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i43%M61AWINOEfi..ma -P- OOVED BY T44E
JNSAECT�A FJTAP. EWG GRANTED
CITY OF S tEM
NO. � �� r Dab al
:
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ft Cara w@W Am? Ya_No X
BUILDING PERMIT APPLICATION FOR: '
Permit to:
(Circle whichever apply) Roof, Reroof, Install Skligp, Construct i Deck, Shed, Pool,
Repair/Replace, Other. a-os A k�f�
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCEBIM
TO THE INSPECTOR OF BUILDINGS:
The undersigned here Iles fora permit to build according to the fol
� by applies fre g kwrh0
specifications: \\ `
Owner's Name 1 Y1a�crWl �cvctS
\a c�roo�oo, Wwy ��S) 1yS-I ll��
Address & Phone ��Q�h�MF1 -=-10
Architect's Name �rr�c��Q1C1 �rvos<valL�rk �+vC
Address & Phone 0`v �^�1W pkg33 6-18) 353-C�a�-7
Mechanics Name
Address A Phone n\S1C
what Is ttw purpow q buiklYq? \C-- 0
MnW W of bWWnO? q a dwaWN.for how mmy Iornow?
WN buildup cordomh to Ittw? `ISL Mbega? CS
ENYnued $IWA m e MCSO l r:
Scant luprmm
96 Lie.
. i Signat of App11 I i +
GN ND THB
E,
F P
UHT „lu
DESCRIPTION OF WORK TO BE DONE �
c� �4c�w„ �wr� ���bro ihacryQ5 Vxa�ca` n
00:7
.Ah
MAIL PERMIT TO:��rv�//�rl44 �j S•aZ�vc .000 .1
i4.R .,
.,
APPLICATION FOR
PERMIT TO /
�ie /'C ri`Or /S Ch ho✓si7'��o—f
LOCATION
PERMIT GRANTED
AP . OV�D
INSPECTO OF BUILDINGS
•
42
s
r
i L.,. i�
COlrimoniv�ahk 01 MW-,aCL..t&
-29paAFAS i o/9eLOwf�4C6
sl 1,
600 ryW&1,,j"-3L,,J
JIM"J.Campbell �oslow, /l�auaekaswW 02111
cotrmtss+otw
Workers' Compensation Insurance Affidapit
1,
. . with.a principal place of business at:
(Ckrdaaa✓a4)
do hcreby'ctnify under the pains and penalties of perjary, than:
I am an employer providing workers' compensation coverage for my employees working ein
this job. `
.N\• �tvwlSv.�• tCp• ,nn-tUo00\ao0y
Insurance Company Policy Number
I 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:
Contractor insurance Company/Policy Number
Contractor insurance Companry/Pol'scy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I71he rneencint wt ob"r es.,vrm r.a br for arme W Ox O(Gcr of Imatirawm of')A DIA la co'rr&It codon Iota��r 1O WWI
co. nt y tr rro U" �ecoon ISA of MGL 15 2 can kao to tM"rnoontton bf cfkr""'otnnua cora tint of a (w of w ret I.SOOJDO ander 9"
r<an"tarso vo>s ' ' to form of a STOP WORK ORDER ano a frw of S 100J30 a eat' 8906M WW-
Signed chis day of Y� foo
i.
LiccnseeiFcrrittcc Euir'aing Depa n,ent
jcercinf E.oare
Seieamens Office
re<Iz!: Gepa!-mer'
PUBLIC%ROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9646
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 ibis Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c 15.,0A4
C°
(gyp SI A 1r-1
scok
The debris will be disposed of at rn Y�1� 1`1`10
Location of Facility
a�
i o t licant ate
co flowing information:
(PLEASE PRINT CLEARLY)
S'.A V�.)a�j –�—�� \CA V nz� ct r
Name of Permit Applic alll t
Firm Name, if ahy
IS3 C"'C
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.