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13 TEDESCO POND PL - BUILDING INSPECTION Y•- 3C) �1ss C K Ir}5' flltNSiMWT-OE fiLe"W MAPROVED BY T+IE Wp=IDA,PFLrt]R TD A_PEANUT RE MO GRANTED CITY OF_SALEM Date •l Is Property Located in Location of — //// tlw Historic District? Yes No_ Building lloYeps[o Is Property Located in On Conservation Ares? Yes No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: 4�So (OA-Cl te4- A*-,Tr- 0)-TZF- 9A M AC PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING 3 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following 16 specifications: Owners Name <?A fir_ Q019okw Address & Phone k)c*-)b 4[.� (94R) Sw ©3 r�1 ' Architect's Name Address & Phone L ) /Mechanics Name / Address & Phone 1� G,� S ( '1 ) �9)9 S�3-3 What Is the purpose of bonding? Material of buildrig? If a dwaft,for how many families? WW WON cordorm to law? Asbestos? Edmated cost aSQQ0,— City license• N P' State Licertee K C—S OSL -1�9 � Farp:ocr�aat Lic• 0 Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE -Q 10 grA-L( I-0-Cbi� J C-A : c !�c� MAIL PERMIT TO: r' N07 I APPLICATION FOR PERMIT TO Al LOCATION 3 � ; PERMIT GRANTED 2.0 APRR �D INSPECTOR OF BULIDINGS i \ o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1 SALEM, MA 01970 " TEL. (978)745-9595 EXT. 380 .i 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-waste disposal facility, as defined by MGL c III, S 150A. The debris will be disposed of at: �b?r—, 1 �u 10 G Location of Facility _3 ( © o20os Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) 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 cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. Myer.�cfrursrrecrs[ rrJ irsugarf lar HCC":aCrrt.9' 011A rBsafF fffess 600 Washington Street Boston,Mass 02111 �n • Workers' Compensation Insurance Affidavit name: y� lJl _ m location: LLL �EL &r Cif_ �_F)(a NA I am a homeowner performing all work myself. phone# ❑ I am a sole proprietor and have no one working in any capacity ® I am an employer Providing workers'compensation for my employees working on this job. 7-7 x �r. r ho eJf , ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who +ilia have the following workers'compensation polices: ]" d com an :natnas ,c � .; Vi addre8s. p 777 v. Mine-i{: a corn 9 +�`e:�•� x r a ,� ; +� I is a }Zvi aRx3ca"=k'.3'*s��• 6. - s. ir` ^^i v a 60 i � <a 4 Failure to seeare coverage as required under Section 2sA of mcL 152 an lad to the impmifion , one ycsrs'imprisonment as well as civil Penalties in criminal io the form of a STOP WORK ORDER and a Gne of SI00.00 day against p ma understood that s Penalties to S1.500.00 r copy of this statement may be forwarded to the Office of lovatigations of the DIA for coverage verification, too hereby certify and, 1, fs and penalties of pe-rJury that the information provided above is true and correct. Signa[ule�_ � k'�_,\ Date Print name �} M fR^mo one# o d.' ` I�Q Ph official use only do not write in this arcs to be Completed by city or town official city or town: permithicense# Buildingcheck if immediate repponse is required ❑LicQselcontact person: ❑Heaphone#- Ofh