15 TURNER ST - BUILDING INSPECTION (3) -PLik 1*VSTaE fiL{O-ANG APPROVED BY T,HE
.WSPECIDB,PFWR TD A PERMIT BEING GRANTED
CITY OF SALEM
No. Dat._..I1 l d�J
�..
Ward
Zoning District
Is Property Located In Location of
the Historic District? Yea No_ Building
Is Property Located In
the Conservation Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) oof, eroof, Install Siding, Construct Deck, Shed, Pool,
ldReplace, 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
Address & Phone2X
Architect's Name
Address & Phone f )
Mechanics Name
Address & Phone i )
What is the purpose of building?
Material of building? If a dwelling,for how many families?
WIN building conform to law? Asbestos?
Estimated cost 00 City Licenser state Licenser CAL
tie Isproveraent
Lie.
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
V
MAIL PERMIT TO: / ✓ 4 17f to ✓ 0�9
No.
APPLICATION FOR
PERMIT TO
LOCATION
PER IT GRANTED
APP,ROV
U/ 2
INSPECTOA OF BUILDINGS
J CommonluyuiLUL Of 11/a�aC �d
b •1J.paar.e.at�.11raf..�«d..t�' i
600 W.A.16SL-.d
ism"1 Gncom &Al w, 02111
conanaaoa.
Workers' Compensation Immrance Affidsph
with.a Principal of a»a
P V0
do hereby'cerslfy under the paint and penshties of perjury, toad
() I am an employer providing workers' compensation coverage for my employees working cal
d6 Job.
Inturanq Cempasq 01W Numbor
I am a sole proprietor and have ne one working far me In any npacky.
() 1 am a sole proprietor, general comraetor or homeowner (circle one) and haw hired toe
contractors listed below who-haw the following workers' etimpensaeion pogden
Contractor Insuranis Comparry/Poky Nunnbelr
Contractor insurance Compssry/Policy Hmnber
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
• I vae.ntane mat a copy of dib su$#nare.i be fon+areee o on CN%c.et In.eskj owa of eM Dhk for corsrara.alio4a me an lira as W=M
c~atr Al$#woes.near Saeien SSA of MGL 152 ran kad wow in-, -,w d prams oeandn cenONiat Of a it of as aa•i i•S00A0 aaYar awe
rear'inwoonwlrm a vs a dri e.nswiu in the corm of a STOP WORK ORDER ant a far i 100.00 a an spun ML
sirned this • day of 14
.iccrs�Fcrinitttc Building Depa ment
uceruing Eoare
Selectmen Office
=ealth Deparmer,-.
.. - CCC - s 0e 405, e e 77c
UI& PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREaT, 3RD FLOOR
SALEM,MA O1670
TEL (976)743-9380 EXT. 360
FAX (976) 740-9646
STANLEY J. LISOVICZ, 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 S all debris resulting from the construction acth*
governed by. this Building Permit shall be disposed of in a propaly licensed solid-waste
&Wsal facility,as defined by M(3L a I14 S15
The debris will be disposed of at:
Location of FaciMy
Srgrutrae OfPermitApplicant ate
FULLY complete the following information ,
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
V ��
Fifin Name,if:my
Addn et,City dt State
The above statute requires that debris from the demolition,rwovatlon,rebab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by M(Z clA S 150A,and the building permits or licenses are to
indicate the location of the facility.