17 RIVER ST - BUILDING INSPECTION v
1014*116INUSTIBE ffL{G4MID APPROVED 8Y T44E
.WSPZCTDB PWR Tp A PERMIT BEING GRANTED
\�\ (\\1 CITY OF_SALEM
\/�
No. Date , ® y.
l� s:
ri ward
Zoning District
Is Property Located In Location 01
the Historic District? Yes No_ 11u:111ding
Is Property Located in
the Conservation Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(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 Isarho'A
Address & Phone
Architect's Name
Address & Phone ./
Mechanics Name
Address & Phone 2gw ` .t�' ` s S� "1 �( S I R YLj
What Is the purpose of building? W 2 L'— I ^�C
Material of building? p If a dwelling, for how many families? _
Will building conform to law? / e ,s Asbestos? IIVQ
Estimated cost IS] a9 City License it 6qo state License M
n�1 Horse Improvement ,r \
11 'o o Lie. C —, A 4 1
Signature of Applicant��/ —
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE i
Eti u-z d S. cJ,�,. � � � ; ,,, . �t`cz R' t-,-�' /JOf✓i L.7L
4,1l l ('
MAIL PERMIT TO:
Or �t7�
.t
No.
APPLICATION FOR
PERMIT TO
LOCATION
.PERMIT GRANTED
APP V�D
Nb
INSPECTO OF BUILDINGS
ContriSonaual�{t!{ o f I1/a,ldaehWs�d •
b "..GJepaalas..t.�.11a;.G.f.�etl...l.•
600 W.Aujiae.Sr. .l.
�e.w 1 uslm.e &.&, M..aAaaalfl 02111
ew.taoaoer •
Workers' Compensation Inwrame Affideyk
.le C l GG f Ida✓t �4 r �L
. . wl*-a principal place of business sect
do hereby'cert$y under the pains and penshies of perjery, tbm
() 1 am an employer providing workers' compensation coverage for my emplorees workbg as
this jolt.
Insurance Compoxy Policy Humber
1 am a sole proprietor and have no one working for me in any opedq.
() I am a sole proprietor, general contractor or homeowner (drele one) and hew hired t1N
contractors listed below who-how the following workers' compensation policlan
Contractor Insurance Compatry/Poiccy Number
Contractor insurance Compatry/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I wfto Kee e a eaq of tli SUM"M oe be fon.ae.e M Or Ogee it iwad now el Or 01ok for ce.e at r.wlaraden ww am blew is man
ce watr r manor.eeow Sscian 25A of MGL 112 can kae wow Wmea m of aiai oanade corJ.det at s ate el s.wi I.5000)sower ace
Teal:nwwf"wm a no a d.i amide in ghc lone eta STOP WORK ORDER ow s be of 1100.00s an wommor.
Siirned this , l _der of ✓ I `7(, 2.t� d y
.icerseeiFenni tet ouiiding Department
uctrsinf Eoard
Seieamens Office
=eslch Gepar:merc
__ . 7 _ - ;: :._ Z . Z , - _- =oc y 4e4 405, ape, „!
r PUBLIC PROPERTY DEPARTMENT
120 N(ASNINQTON STREET, 9RD FLOOR
I SALEM,MA O1 S70
TEL (976)746-S396 EXT.360
FAX (976) 740•9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRL4 AFFIDAVIT
In accordance with the provision of MGL c 40,S34,I acknowledge that as a condition
ofBuilding Permit M .all debris resulting from the construction aodvAy
governed by this Building Permit shelf be disposed of in a properly licensed solid-waste
disposal facility,as defjned by MOL c M,S 150A.
The debris will be disposed of at s WA eS /L Jf
Location of Facility
1
Signatlrre ofPem=Applicant Date
FULLY complete the following information;
(PLEASE PRINT GZEARLY)
Name of P=mk Applicant
�.
Firm Name6 if dry
Address,city&Staft
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or stricture be disposed in a propedy-licensed solid-waste disposal
facility as defined by Ma clA S 150A, and the building permits or license$in to
indicate the location of the facility.