16 SAVOY RD - BUILDING INSPECTION (2) ,: l � S
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IdSAECIt�H ?31gR D aBiNR GRANTED ±`
CITY OF SJLEM
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BUILDING PERMIT APPLICATION FOR.
1
Permit to:
(Circle whichever apply) Roof, Reroof, install Siding, Construct Deck, Shed, Pool,
�1 RepaldReplace, other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCEp"
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
Specifications:
Owners Name $-ce Z)`1 (q 53;ta(.ID,
Address & Phan Gi-, &, Lb�4 q a 5 -'7 A I I
Architect's Name
Address & Phone
Mechanics Name
Address & Phan
whd h b pupow dbaw ;;
waww a a� 1 w.dw«wp,for how many bmMn?
WE bWkRq oWonn a low?
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aar Inpro►rnt
Lie. /
Signature of Applicant
SlGNgFA UNDER THE
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
i
° MAIL PERMIT nau"'D�mo '
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NWO.'
APPLICATION FOR
PERMIT TO
Gjr^yQ ofr t� �ln✓ /�/
/ /
LOCATION `/
G G 7�✓�N /Y en
PERMIT GRANTED
APP OVFD
INSPECTORAOF BUILDINGS
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Workers' Compensation Insurance Affidapit
1, 'DAN ke i —rr-e Mb lay
. . w'ith.a principal place of business at:
M r - I'rd cs
. . toot
do hereby'certify under the pains and penalties of perjury. thm
I am an employer providing workers' compensation coverate for my employees we'rkin on
this job.
LtDe -, x mu4u" _![ s Co Vt1C ]3IS31 �' t(ofa
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation PC Cis :
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Polley Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoencana aae a caor of die avamem WE be fon.arasa w dw Onca el InbdiaW of dK DIA la Cove ate VerWadon.race am Nine m MRe
co.arara .rewrea unow Secdon SSA el HCL 152 can kad w du inoofwon of cnnnai oen.an eonaadnt of a fwe of m oat I.SOO=ender oa
"an, i:.oroonnent v-A .eni oenahle it the loan eta STOP WORK ORDER ana a fine of S100.003 4M SOMA WA.
Signed this , day of
ictr ct/Fcrrittct cuilcing Gepar-cr-ent
lictruinf Eoare
Seiectmens Office
r
PUBLIC PROPERTY DEPARTMENT
� 120 WASNINGTON STREET, 9RD FLOOR
SALEM,MA 01970
- TEL (978)745-9595 ERT.360
FAX (078) 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 III, S150A
The debris will be disposed of at n n
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
DABIe
Name 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 structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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