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69 SUMMER ST - BUILDING INSPECTION (3) ii'-L� MU i APPROVED BY T*IE IPECTpt ,PF ]R Tp;A.PERNllT.BEWG GRANTED CITY OF SALEM No. 2- ZOO t-(' ,�`� ..�.��'p� Date 23 •a�; T pia MINE Is Property Located in Location of the Historic District? Yes_No Building Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck hed, Pool, Repair/Replace, Other: �f' ir�HlYv.� 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 V � Address & Phone Architect's Name Address & Phone Mechanics Name l /�L Address & Phone e 0jJt,/1/.,�C What is the purpose of building? rl v'x Material of building? ( 6bj If a dwelling, for how many families? I Will building conform to law? Asbestos? NO Estimated cost City License # N A State License # CS D 6J 7S 3 /J� 6 BorneLic. Improvement Signa! a of pplicant 5LA SIGNEDAdWER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE qC orb✓� urn `yl SAI f 1 /r k MAIL PERMIT TO: l9 SomYtt-r- `o No. 2-3'? --20©� APPLICATION FOR PERMIT TO LOCATION, PERMIT GRANTED A ROVFD INSPECTO N OF BUILDINGS f OF 5ALEM. tTrF�nta�.nv {off PUBLIC PROPERTY DEPARTMENT 120 wAsmmGTON STREET, 3RD FLOOR 2 SALEM,MA 01970 TEL. (976)745-9595 EXT.380 �q 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 15,S/150A../ The debris will be disposed of at: Location of Facility igna of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant er cp dl �� er4/rL2S Firm Name,if any yoP 6� �M o�833 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 MGIII, L c S150A, and the building permits or licenses are to indicate the location of the facility. (f0cfn�m0nwt:aR of 1 w6acketb �Jeparlmutl o/.7as"iaf eiGan(J boo 'rrW"LLI"Sillei James I camoees ��O"� //f°�aach4aaW 0.2111 Cormrsnona Workers' Compensation Insurance Affidavit la�a...na.w.mt) with.a principal place of business at: y4PoS� taeras.ar.rsaq do hereby certify under the pains and penalties of perjury, that: () I am an employer providing workers' compensation coverage for my employees working on this lob. Insurance Company Policy Number eK� 1 am a sole proprietor and have no one working for me in any capacity. Q 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polities: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Numbet Contractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. • I understand tnat a coon of"statement wM be foMaromd to the OrrKt 07 lnvodtawns of the OlA IW eoe ant�Oon V4 am UIWC to Wave co cram v «vireo dncer Section 25A of MGL i S 2 can lead to the i+roos,tion of crv*mm cenx&j"cor_wtint of a ham of w to3 i.moo ardor one rear':zoroenc v Kss as eie9 oenalrles in chc loan of a s7OP WORK ORDER and a his of S 100.00 a air ararsst nae. nmn f o .� r � Signed this � � say -Avg - v03 � / e � building Departn ent Licensec/Permittee Licensing board seleamens Office Health Department ;pc, 375 7C ':''SRi COVER4,.0E iNfO... .. . iOh CALL: i ,