12 SAVOY RD - BUILDING INSPECTION (3) rl
14;7r M1AUSTIBE fI .*B--A a AfhPROVED BY T44E
.WSPECIpR PIit1QR TD A PERMIT$SING GRANTED
CITY OF SALEM
No. Date 7 �3 o y
Ward
Zoning District
Is Property Located in / Location of
the Historic District? Yes No V Building a Saves (Zc�
Is Property Located in
the Conservation Area? Yes_No_
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) ' eroo Install Siding, Construct Deck, Shed, Pool,
epair/ eplace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit Ito build according to the following
specifications:
Owner's Name �� _
Address & Phone �a _(Z� _ (q-n- 7yy - -7
Architect's Name
Address & Phone
Mechanics Namepit A
Address & Phone (1-a) g(ZI g64q
What Is the purpose 61 building? eeSi c\Jc� — Gi's L ',1..
Material of building? 11 a dwelling,for how many families?
Will building conform to law? Asbestos?
-A
Estimated cost I�,3 ea City License r state Ll
�3!Rom Improvement «� —
Lic. i
a
X
( J ure p icant
SIGNED DER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE ((DONE
asnL.�l� r'-ocs� SI,,,.c1eS
MAIL PERMIT TO: five),/
.t
No.
APPLICATION FOR
PERMIT TO
LOCATION II\\
U
0
PERMIT GRANTED
19
AP OV�D
INSPECTON OF BUILDINGS
� � , COmmonrurt64ILOf irlLWaGhWt�d ,
b �.p..re,.at��.1.�wf..�tt:lala•
l'boo w.A.11.Street,.ma 1 caaoas M.rs" 02111
C.daaeaOW
Workers' Compensation Insurance Affidarrk
. . wl*& principal place of business at:
(`� c.�'�Sla,., 2� . ' � .•�1�. e�LA of � � s '
. . •ra•rars �
do bomby'cettfly under the pains and penuihies of perjo y, thm
1 am an employer providing workers' compensation coveraft for my cm:pIvy**s working osl
this jeb.
/ 7, % S3:1e.
Insurance Company, Poky Number
L
I am a sok proprietor and have no one working fdr me in any copeck►.
O I am a sok proprietor, general contractor or homeowner (drde one) and haw his the
contractors lined below who-how the following workers' ctisnpertsatioa policies:
Contractor Insurance Company/Poky Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Poky Number
0 1 am a homeowner performing all the work myself.
• I vw.ayime our i eery e!dir wan,m we e, ferwwoed a ew Offeo M lorc4mves of ON DIA ka colors"vrevAbdw mw ON hire a we
cc air n r„mrr.onoa S,cian 2SA of MGL 1 S 2 can kid w ow armored of oiwnrr osaade cxa.irrt eta h"of w roi I.SODAD omVer ee,
tram'imerwnn,m a va a dti aeuwa w the knee ors STOP WORK ORDER sm a hw of S IOOAO a ern's"irt se.
SiEned this • f� day of �, /,i _ �o y
ricers r erm ouilding Department
centint Eoare
Seieamens Office
.-�,calth Gep;mmen*
_CC Y . - 404 ape, _ee, 775
PUBLIC PROPERTY DEPARTMENT
. 120 WASNIN9TON STRENT. 3RD FLOOR
SALEM,MA 01970
TEL. (976)7464695 EXT. 360
FAX (976) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ.c 40,S34,I wJmowltdge that ae a condition
of Building Permit M_ all debris resulting fiom 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 Ii4 S15M
The debris will be disposed of at
Location of Facility
t ,
i =1cft
cant DateFULLYollowigg inf rush :
(PLEASE PRINT CLEARLY)
�.
Name of
Permit Applicant
Firm Name,if gay
n51e ever wS
Address,City&State
The above statute requires that debris fiom the demolition,renovation,rehab or other
alteration of bnildmg or s> wtlm be disposed in a p u Wly-licensed solid-waste disposal
facility as defined by WX ca SI50A, and the building permits or lieenaea are to
indicate the location of the facility.
' j