10 VALLEY ST - BUILDING INSPECTION �Ild.l.�al!`I l!UT•.�Ih
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111110111*'O Fi-
VI-D BY TiiE
AISP=,dB IQR D 1 BEING GRANTED
CITY OF SALEM
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Is RopM1y Lomm in Location of l U U
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Cirde whichever app�Rercof, Install Siding, Construct.Deck. Shed. Peol.
/Replace. Other.
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROC$
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby, applies for a permit to build atxording to the bUowhp
speWcations:
Owners Name C7�-h A/ Al.
Address A Phone lit
Architect's Name
Address & Phone
Mechanics Name l J �iir
Address & Phone 92 2- 2q i
What Is to p Wm ar hultEW
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EdknaWwd.
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NMI Iapraw . t 7
'-Signature of t
SIGNED UNO THE
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
1
MAIL PERMIT TO: IL 61 -LC n7
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APPLICATION FOR
PERM TO
LOCATION PERMIT GRANTED
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APP�Vf D
1/!/r, I ,
INSPECTOR'OF BUILDING
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6
,' 1J,parlaaa.i a/.lad�rial./�ccia�t .
Jamea a eamood �aslsa. M..A..Ib 0.111
Caaanssnow
Workers' Compensation Insurance Affidapit
t
. . with.a principal place of business at: p
Ica.,dwdalrr
do hereby•certify under the pairs and penalties of palmy, thm
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in Bury cspaaty.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation polieks:
Contractor iruuranie Comparry/Policy Number
Contractor Insurance Compatry/Policy Number
Contactor Insurance Comparry/Pol'iey Number
() I am a homeowner performing all the work myself.
1 vnoeruand tot a cam of the wwnem we be for wmt to d e O1rce ei hnedeaoom of One OtA 1« cc. are•eeiicaden a"d Ytx!t➢•te to beeare
co.erart .reavrea under Section SSA of MGL 15 2 can kad to the inoeaetien Of cre"nat oetutde cor"tint d a hm of we w4I.MXLW aeWw we
nan'irnorwnm nt W ve as ci i eeiwtke in the Zorn+of a STOP WORK ORDER bete a ix of 100.00 a ON ,µ 019 tot.
S1 ed this • day of
nseei F crrniute
t uilcing Departs eat
:�censing Eeart
Seiectmens Office
nc:ltl'� Gep:!-men-
=cis, �,�
PUBLIC PROPERTY DEPARTMENT
r` 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
- TEL. (978)745-9595 EXT. 360
FAX (976) 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 IIIlL S 150A
The debris will be disposed of at: LJ �/y�'J
on of Facility
2 d
Signature of ZthO
cant Date
FULLY completeng information:
(PLEASEEPPRINTY)
'
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.