81 VALLEY ST - BUILDING INSPECTION fiOlU T-BE f+G--AN0 APPROVED BY T44E
.11IMPECTDA ,PRWR TP.A.PE 3MT.B,EWG GRANTED
CITY OF SALEM
��NU�:
No. ;?`�� ����T� Date eg`'9'U5 I
P`
\9�MIN6{�y
Is Property Located in Location of /
the Historic District? Yes_No Building 09l41X&r,Z 52/ ,
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, nstall Siding, Construct Deck, Shed, Pool,
Repair/Replace, t er:
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 �A&)
Address & Phone _Q l Ui �>• 5� ( )
Architect's Name
Address & Phone ( )
Mechanics Name out
Address & Phone t J� 7 •a(( �S"9 _ { �� � Ii) �l 2 2 U
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?Estimated cost City License# N/0' State License # 0 3F J - C
i� Home Improvement 7
Lic. / l�� �r� Signature Xu 4c of Applicant i
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
I/t ti� (s�D�'
MAIL PERMIT TO: A�4 13 "Y'
•1
NO
R' 9-
APPLICATION FOR
PERMIT TO
1&5,?V 1. tl%yf'& s/a/.ya
LOCATION
PERMIT GRANTED
APPROV D
,
INAPIECTOR OF BUIL INGS
' /I
�
�ommanwr:a h o 4m:sacL3eff6
n
5 �ePa�lma.s/ o/9,tL.,t<iaf..�«�:ny
1 600 Nwhmt.11o.r Lae!
James J.CamooeB -
Con-.rtusswW
Workers' Compensation Insurance Affidavit
tain.,�„er•it.tf
with-a principal place of business at:
icans....iyq
do hereby certify under the pains and penalties of perjury, that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any opacity.
1 am ole proprietor, genenl ContnCLor or homeowner (circle one) and have hired the
contractors Sit a ow who have the following workers' compensation policies:
"4y)te— 5UI-L , LA)L.2 d eel o
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unaencano wt a copy of ft suttment wig be fors voeo to the Offiee of Imestitatrent of the DIA for coeeratt eeeikation vw uut facture to aecwt
cow;ratt x rtourto unoer Section 25A of HGL 15 2 can ioo to the inpostipn of crrkriiroi otrunies cor"tint of a fine of w ce31,500A0 anWor oat
rears'insoruonn+ent a.xg u cia oenafutt in the loan of a STOP WORK ORDER ano a 6"of S 100.00 a an atainst me.
Signed this , �p�� _ day of
\ % r
Licemee/Fermitih Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403 , 404, 405, 409, 375
��aYT ;' OF SALEM. S�LASSACHUSETTS
PUBLIC: PROPERTY DEPARTMENT
e e 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
�Gnmu 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,S150A-
The debris will be disposed of at:
Location of Facility
o `0�2--0
nn
Signature of Perini phcant 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 I50A, and the building permits or licenses are to
indicate the location of the facility.