25 RAWLINS ST - BUILDING INSPECTION (4) �is9gQS491liS EfiLfQ--tND 'i�,',PPROVEO BY T44E
u JL# i ; ipR `lP' PEAT BEING GRANTED
CITY OF SALEM
No. 3b' Zc�o ( �t Date G l Q 3
if n
Is Property Located In Location off �!
the Historic District? Yes_No BuildingLi NS yr I
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
eroof, Install Siding,(Circle whichever apply) Roof , Construct Deck, Shed, Pool,9
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 < Dlian►t ►Y1EfU�SL6
Address & Phone P u to VJ_5 c5F
Architect's Name
Address & Phone ( 1
Mechanics Name ' I I 11 GirIQ.e(AW-3 r
Address & Phone <41 t4f?THENO L
What Is the purpose of building? ec—>t otWT t L
Material of building? WCCch If a dwelling, for how many families?
Will building conform to law? Asbestos? f 16
Estimated cost '" City License# N state tense #
- 'r - ditty
Bome ��r�o�v�as�/entAA MPA
Lic. ' I.U��—
uC t q 3� Sig ature of Ap lit t
SI NED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
c
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S`t
MAIL PERMIT TO: a VAWU"�S
No. z C7 L-!
APPLICATION FOR
PERMIT TO
Ivor-
.
LOCATLORI
25 i5oc;wu i r j 5 S -r
PERMIT GRANTED
'7-:I ILa-c`?--5, 19
APPROvpn _
INSPECTOR OF UILD NGS
fomrnonwaaL of ///a6sac"eff6
nn I •
S �epa,lraaanl o/.7ud�tftiaf sccia�+
/ 60ow�"k-1r1--St<..f
James J.CamooeY !>oston, ///aseaehusaW 01/ l l .
Comrrasswaa
•Workers' Compensation Insurance Affidavit
(ata.revtne�iaee)
with.a principal place of business at:
A 'h' MA 6iolW
fcatrase.r.tsyl
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 Company Policy Number
I am a sole proprietor and have no one working for me in atfy capaaty.
() 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 undentana wt a Cody of this wren ent wriP be ion voed to the Me of InvesdPtores of[ht D1A for coeerage vetifKation and Mat LAW" to secure
couerast as reaireo under Section 25A of MGL 152 can lead to the inposufion of cri ninal oenanin contesting of a fine of ao M41.50000 and/or one .
years'�xwnm nt of and at chi oenaluu in the loan of a STOP WORK ORDER and a fine of S 100.00 a day 29 t ne.
s � 3
Sign is '% day of -
y�r
Liccns c/FcrrflitteE Building Depamn,ent
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 6- 17-727-4900 X403 , 404, 405, 409, 375
�o OF SALEM. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
g SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
�Grnra 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 defined by MGL c 19,S150A.
The debris will be disposed of at: ( fFacil l�
Location of Facility
Si tune of P it 6bplicant
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
N`a�me of Permit pli c8nt
' / y�
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 clII, S 150A, and the building permits or licenses are to
indicate the location of the facility.