18 ROPES - BPA-04-969 III''{:•' ' ,,. i
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fL'dlNSi�fST'isE YEf) BY T44E
JIsL3AECznB d qW9 D PE14T=INO GRANTED ?�
CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Chb whWWW apply) Roof. Remof, Instell Siding, Constrict Deck, Shed, pool,
epleq, Other•.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCIUM
TO THE INSPECTOR OF BUILDINGS:
The u�reigned hereby applies for a permit to build according to Nye foNwAi ng
sPeollOwners Name Al/ h 0,✓ -T le�
Addrew & Phone NI �a lwrMovh/t i9;Al rlo-2, 2r`l`I/
Amhked's Name
Address 3 Phone ( t
Mod mics Name
Address A Phones 1
1 .6
wha N to P APON ar war
ta.ww d wldYgv _wb�/� 1 rm L N.dwN,w,for now mmy amwy 7
eta wait MR OR to wr9
oo t.0 0-) qh Umm r N p` own U08 r-r Af A
' Lic. I ,/►1
Signature of Applicant ".
SIGNED UNDER THE p -
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
GsC_��osEsy •
CSC'" �/J /w" �Gj fv��✓ li✓yt sz�d��+ -
�Y 6
mo
MAIL PERMIT TO• �Gr , /� /, GG C s
I�.G��� ova • .
APPLICATION
LOCATION
PERMIT GRANTED /
APPAOV�D
J /✓
INSPECTOR OF BUILDINGS
�oryrym,,monurt:aLih o ,, t1�ac�af>`,
s .lJepn�luauel el,�a�a(�icciarafs-
600 U/asLl4mt SWJ
�ameslCamoeN Qalew, /l/.u.cr!i+u.tb 021 /r
cecaresatoacr
Workers' Compensation Insurance Affidap41
. . wither principal place of business at
do hereby'certify under the pairs and penalties of pvjmyr cloC
() 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 any opacity.
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
TIC contractors listed below who-have the following workers' compensation polities.
Contractor Insuran a Company/Policy Number
Contractor Insurance Company/Policy Number
Contractorinsurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I unoerwne out a coer of the weemmt"a be ic, .3roee m tcx OffKe el imnxieauoet of the D1A la ceverare e"iicadon am Mat(fie eo some
co.erare x reourro once,Section 2SA of MGL 1 52 can kac to the inootwon of criniNh oemrtin corwtirtr of a inn of w eat 1-50040 end«am
rear7' ciri a in the form or a STOP W ORK ORDER sne a fine of S 100=a car aims"ere.
Si r day of n ��
:ic rh e f rmia- c Vcuiicmg Geparcrrhent
ucerlsing EeaT�
Seiecsmens Office
ne:lt! Ge�rr•^e
- 7-
- - _ c c =n"' . r05,
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 9RD FLOOR
SALEM,MA 01 S70
TEL (978)748-S595 EXT.880
FAX (976) 740.9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGM c 40,S34,I acimowledge that as a condition
of Building Permit 0 .all debris resulting from the consfzvction activity
governed by. this Building Permit sba$be disposed of in a properly licensed solid-waaft
disposal facility,as defined by MGL c III,S150A.
1
The debris will be disposed of at: G2 S
Location of Facility
Signatm of Permit Applicant YDste
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
erns.if
Addrabs
,City dt State
The above statute that debris from the demolition,
re4uues on,renovation,rehab or other
alteration of building or structure be disposed in a property-licensed solid-waste disposal
facility as defined by MGL cM S 150A, and the building permits or licenses are to
indicate the location of the facility.