6 SUMNER RD - BUILDING INSPECTION (2) C
T.
-PEA IS10106 CBE + 40 OVER BY T44E
d JNSPE H JL1R D',)# PEBEING GRANTED
CITY OF SALEM
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Is Property Located In Location of
the Hlstodc DWdct? Yas_No Building
Is Property Located In
dw Cormrvatkm Area? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Re Install Sidin Construct Deck, Shed, Pool,
Repair/Replace` tithe .
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCEBf IMIS
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name
Address & Phone
ArcLftect's Name
y Address & Phone L 1
Mechanics Name
f o g Address & Phone /��` ,vim sera 6� • �is��
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What Is Bn purpose of bdldkrp? Zds
(3 t iat«w of bWlaw G orb i=.�'F H✓ I a dw:fty,for how many farrill Ili°
WIN bulldkp conform to law? S Asbestos? nid
Esftated cost. .d Cay L►oaue r N P` State LION=M
Roma Improvement
Lie. 1
Signature of A#11daht
SIGNED UNDER THE 11064
OF PERJURY �I
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: 0
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APPLICATION FOR
PERMIT TO
LOCATION
{
PERMIT GRANTED
AP�°YfD
INSPECTOK OF BUILDINGS
s
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PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RO FLOOR
C SALEM,MA o1970
TEL. (976)745-9595 EAT.380
A
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-waft
disposal facility,as defined by MGL c III,S 150A
The debris will be disposed of at
Location of Facility
Signature of PernAvolicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
wi011�h 2-4"-e coU6
Name of Permit Applicant
Firm Name, 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 cIlI, S 150A, and the building permits or licenses are to
indicate the location of the facility.
�iJ n�nsnt I
Coee�7mmonun:aWteO1' f.rlaflbnAthWaui
S �Jepartaaa+tl o/..7da�4ia(J'�eew�a.
600 ryW-16,I�3111dl
JamealeamWN &I., ///aaaaJw.6OZ! II
Cotawasswar •
Workers' Compensation Insurance Aff-ldapit
.la C/JCU.-c'.�D �/3•�CQ U�. -
- rater
. . wither principal place of business at:
. . - tutrfatr.ra+q •
do hereby•certify under she pains and penahim of Perjury, thaC
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
In ranee Company Policy Bumbler
I am a sole proprietor and have no one working for me in ally capaehY•.
I am a sole proprietor, general contractor or homeowner (circle orasMaiwed have have'.red the
contractors listed below who have the following workers' comp D
Contractor Insurance CornpatrylPoitty Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I unotewno that a copy of that wtaetec.a>t ion wftd m ow Ofrce et In.e6c39otr of All DIA 1W co.erate'"w2tiew awe OX(sort m seem@
eo.erart al rroveee unOtf Seeton SSA of MGL 15 2 can W15 to nr iinowtwtow Of c4rwnat oenattra eorwting of a frr of ne w41.5000)wWw Om
1tx7'inaroonTtnt y tN at ciri mrAda in the loan of a STOP WORK ORDER ana s far of S 100.00 a ear ap.oc tat
Signed this o� day of /✓xl —
ccnseci F it ell cuilding Gepart ent
Seen ing ! cart
Seiectmens Office
�,e:lth Gepsr:rnenc
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