10 RAND RD - BUILDING INSPECTION (2) _ f
i
IKAM b4HST-OE fH--ED-MO APPROVEO BY T*IE
W5P XT-0R ,PRWR TO A PERMIT B,E NG GRANTED
CITY OF SALEM
ADr
No. A') — J,\.j�\ New` ' �\ Date
Li y r I
Ward
� pmN600° Zoning District
Is Property Located in Location of `
the Historic District? Yes_No_ Building /v &4�Q Oti ez
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
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 l,C Do xgi/.Ueau
Address & Phone
Architect's Name
Address & Phone ( )
Mechanics NameON f�7,gh
Address & Phone �R,�04 (97�1.4AIj227ZI
What is the purpose of building? llefwx!s{
Material of building? 4f PO If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost 9SUo city Lice I� State License x 45>3 Dy/
Home Improvement
Lic. 0
Signature &4Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: /?D/v �l9LY'o
APPLICATION FOR
p PERMIT TO
°l e�•. �i 1 +�i�dt/ .
LOCATION
PERMIT GRANTED
APP D \
INSPECTOR OF BUILDINGS
� CommOriurai4Lfh of�o.„acjlwafte
600 W.4ryw1-e.f
Damn 1 c.noas &.1., N/a .A. & 02111
co nsass o w
Workers' Compensation Insurance Affidwk
1, ok cb A
. . wkba principal place of business ac
ArI'f�tdab ,�/3
do hereby'cerstfy under the pains and penohies of perlery, dmU
I am an empi wyer prwAditag workers' compeand an covers#* for my ItmPioyees working en
slats job.
JZ)9.9� 9
insurance Company Policy Number
z
I am a sole proprietor and have no one working fdr me In asry capacity.
O I am a sole proprietor, general contractor or homeowner (circle one) sad haw hired the
contractors listed below who-have the following workers' compensation poUCIM '
Contractor Insurance Company/Polity Numisr
Contractor Insurance ComPasry/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing ail the work myself.
• I unarm out a coot of oiia auunwa,we M fort.araa m tar ORBe of in.adlawtr of rlu M&for ca. ste•a fkaiaw aM eon lira r Boot
to.aralr at rrourta anon S.cian 2$A of MGL 15 2 can ksd ra or ir4orwion d crw&m oan.da corjsdm of a nr of w aoi 1 J00M MWou ON
rran•Lnaeacwnrm as%a a ew &Lwwo in tit* jam at a STOP WORK ORDER am a fine of s 100.00 a an as+rrr MW
SiEned this . 6 Of 5-U`( day of —
�_-_.
:iccrseci'Fc rrAftEet ruilang Departrwent
jjceruing lioare
Seieetmens Office
�e:ith GeFar-mere
- _ ene epc _pe Tic
PUBLIC PROPERTY DEPARTMENT
` 120 WASHINGTON STREET, 9RD FLOOR
SALEM, MA O 1970 TEL (978)745-9595 EXT.880
FAX (978) 740-9846
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 defiled by MGL c III, S 150A
The debris will be disposed of at tiDe/7i,Pibi � �G (rvf?/ Jf6i��7b
Location of Facility
Signature of P6mit Applicant 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 othea
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits or licenses ace to
indicate the location of the facility.
ty