12 SYLVAN ST - BUILDING INSPECTION ,
f" 9E fIL{�-1idD' A?PROVED BY T+IE
111SP,BCTEIR PRIOR Tp A PERMIT BEING GRANTED
CITY OF SALEM
4y- Zoo
No. t�. '�a�.\ Date
Is Property Located in Location of T
the Historic District? Yes_No-Z Building ? Sl
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:
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 �� �/ ��h D 10/d
Address & Phone
Architect's Name
Address & Phone ( )
Mechanics Name Z ec/Address & PhonekfZC�/' PL.> ' //f//0 IL 4 ,4) 23__3 —JAM/
What is the purpose of b e2�/building? i�iT/
°
Material of building? r U O`d � If a dwelling, for how many families?
Will building conform to law? Asbestos? 1l(Q
Estimated cost Z 6 —City License # N A state ucffw #
L D� Rome Improvement o
Lic.
S' nature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE /
�vz STD/� l�//? / ill /,2 /
/9 erI✓��7cPm6)4Z_1�i172'd Gas
MAIL PERMIT T0: 0 C SS/� �� P r-'/Dl! S
cvee_ _V,
/lek/c 7d o/ real
del /- (' y' ' - l 6 - r '�
No.' O Zbb�
APPLICATION FOR
PERMIT TO
LOCATION
/4� ,
PERMIT GRANTED
7/ ,1 (ate 2-0
APP VFD
7
INSPECTOR OF BUILDINGS
f
OF SALEM. MASSACHUSETTS
. PUBLIC PROPERTY DEPARTMENT
J20 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
'?r TEL. (978)745-9595 EXT. 380
Gmra FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge 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,S150A.
Wegg ''(y f'
The debris will be disposed of at: ,(/ � �r; ���r (' �
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
`
Name of Permit Applicant
Firm Name,if any
/ 7�z
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
CommonuiaAk o/ Y&aeackwetL
�epa,Im.n1 a'/19,�,G�f..^aaia:nv
600 WU.a -31,..I
James J.Campo" EJoalon, /Ilaaaae ..(1J 02111
Cornmtsstorw '
Workers' Compensation Insurance Affidavit
(a—raMine )
wich.a principal place of business at:
X/Pi//Cc�O' 'lam✓ C1 l C�n�
tcnnst+otalr)
do hereby certify under the pains and penalties of perjury. that:
�1 am an employer providing workers' compensation coverage for my employees working on
this job.
,-
Insurance/to mpany Policy dumber
1 am a sole proprietor and have no one working for me in any opacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Doi
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I understana that:a.cony of the wtemtnt wa be for arced co the OBce of invadt+wns of the DIA lot coverage vtrWKadon and vat bi ee b*are
coverate as teddrea under Section 2SA of HGL 15 2 can lead to the itspostdon of crimnm otnanks corsttdnt of a !rat of ao toi I.SM-00 and/or one .
years' inoruotrnmt a xo as cKi oenaida in the form of a STOP WORK ORDER anda fine of S 100.00 a an alaiat me.
Signed this . /) j day of ( J�
,q �_
Li ensee/Fermittee Building Depai-Er-mcrrit
Licensing Board
Selectmen Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617 727 4900 X403, 404, 405, 409, 375
✓-
Board of Building Regulations and Standards'
HOMEIMPROVEMENT CONTRACTOR
-Registration 103158
..•Expirat+on6,;l/6/04 -
_ Trype?'Indlvldual•'
FREDERICK E..REID -
Frederick Reid ' --
104 Green St
Woburn,MA 01801 -
i Administrator
0