42 SUMMIT ST - BUILDING INSPECTIONI
Cite D� a�PTTi, a �aL�U�Ett
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building ,;.
Building Permit Application For:
`(Circle whichever applies) Roof, eroo Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other: y
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:
Owners Name: Contractor: { �y
Street a Cin Street Cit'y/ /
State—� Phone ( ) State Phone
Arcbitect: City of Salem Licit L9
Street City State Lic#OO "' HIP#
State Phone I Homeowners Exempt Form__yes_no
Structure: (please circle) Single Family, Multi Famil Other
Estimated Cost of job S /1 5 00_ /
Will building confirm to law? yes no
Asbestos?_yes-4.1—no ` ^n
Description of work to be done:
Drawin ;Iktion,
no Mail Permit to:
W
x e2 7�1�
Si store o SIG D UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BEsCOMPLETED WITHIN SIX (6) MONTHS OF PERMIT ISSUED DATE
Department use only: Penn4#� Zoning Map/Lot-
Permit fee S
COMMENTS:
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Commissioner
Workers' Compensation insurance Affidavit
I
I,
with a principal place of business at:
Iuivn Waal
do hereby certify under the pains and penalties of perjury, that:
0 1 am an employer providing workers' compensation coverage for my employees working on
this job.
/Vo
urance C mpany Policy Number
() I am a sole proprietor and have no one working for me in any capacity.
i O 1 am a safe proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation poliden
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I undenune Chat a CODY of the statement w10 be forwuoeo to the Office of Invesuctoom of the 01A for coverage verdlation via ULU Wkire to_taan
coverage as«autea unoer Section 25A of MGL 152 an seaa to the miccattan of mmma oenauH consoung of a fine of u0 0 1130040 Nwor ant
vean•mtoroonmem as wen at cm oenamea in the tom of a STOP WORK ORDER ano a fine of S 100.00 a aav ag atst me.
Signed t fs day of
nsee/P hn a Building Department
Licensing Board
Selectmen Orfice
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 37S
C�itg n� IIiPm, II��aLhusP
public pruputu aspartmrni
— %libing BxVnr=rnt.
coat e.igm scan
508 71i=9595 E0. 369
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MCL c 4allsdebris acknowledge
fromthat
the a
condition of Building Permit # by this B
construction activity g uilding Permit shall be disposed of in
a properly licensed solid waste disposal facility, as defined by MGL c III,
S 15OA.
The debris will be disposed of at: locat� f'n'a;itv
Sig ure f e t/ licant
Date
Fully complete the following information:
Please print clearly)
Nam of Pe t plicant
4FiNaime, if any
20
idjdre—ss. City 6 State
The above statute :e?uires that debris from the demoiition.. renovation. rehab
The
astatution. of building or structure be disposed of in.a properly
or otherlicensed solid waste ldcsepnseslafacility
re to icatefthe dlocation by r-GL cofi l as
thefacility50A and tatt
or
building permits