6 SUMMER ST - BUILDING INSPECTION ' � a
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,PITY OF SALEM
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No. Ul _ZOO Date
r
ah � Ward
AatyyeN% " Zoning District
Is Property Located In Location of
the Historic District? Yes_No_ Building 50 M M i T 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,
Repair/Replace, Other: Vnof
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: q 2
Owner's Name /i�Mli r' lD I A N
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Address & Phone (P
Architect's Name 6A461(A Q I000(:-er->
Address & Phone ANU QAr)C S-)- No,j,¢443 67�-) &6N -O&W
Mechanics Name
Address & Phone op ( )
What is the purpose of building? 9,co •�
Material of building?i/"6P"1V Sh:V�le If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost Jf O 4 S City License # State Licenss�e #
CSL� Home Improvement j lGl 101V'-1
�5 Lic. t 13� Irf3
Signature of Applicant
SIGNED UNDER THE PENALTY
�C�4 -7�tsiy OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: IAafy)
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co CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
a.
120 WASHINGTON STREET, 3RD FLOOR
' SALEM, MA 01970
PG TEL. (978)745-9595 EXT. 380
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 III, S 150A.
The debris will be disposed of at: W()C)&.'VL-NNP_ J e,GaA_�
Location of Facility
/o
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
2) 8�k-e_ 11ZW
Firm Naihe, 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 cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.
is F
�— fornmonwr:aft of 111a6aacL6U6
` �, _�.J.padmaaf or�a�ria(,�?cciwnls
�7 600eWasLIlm �f...1
James s.[ammo.. / .ba, ///as�ae�i+wlb02111
cor..nrssoae
Workers' Compensation insurance Affidavit
I, W I a V, -tom Lo 2d.
-
with.a principal place of
business at: j��
R� �IY�
. Iran/sw✓taq .
do hereby'certify under the pains and penalties of perjury. that
() I am an cmployer 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.
01 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
q E . . C�g'? 60b
Contr cwr Insurancc Company/Pohcy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I une<ncanv wt a every of the uaeemene rjQ be iorv.ar"d 0, the Office el Imotitatrens of the DIA Iw [crestc versfsca0on aw.hat(mete to xeure
cvrerap v rewrea uncer Section 25A of MGL 15 2 can 1"0 ter the irsvosrYon of arsr:"' venmues eorusunt of a fine of em ta-S 1.500A0 awe(one
r<an' 'r..vrwnm<nt n v0 M ciri oe"160 in the20,
f a_/STOP WORK ORDER ano a bu of S 100-00 a cm v9"t me.
Signed this ,�� , }}M l'_ day of ���
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ccnseci Fcmitcte builcing GeparL n'
licensing board
seiectmens Office
c<Ith Gepar:ment
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