81 SUMMER ST - BUILDING INSPECTION f1.lklfSlMH8T19Ef`ILW� APPROVED By T*IE
MSPFCTIB.PRIOR TD A.PERMIT WMG GRANTED
CITY OF_SALEM
No. Date
i
Ward
�. Zoning District
Is Property Located In Location o
the Historic District? Yes No� gnLM;Lng f
Is Property Located in
the Conservation Area? Yes_No ( 7()
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair eplacea Other: P o ye- C t{
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 / I t`TK0
Address & Phone
Architect's Name
Address & Phone
Mechanics Name ) rj"
Address & Phone �j0 �/oj SF_ SfrL - 4 70
r?(�7 g) 7d- 1 �'7!E FS
What Is the purpose of building?
Material of building? If a dwelling,for how many families?
Will buildling conform to law? Asbestos? p
Estimated cost 7I7 nD w City License k state Licenser D n 7 3 5U
Hasa Iwwve e t
uc. 1 1 -7. &natur6
^�1
pp icant
ER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TOBE DONE
of A- I /`- 1 ° '�Z- c- I�
MAIL PERMIT TO: 1 sue' 't '^'�t`�� S�7' -9 :LC-`
' oi�7o
.t
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRA TED
APP OV D
INSPECTO OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
• 120 WAsmjNaTom STREET, 9RD FLOOR
SALEM,MA 01970
TEL. (978)743-9595 EXT. 960
FAx (97q) 740-9a4a
STANLEY J. USOVICZ, JR.,
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge that as a ca xUm
of Building Permit N_ all debris resulting from do construction activity
governed by this Building Permit shall be disposed of in a properly licensed soh&w&M
disposal facility,as def ned by MCX c IQ S 150A.
The debris will be disposed of at
Location of Facility
-7 3
Zy:plde
Permit Applicant Date
the following infomation:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
E Li � i r ND . co t-1 r
Fun Name,if any
Address,city&State
The above statute requires that debris fiom the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MCR,cnI; S150A, and the building permits or licenses are to
indicate the location of the thcility.
i
"- � COmmonul�lar:[h 0 f i►INJO.C��d ,
.� � �.p.a�a..t.�.,7a1ir14i.1�eti...b•
600 W.11.11.Slmd
Jo " ee a 1 Ca. es &do, M..eA 0211/
c
Workers' Compensation Imam Affsduvit
t
. . wio-a princfpai place of business at:
do hereby'certify under she pails and pessiMea of perjury. the
() 1 am an empbyer providing workin' compensation coverage for my stnphsyees working on
this job.
Insurance Company Polley Number
1 am a sok proprietor and have no one workhsg fx ssse in asry espedry.
0am a so a proprietor, general comraaor or ner a octal) aced htive hiesd the
wntractors listed bebw who have the
following workers' eeienpensasbn poQt3nt
Comractor Insurands Company/Policy Number
Contractm Insurance Compassy/Policy Number
Contractor insurance Company/Policy N;;ZWm
() I am a homeowner performing all the work myseN.
• I WROW aae du1 a Call df dO wa"MM we Ce for�are.d as ae OfRc.of Sa.aknoa 0f da DIA Im ceearste nAlrsia ar wn blot rr Iowa
C0.warr a ree0red•maw Secden 2SA of MOL 15 2 can kid so ae Orwom e.of am "a cermde c*nmdm of a tae d so n41•f00:00 aidler lea
roan'6sawwwrmw a no a chi Peurie in me kale of a STO P WORK ORD ER v a s bw of S 1f70.00 a on ap➢at nL
Signed this • � day of Z 2 O
eeiFtnixEet ouiiding Deparsn.ent
ucernsinf Scare
Selectmen Office
--;e:lth Deparcynert
_ . -ccpr .. . _ ace epc _0e 7-IC