16 ROSLYN ST - BUILDING INSPECTION ieL*NS*WT19E APPROVED BY CIF
ASPJEMW PRIGF!TD A PERMIT MNG GRANTED `
CITY OF SALEM
N0.
Date 2 ' G
Ward
Zoring District
Is Property located In Location of
the Historic DldrL-t? Yes No auilding
Is Property located In
the Conservaffon Ana? Yea No X
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 accorcLig.to the following
specifications:
Owner's Name S'7Eir6N D46 L/ U
Address & Phone /G• -eo s c A) (791 ) 7/o - 7x 98
Architect's Name N�.R
Address & Phone If )
Mechanics Name PA 14 c -)-�q w IA
Address & Phone w,Q-j)r-o 2,) (601 ) `f.18- y 23<�- _
What Is the purpose of bullding? Jp c k
riel Mate of bulldptq? 1 ul 1 R a dw"M.for tow many famYbs?
wig building=ft m to law? Asbestos? f/6
Eelmated coat G o o ,co Cny t kartca r state Llcwtea N (`dog tl
HOW ImprovementLie. 0 � �—�7�--
ignature of Applicant
SKiNED UNDER THE PENALTY`
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
D-er+.� � �ecoNsi►ea�.� 2F�uuR n.ec �� � �� o '
MAIL PERMIT TO: A-'/) / 4C _5 - i c ✓ice
No.�_�+
APPLICATION FOR
PERMIT TO
q C y/
YiLl /
LOCATION
PERMIIT/GRANTED
19
AP OV�D
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WhsmimaTOR STREET, aRD FLOOR
SALEM,MA 01970
TEL (976)748-9595 ENT.860
STANLEY J. U60VICZ, JR. FAX (976) 740.9646
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance With the provisions of MQ,a 40,S34,I aclmowledge that as a condition
of Building Permit g . all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed soH&w=W
disposal facility,as defjnad by MGL c III,S150A.
The debris will be disposed of at hl(J a T 04 S 1prt F T 10
Location of Facility
Srgoamre of Permit Applicant Date
FULLY complete the following m&=atm
(PLEASE PRINT CLEARLY)
Naas 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 Muct ue be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL clX S 150A, and the building permits or licenses are to
indicate the location of the facility.
G,
' �Ommottu/11�Wa 0��o�ac�iueatfd .
b •1JaP.a1.+.a!o/�.fifwaf�ssl..ts' .
booUla,�raSa.l
�.ala 1 uslssar &dam ///..rJ.& 02111
Conesaeest
Workers' Campenndm Insursnce Affidavit
.1, bbu � �� CVAPTta Iatj
- W101'+ prindpd place of btrsineo ac
do her0y•cer* under she pains and peniftim of palmy don
() 1 am an employer prwAding workers' compensation coverage for my siv*b*se woekleg as
dab isb.
Insurance CempaW NOW Number
I am a sole proprietor and have no one workbag fdr an In any npadq.
() 1 am a sole proprietor, general contractor or homeowner (drde am) and haw hired d a
contractors lined below who-ha" the following workers' ctimpensstion poRden
Contractor Insurance Company/Polley Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Ntmsbor
() I am a homeowner performing all the work rayself.
•I v.aery„ane am a Copt at db auwnww.e N fon-aeeee a+ ew /Moe r mvcwg ar of Ow DU to ce.erare.eetffudeo and ex lire w+eaere
Conrar+ a brown rota Sedan SIA a/MGl I S S can kN se ow beaovioe of abinw afaads cen+oEnt d a an d op eei t. MM antler a++
trn':aarnownrec a„s a cw Dwaswo w Ow inn eta STOP WORK ORDER sir+6w of S I00 00 a ear apiot ese
signed this . 8 day of SU L 2C)o�
.ucrsceiFennitcec ouilasny Depariment
PAUC l ,A ea VARTpNIgrJ Jcensinf Ecare
Seiectmens Office
=eJlth Deparsmenc
-- - ccpr eQe epc :ere 775