40-42 ROSYLN ST - BUILDING INSPECTION No. 2- 1 7 - ZOO'S
APPLICATION FOR
PERMIT TO,
LOCATI N
PERMIT GRANTED
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AP ROVFD
SPECTO OF BUILDINGS
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IdOST'$Ef Lf- �tID,APPROVED B1 T44E
.MMPFXTDI13 ,PFWE! TD A PERMIT BEWG GRANTED
CITY OF SALEM
No. ��� "L acc \ Date
� 4NIN60'�a
Is Property Located In Location of 7 a�
the Historic District? Yes_No Building L/O/SoS r'�L/ S�
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repai eplace 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
Address & Phone 410 Rr,sE/✓✓ <� (7,l�) Soy- 880t
Architect's Name fJ
Address & Phone )
Mechanics Name 4 /A a
Address & Phone ( )
What is the purpose of building? go 5.A c
Material of building? ����//�n� If a dwelling, for how many/families?
Will building conform to law? S Asbestos?
Estimated c� City License # N A StateIdbense #
Home Improvement
Uo Lic.
Signat a of Applicant
SIGNED UNDER THE PENAL
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
nZVY/c,I.Q o/rl AV/-fP LiA✓/ .oeZ -S,<./r / rgtyj 14,4dL' 2 .t/� -e
IC or,,rd/ wNnvoe 1�� �c4Pn/ 11e4iNft<
f� etieo�e �/c✓ /�A-� F;.e�va�� ���/,4re t�/a/Pf.✓
MAIL PERMIT TO: -/- Osr o rTnrtiA �� i 07
$�0 ?�rj q-40'.)s fyNO -4 $ S P,�' .
s =
boo ey'wsaa v11m S1,aal
m James I caooes alnag YYiaa> L.1b 0.2111
cGrmr:,� .
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
ya Ne nr ouaa�
Q r O/9 G 7
. . toer�asu✓a+N
do hereby certify under the pains and penalties of perjory, that:
() 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
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.
I YnOTono Otat a COO, Of"iUtemtnl will de ioM1 arced to the Off Ct of Irrvodtaeamd of the DIA for coearate Verification and enat faiire to seea re
coV atr at redurrd under Section ISA of MGL 15 2 can lead to the imvoution of crinirut oenuties corsutini of a (we at w urs I-SM-400 ww*r one
Years*Ym oOnment a1 r,a at eiA "naities in the form of a STOP WORK ORDER and a nne of S 100.00 a oar atako"me.
Signed this Ad day of
Licc ns Citfcnnittee building Deparcn,ent
Licensing board
Selectmens Office
He-21th Department
c - c 4Ot -04 775
�GVEni�T CG'JrP.1.G iNfO'r:T.-=.iION C�;L-: ci7 -=7-`900X , 0 40 . ,
�o ._. . ' OF �ALEM. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
3 ° 120•WASNIOGTON STREET, 3RD FLOOR
" yp SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
�arn� FAX (978) 740-9846
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
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c]/II/,S150A.
The debris will be disposed of at: %���,v/'� /.�� ��"� ��•
Location of Facility
2 0
Signature of Permit Applicant Dafe
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
/ . Seeell
Name of Permit Applicant
Firm Name,if any
/3.yoa� Uco9�l Sf S;-+4_Ar
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-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.