2, 4, 6 RUSSELL DRIVE - BUILDING INSPECTION -Pi*-M OSi'-BE f L-*B 1#D;d'?fxROVEO BY T+IE
U�SIYF.CJCiA t F�lpA PrP'A P.EAIjAJT .13,FJNG GRANTED
CITY OF SALEM
O �+1 4 ,NU �',
No. �.� err � :: ` •� $� Date
T
Is Property Located In O Location of // ✓
the Historic District? Yes_No_ Building e A LSSO�l�/ G
Is Property Located In
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Sidin , Construct Deck, Shed, Pool,
Repair ep ace, 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 ���> `// /�Ilb xriri��S
Addr (/T/) ZIP � 2�
Architect's Name Alf.
Address & Phone
Mechanics Name
Address & Phone 0021 &213 ZM 3
What Is the purpose of building?
Material of building? XMLW6�OL If a dwelling, for how many families?r Of
Nil building conform to law? Asbestos?
Estimated cost 00 City License # N A State License #112J
S Home improvemen
Lic. X
Sig ature Applicant
SINED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
n
G
C IAAAd S
�"
.411
/4k=
MAIL PERMIT TO:�L�%G /�C� �/✓/Y /�' 151'/ /�is�9�
i
.1,
APPLICATION FOR
PERMIT TO
LOCATLON.
21 �U`3
PERMIT GRANTED
APPR f,D
INSPECTOR OF UILDIN S
f h��
-7/2`_1
c�
2--
2_z- '
ii
�'-
t4==-�
� �
k
�l
it
��
,�.
}
r
i OF SALEM. MASSACHUSETTS
Cow b PUBLIC PROPERTY DEPARTMENT
�2 ® 120 WASHINGTON STREET, 3RD FLOOR -
�` D SALEM, MA 01970
;1 . r
TEL. (978)745-9595 EXT. 380
�ghna 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
govemed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
The debris will be disposed of at:
Location of Facility
b
Signature of P 't Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
r I
Firm Name,if any
�
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
L-
�— �orrmonfutia& 0/ 1I/a64achtdetb
y �aparlm.nl d/.Jnduslriaf irccia snLa
//77600wUV�-31...I
James J.Camma f>oalon, Malmstc"11i 02111
Corrmnsoraer
Workers' Compensation Insurance Affidavit
i6�.rr„narnw)
with.a principal place of business at:
itaerfas,w i
dooh hereby'certify under the pains and penalties of perjury, that:
(7 I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Cc mp�m u��19 CO. Ull�G6DOo?86G?�/bGb ro,V 63Idf .
Policy Number
I am a sole proprietor and have no one working for me in any capacity.
0 1 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
0 1 am a homeowner performing all the work myself.
I understand wt a coot of thb natrment wM be ica arced to the Office of Invatigao ges of the DIA for coverage veAk3don and dug faattre to secure
coveratr as reouvro under Section 2SA of MGL 15 2 can lead to the irsoosstion of t:timirut oenatdes corsatint of a ttte of w ttsi 1.500 CO and/or one
rean'imorwo E as as as ciri oenalties in the form of a STO P W ORK ORDER mo a fine of S 100.00 a an against nte.
Signed this G, / day ofIvi
_ r7403
ice se a tie Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: L 17-727-4900 X403, 404, 405, 409, 375