9 SYMONDS - BUILDING INSPECTION t1b�
1.9x1�psi f Lf f!{3 APPfgED 8Y T44E
W5.PI=CTDA .PZR TD E► .P.ERMIT $EWG GRANTED
CITY OF SALEM
....".."T.\`
No4l( 6-Zoo 1 y�"� . � `\' Date
mne
Is Property Located in Location of
the Historic District? Yes_No X Building mnncl S
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Re(oof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: A— V-�!,>rmc-v--
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: II
Owner's Name )IcS �e.10reryZO
Address & Phone q C4 r.Av.,jS E (q) fl y1 — qI Ir?
Architect's Name /VZ/}
Address & Phone j )
3/ Mechanics Name 7' C r lvens P w•cx"Ti, Seru LS
Address & Phone 51 Curc�c Se_ ST- ZyW 0
What is the purpose of building? &szlyL.nr
Material of building? wood 57.v,cx-,r If a dwelling, for how many families?
Will building conform to law? Asbestos? by
Estimated cost 16,o00. City License : N A State License # 74,2YS
G S Home Improvement
Lic. 1 ►24Z92.
$ I p ( Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
G` ST-ro aJ �c.robF 2�rs-IeTC-f-�^�c."Turt. w,T� !3 *4
-�`'++�\6r,/ ('_•,� c�..-T' lo ' C-4- i LSD' o Y S`fr�, -'lure.
2x Y 060s-tw, ion
MAIL PERMIT TO: �e�ar.,�� �� Cf 5�.. • � d� SC; n 019-2 0
L
No. z i $ zooms
APPLICATION FOR
PERMIT TO
LOCATION.
PERMIT GRANTED
APPROVED
INSPECTO, ff OF BUILDINGS
Y OF SALEM. MASSACHIJSETT5
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
y0 SALEM,MA 01970
�s = TEL. (978)745-9595 EXT. 380
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�IcCI`II,/S15 A. �p
The debris will be disposed of at:
p Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
1 na mAS l IV2rQ
Name of Permit Applicant
T St,yer�q �rpPCrTL SLr-ulCe S
Firm Name,if any
SI ev'C."Sc 3T 1j4nucrs vr++ dIs23
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 clII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
I
k
C0fnrn0ntustaAk 0f 1/la6iacku6affi
' �:Jeparlanaatl a as lrcciwnla
9 600 ld "L1Iart,,, Wal
James J.Camwel &slon, M"iadh+rut[! 02111 .
Coramrssaona
Workers' Compensation Insurance Affidavit
I, _ i SA"imt; Prom Sen�IccS
faa....r.erreeef
with•a principal place of business at:
si ST �c>^�c1S 1+14 0�923
tcaar�swrsap
do hereby certify under the pains and penalties of perjmry, the
1 am an employer providing workers' compensation coverage for my employees working on
this job.
t QY'n.•FA M. �
Insurance Comp ny Polity plumber
1 am a sole proprietor and have no one working for me in any capacity.
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Polity Number
Contractor Insurance Comparry/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unotruanc mat i coot or Ltta sutemem wis be for coed to the Office 07 Inveatitataom of the DIA for cae ate verwKadan sm that faun to aeeure
cosratt as seaurea under Section 2SA of MGL 15 2 cm lead to the :maornion of crirrinm oenitties corsutint of a nee of tv toi 1500i00 anGor one
ytars'imarttonmtnt v.0 as civi ,",ties in the loan of a STOP WORK ORDER ano a fee of S 100.00 a Oar atsstst et.
Signed this , '� // 1� day of v-Z�-o3
LICtnsee/Fermittee building Departtaeent
licensing board
Selearnens Office
Health Department
`iON CELL _ I - 4400 X4C: 404 c0c -05, =7S
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