ?fs3 1
Aiefriteets Na[rrla �Av�� ��'crr'� /T a�ary� ���•.r�
Address & Phone 5 - 9--y-A'A� 195-d. - QFG(o
Address & Phone
What is the purpose of building? �1 o4F� -.
Material o1 building? If a dwelling, for how many families? _
Will bullding conform to law? Asbestos?
Estimated cost 4', ZO City License a State License a
Lf�7 I!' Bone Improvement
Lit. / S �•I
Cie- 15S� SI urers ' ant
SIGNED DER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: /�G�� /ya�vti5 J�'l joc >rj La" �� ,
m - Qd
33 n a
C 0Z
P
V0 i W)F PTI ;gfi,"5110 I
p --......._. tt ✓h . {.« B' (i ` Y?.s4 V. ^�
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f,•i�u4r�:3'.1 I¢E��it d P ti`�d.'•��3 i ��"�`i;�iR>< it :- ,l,.?'
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OF SALEM, MASSACHUSETTS
- PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
yp SALEM, MA01970
'?r TEL. (978)745-9595 EXT. 380
�Gnrta 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 ri c, 1
III, S150A.
The debris will be disposed of at: 1 k Z
Location of Facility
rgrahrre 0 plicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
�— CommonfoIAk of //(ae6acLetf3
' Jeparlmanl or..7adullrial �eeiiutla
S F fr�,�,/
boo /W,ski-y".SIraaf
m Jaes J.CaM000 f�osfon, ///aaaae/ .ib o2 i /i . .
Carmrsstoeter
Workers' Compensation Insurance Affidavit
- (ava..r9oioet)
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 Com any Policy Number
I am a sole proprietor and have no one working for me in any capaeiity.
() 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 Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I wnoertune wt a coot'of tM Statement wM be for arota to the Offct of L V%6t3 om of the DIA for co+eratt verification am that uat re to secure
covefair M reoieea unaef Section 2SA of MGL I S 2 can lead to the irtoossden of crir"I otnatties corsadnt of a ftnt of we 0o4I.50000 aeefor one
rear'inprtwnmrnt z.ero x did ""Ides in the loan of a STOP WORK ORDER arse fine of S 100.00 a ear apirot ma
day of
Signed this , Roo 3�
Licensee/Fermittee building Department
Licensing Board
Seleamens Office
Health Department
TO VERIFY CGVERAGE INFOR?-=.TION CALL: 6 1 �•727-4500 X40 404, 405, 409, 375