5 VARNEY ST - BUILDING INSPECTION • 4i. ,
L QS E�EffLfi �AtJ�I','PPROVED BY T41E
U�SFTLIRI1DR rp;J1 pFIT BEING GRANTED
CITY OF'SALEM
lO 2 �o0y Date 0 0
No.
Is Property Located in Location of
the Historic District? Yes_No Building GC t
Is Property Located In
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
epalr eplace, ther:
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: pp 1
Owner's Name f�� �ar/� �c� j S0.
Address & Phone 5 �/a�.,T S�-. (1,78) -146 - O S 2-7
Arc ecV
ddress
Mechanics Name ZAA- Now-e.. S ru'US� -Lh(,• '
3` s &r-& t.wo0d sk,
Address & Phone \i6rr & .%A-< M 4 61168 (561A) -154-6186
What is the purpose of building? I F w!t= 1i
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cost #ZtOb o. city License # N A State r
co Hose Improvement
ZO lcsr7 Lie. of I26 64 Signature of Applicant
9 431 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
t.I�r% owst n o -S- t1i U6 174
0.3l�
b
MAIL PERMIT TO: Nome., Wye s,r'
i
i.
No. (v2
APPUCATION FOR -
PERMIT TO w
LOCATtOt
PERMIT GRANTED
Z -
INSPEGTOR O:. BUILDINGS
• J
OF .SALEM. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
3 120 WASHINGTON STREET, 3RO FLOOR
70 i' SALEM, MA O 1970
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,QS150A.
The d ris be disposed of at: 1\Q.SCA 0.y A yS Ma
Location of F 'ty
Signature of emut Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
�1�� �oy�-e Se.�v ► �S
Firm Name,if any
Address, City& State
MCk . 01 bbl
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.
r
Commonwaahk o/I /&6eacht"R.6
jv
J' eparlmenl o`.J�w..lriaf\�jsccia�ihi
//�� 600 �ywyy��al�lon Sirsel
James J.CamDoel f�oalon, ///ataaachaaaella 02111
Corr+ntsstorw
Workers' Compensation Insurance Affidavit
Ir La� �Jer a _ of ^MA 40rN Seryeces IQ(
with.a principal place of buussiiness\\ at:
32o0 cxb�
tca4twwaaq
doZtrecertify under the pains and penalties of perjury, that:
( an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Ccmpany Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I unoerstand mat a coon of this wtenwm vria be for aroee to the Office of Imssdrauont of the DIA for (overate Ywi radon and trot WWI!a*We
coverart a tea49ed under Section 25A of MGL I S 2 can Itad to the :nocution of criminal oenaniet corsudnt of a fete of tto W41.500,00 and/or one
years,WW ent x-A as CW penalties in the harm of a STOP WORK ORDER ano a fine of S 100.00 a oar a0rat mt.
Signed his day of —TV 2.4 0-3
1 '
Licensee/Permittee Building Department
Licensing Board
Seiecsmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617.727-4900 X403, 404, 405, 409, 375