88 TREMONT ST - BUILDING INSPECTION APPROVED BY T44E
fL�iflSlMli6T�E fILfB��NO .
JpIS,PACIAft P9WR TD A.PEF1WT DING GRANTED
1 �\ CITY OF SALEM p
NO.
� U ) V i Date 2S 0�
is Property Located in Location of
the Nistorie Didfict? Yes_No_ Building
is Property LocaW in O %6 %/Z p FM°ti T
ft Cormemadon Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, tall Sidin 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 r C /-//}rzy Mbt>L Z 0 E
Address & Phone 7�z vf^-r0NT ST (0-� 74'— �642
' Architect's Name
Address & Phone I: 1
Mechanics Name �jL,ti
L/ C p 3 a,c Ai �ev A/Cr5go 2d
Address & Phone
What Is the purpose of building? 121 5 /-bZA'7ZA L
MaWW of bukUs? / A-!-YL Sr-/v g a dwelling,for how many families? /
WN building cordorm to low?
?1 ,,\\ Asbedos?
Estlmaled rx> City License t N k State Lbanse M
Bans leprowment
Lic.
Signature of Ap licant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DRONE Iva
1NST'� t� vrvy� JZ� /A�Cr " a �%?ZctCF4�Z�
C rA veq
MAIL PERMIT TO: B ,�ROEiN CHHOUY
' LHOME DEPOT
4 COBURN RD.
YNGSBORO,MA.01879
L
.T r
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2.0
APP D
INSPECTOR OF BUILDINGS
o
i
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
s y. SALEM, MA 01970
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 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: �7 y� �e? £iywoOh Si
Location of Facility
Signature of Permit Applican 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 cIIL S 150A, and the building permits or licenses are to
indicate the location of the facility.
Th(! care'!mor-1 vcafrh a
Depgrfmcnt of In&s0ent A ecedents
600 Washington Street
A.
Boston, Mass. 02111
Workers' Cow M52tittn Insurance Affidavit:Bujld�!WiTlwnbin Electrical Contractors
n E)LU\j C H 1-+0 LAy
address:
city C-f se>0 P,6 state: MA zilx_0_10� i)bn,# q 7&-50 —557469
C -A _S I
work site location(full address): Cl� '/1Z?VM 0,4j r—
❑ I am a homeowner performing all work myself. Project Type: EJ New Construction ARemodel
❑ ctor and have no one Forkin in an ca F I am a sole propn M Buildi; Addition
AM MWAWAMMAWMIMIM
IMamManM 01W M
employer for my employees working on this job.
eons nsury name:`1 47Ja1;Q. Zoed;,O-�: �A-k e
addreA. qq go&
one.
lea f
IV A
I am a sole propridor, general contractorfor homeowner(circle one)and have hired the contractors listed below who
have the following workers'compensation p6lices:
10MD suite:
iddreni
city: . .....
e .
i M � :.:� !� .. ..: . . 111% '1 In,
...... .... ....
sumps veenve:_
ddress:
eft
iniunneeco.
MAP=SM
FeUture to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of cri-l-al penalties of a fine up to$1,500.00 anallor
out years'inyarlammunat as mH m;civg penaltim In the[am are STOP WORK ORDER and a fine of$100.00 a day agolust me. l understand that a
copy of this statement may be forwarded to the Oince of Investigations of the DIA for coverage verifleation.
I do hereby certify under th epain s and pen aides ofperjury Our the information provided above is true and correct
Signature Date
Prior Dam 11�0k!_ —Phone# 7 67 62
offtelml we only do not write in this area to be completed by city or 19"official
city or to": permit/license#_C]BuBding Department
OLIcausing Board
[I check if immediate respons,c Is required Elsoicetmews Omec
Deportment
contact person: phone#;
(mbef Sq*2M) t