32 RAYMOND RD - BUILDING INSPECTION (2) >!iS�dIHST-BE ffi£G�,APPROVED By T44E
=P,ECTO13 ,PFWR tVA PEAMIT 13,EWG GRANTED
CITY OF SALEM
No. G+7 -"� y - DjElmp,"�F_
Date.
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:
Permit to:
(Circle whichever apply) Roof Reroo , Install Siding, Construct Deck, Shed, Pool,
Repair place, 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 1 sj: 4 C m_e ywc,�)
Address & Phone s n trn�)n�
Architect's Name
Address & Phone p
Mechanics Name FYl L e(yr U�c�ins, � 4 R o oc�
Address & Phone i f \a 9 /D3 t S S 7
What is the purpose of building? C����OC-) �Gy�W , 0I`�6fp
Material of building? , 5,f�Ln4Q_ S If a dwelling, for how many families?
Will building conform to law? k/�5 Asbestos?
Estimated cost 60, oo City License n N A State License p
Home Improvement
Lic. I X ,
2Gon CL< I Si nature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO�) I[ t��P�)�������4��.
No. 2�7 4-22?Y' '\
APPLICATION FOR
PERMIT TO
LOCATION,
PERMIT,GRANTED
AP/PROVFD
INSPECT,_ R OF BUILDIN S
j'
f C
OF �?ALEM! MASSAGI-ivac ' i =
PUBLIC PROPERTY DEPARTMENT
• • 120 WASHINGTON STREET, 3RD FLOOR
< ? yp SALEM,MA 01970
y
TEL. 380
FAX (976) 740-9846
:l
iTANLEY 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,S150A.
The debris will be disposed of at:
Locationon of Facility
9- /(", -Cc'
Signature o eri t 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 other
alteration of building or structure be disposed in a properly-licensedor licenses are to
dorsal
facility as defined by MGL clll, S 150A, and the building permits
indicate the location of the facility.
�— Corrmanwi:ahk of 1/la66atL6etL
Jeparlrnaaal a f.Jinf a nle
S i
600 w1,11m
021 if
Crmrssroaer
Workers' CompensaLL
urance Affidavit
' -
with.a principal place of business at:
statris.ar✓taq
do hereby certify under the pains and penalties of perjury. that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
P- y3C) S Y
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 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.
1 unotntanC wt a coon of t}io wtemtnt wii be ion+aroe0 to the OttKe e7 Imcciawru of rht DIA for coreraTe�at°On am Nat(.lure m taeure
cortrarr v rcaarto uncer Section 1SA of MGL 15 1 on lead to the imooyuon of cr,rrwnm oemm�es conusuni of a 6ae el w to-S I,SOOAO arbleM one
rears' ino uonn tnt x as t rs Dena uo in the form p
of a STOP WORK ORDER ano a 6u of S 100.00 a "m a +ut me.
Signed this �C= �/I! ay of O
ccnsee/Fcrmittee building Deparzn+ent
Licensing Board
Seie CtmenS Office
Health Department
_ 7-7 -7-4_eOO X=C= 40'� a0c, -00 77
Board Of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR '
Registration: 1.38605
i Expir"n: 4/23/2005
Type: DBA -
SML ROOFING&ROOF REPAIRS
STEVEN LAMONDE
11 RALPHRD. _ p
PEABODY,MA 01960
_,_^+ „��,� Administrator
0