17 ROCKDALE AVE - BUILDING INSPECTION a� IL
i
fL9gQIS WWROVED BY T44E
AMR
9mn GRANTED p
Nr�?'i;
CITY OF SALEM
No. G- --���� Dab
rw'- -R 'n DMdcl?� y pip i/ faeation of
N hopuly LoopMd h
M Owwiwll9n Am? Yak.No
WXLDMG PERMIT APPLICATION FOR:
Permit to:
(Clyde whichever apply) Roof, Rwroof, stall SId. Cons W,DUK Shed, Pool,
Repair/Replace. Other.
PLEASE FILL OUR LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROD
TO THE INSPECTOR OF BUILDINGS:
The WW hereby applies for a permit to build acoor ft to the fodowinp
speciftatiorme
Owners Name /:9�n iv✓r.P l�n y
Address A Phone /� ,�c/��/e Au. Y/— a r p
Archlted's Name G<a 6'
Address & Phone ?oo />/?hn S��PY (f�Yl y�z_6i� a
Medmics Name 4A2/ /�/j /�y
Addreu & Phone
wrw N sw pwpow d mddk�P ,�'��, P j:�
tYwnw a a+dtiot e e dwaaq,for now nwntr l maN4 / t
WE b Adiq=ft. lo Iwr'9 V�I Mbeposq Gv a ! l�
EM"wN -ooa. 3_ °���Cq uoww 0 fU p` ewo LIM=0
Lie. i i2.Y'pS"l—
Signature of AppHpnt
SIGN40 UNDER THE 101111110",
OF PERJURY
DESCRIPTION OF WORK TO BE DWE
I!
//��MAIL PERMIT TO• �� �� alV-31.zf 1-/ 9ilr
�s
APPLICATION FOR
PERMR TO
LOCATION , E
PERMIT GRANTED
INSPECTOR OF BUILDINGS
t
Carnmonfu /yy�t:a� o� /llae4ac�waffi
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I� JJePaalrnaaf o/9.1+�nf.J'+«ia.a�f . .
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60O W-sk:+y6-gWaf
Jsm".L Camooea C�oslee, /!?..a.c�+u.w 02111
Cotrytitsstoaw
Workers' Com/pensation Insurance �dapit
f�G9f2��/ice i ev '/C y' -
/%so---r�l
. . witha principal place of business at:
�"� �v�,9s�� S/ ��2�t/fAi /!�!/�• file/Z_�7
. . Itacr�aw✓7ar) •
do hereby•cercify under she pains and penolties of perjury► that:
() I am an employer providing workers' compensation coverage for my employers working on
this job.
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 Perteks:
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Humber
() I am a homeowner performing ail the work myself.
I uroamwne wt a codr of rim weentrm Wo be ic, +3roed m the Oflce el J,,,katrom of the DIA for cam ate•Hlrtcado am atat faiee to"core
co.erart v ttoureo under Section 25A of MGL 15 2 can kad to tree ineewom of"'nine oetwon corn tint of a foe of se=41.50f M mWer one
7eM•ilarnorrntnt x era at civi oauluo to the form at a STOP W ORK ORDER and a bu of 5100.00 a am #Lauer"L
Signed this • /ac V day of
7
iccr,sttiFcrrtitctt Building Gep:rtncn
uCtnsing Ecard
Seieamens Office
nc:lth Dtpar-mtn.
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 9RD FLOOR
• SAL.EM, MA O 1970
TEL (976)745-9595 EXT.860
FAX (978) 740.9646
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
govened by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defned by MQ,c III,S150A.
The debris will be disposed of at: P
Location of Facility
Signature of Pemut Applicant Date
FULLY complete the following information:
(PLEASE PRINT'CLEARLY)
Name of Permit Applicifint
G4- w
Firm Name,if any
Address,City&state
The above statute requires that debris from the demolition, renovation,rehab or odiff
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as de5ned by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.