38 STATION RD - BUILDING INSPECTION (2) fLm81Nt16* BE f�LD0OVED $Y TiiE PEWMG GRANTED
CITY OF SALEM
Dab
k Property L.00ated in ✓ Location of
OWHlatodo Dhddd? Yaa_No_ Building
+err'
Is woP.ny Located to
VW Cawrvatl9n Area? Yar{_No L/
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Remof, Install Siding, Construct,Shed, Pool,
Repair/Replace, Other.'
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCfl SI M10
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Ownees Name
Address & Phone 3 `� �t+o� SJ _& ( )
Archhect's Name
Address & Phone ( )
Mechanics Name m a R, 7aou e, /�fc ,
Address & Phone .3/ ff?i 1 ya3- 7l;Z6 7:
What is Vo purpose a euwdrq? /�rs�,t.s.� ,,,;,;:,•„'
mftw or Lx11dUq? 4.1v a D B a dw@*V,far how many hmaea?
we tv np oordorm to taut? Aabatloa?
Eatt Wed ooat. /Soo 0 CAY L.W rw o N k data lkanw• 6 3 11
Hume 9 �ro�nt Ue. g y
Signature of pliant it
SIGNED BE THE
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
uU N e3(.JOG Op l
MAIL PERMIT TO /l41 5 t 01�-�roi✓ ��
3+
No
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
FIOV�D
INSPECT. OF BUILDINGS
S
COmmonwt:ah 00 l�lal�at etL'1
1r I
6I
James Icamooss &dow, ///.asaahauA 02111
Cammssaw
Workers' Compensation Insurance AffidaAt
� l
. . w'1{h.a principal place of business at:
3t Slice �roVy 2 A
. . (tavise•urav) •
do hereby'certify under the pains and penalties of perjury, thoc
() I am an employer providing workers' compensation coverage for my employees working an
this job.
Insurance Company Policy Humber
I am a sole proprietor and have no one working for me in any opacity
() 1 am a sole Proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policks:
Contractor insurance Compatry/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoer "that a coot of tho anacm wS be for aroso to tht Once of lmodtaoont of the D1A for ce.crate eerwKedon ano am($!r to eeeare
co.era{f as rewreo under Section 2 SA of MGL 15 2 can kao to ":nvouuon of crir n r oens'em corn "% of a hm of m 041.50000 MW W one
rcars, iarnonnxnt m vu at t9.i ""Idej :, tnc lour+of a STOP WORK ORDER a a of S 100.00 a ctar 89 arse.
Signed this , day of r
iccn5tt/Ftrrrnttt Building Departrr cnt
lictnsing Ecarc
Sciecimens Office
�,c:1th Gep:r*mcn'
PUBpC POOPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
" SALEM,MA O1970
TEL. (978)745-9595 ExT. 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 cIII,�S1150A
The debris will be disposed of at: ag 19e
Location of Facility
` U 0
Signature of Pplinit Applicant Oate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
1 �
rr�Kc) J ,,,—4,< ,
Name of PegAt Applicant
aic
Firm N , 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 cI1L S 150A, and the building permits or licenses are to
indicate the location of the facility.