6 VERDON ST - BUILDING INSPECTION . l
TLTM lY1W LL T1LiEq�T0I TTTQ VED B 1 l
LNSPI= jQR PFflDIR TDk4 PERMIT 13,ENG GRANTED
CITY OF SALEM
No. Date /
7
Ward
neo°' � Zoning District
Is Property Located In Location of
the Historic District? Yes_No P/11 Building ni
Is Property Located in
the Conservation Area? Yes No_Q<
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Ro Rero Install Sidin Construct Deck, Shed, Pool,
Repair/Replace, GN C L a s /z C44-Po a T
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'7&�uY r c le,4 C'v 7-ON6
Address & Phone A-5. 7y0 - vvsf9
Architect's Name
Address & Phone ( )
Manhanic Name elveis Cof-,g77C /goYr"fir! �NST.e✓ens•+
Address & Phone S .sT 4 '3i«g ciC o ( r,I ) 61l;1
What is the purpose of building? FN CCOS IF C'i9a PO ej
Material of building? LUO o0 d.N • STBVC7nLx If a dwelling, for how many families?
Will building conform to law? kc�'.s Asbestos? Aj
Estimated cost Sys, o0 o City License a state ce s 66-/803
Home Improvement G�
Lic. I idylyo
Signature of Wicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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124 /Da was ¢ V//U
MAIL PERMIT TO: 0�'0/477�f ('n1uSr40C7-,"
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REFERENCE: _
DEED: t'6RT: n,9Y7'
PLAN:I.cc- //Bo Z IS THIS PLOT PLAN WAS NOT MADE FROM
TO: - AN INSTRUMENT SURVEYAND IS FOR
3CBTOL) F E A! (LokL 5A V/N 6 5 $AAlK - THE PURPOSES OF THE BANK ONLY UNDER
I CERTIFY THAT THE BUILDING(S)SHOWN HEREON NO CIRCUMSTANCES ARE OFFSETS TO BE
ARE LOCATED ON THE GROUND AS SHOWN AND THAT THEY USED FOR ESTABLISHMENT OF FENCES, .
CONFORM TO THE HORIZONTAL DIMENSIONAL REGULATIONS _ WALLS,HEDGES,ETC.
OF THE ZONING BYLAWS OF THE GI*r1 of SAL-EM
AT THE TIME OF CONSTRUCTION OR ARE PROTECTED UNDER ��Zh F�''t;4Ll, MORTGAGE INSPECTION PLAN
GENERAL LAWS CHAPTER 40A SECTION 7. LOCATED AT#
I ALSO CERTIFY THAT THE DWELLING SHOWN IS NOT ° c;aL 6VERDON STREET
LOCATED WITHIN A FLOOD HAZARD ZONE AS L_ - ' SALEM
DELINEATED ON THE MAP OF COMMUNITY#Z60%02- SMITH > PREPARED FOR
SALcM MA.,EFFECTIVE No '50`3 �1; Ali rfAov y ii�,. CvTo+uE s,
VTE DERALEMERGENCYMANAGEMENTAGENCY. 'o� R � /L GARA M. cuToAE
��155`Ct1VSCALE 1'=So' FcO. /NZc»l
NORTH SHORE SURVEY CORP.
REG.PROFESSIONAL LAND SURVEYOR 47 LINDEN STREET- SALEM,MA
#1758 D
Ccmmonwt:aUh o/ 111a6eaclud¢ffi
6
�epa.lmanl or�adus4ial seeiaa+tla
600 wosk:.plm Si cal
James I amcod Uo,ion, w�leu.ffl 021 It
Corn-russlow .
Workers' Compensation Insurance Affidavit
--- (Go�rev�.erieeer)
wich.a principal place of business at:
,L'Hrogs -g' ; viLL�2ic,� �2�$. oi8ai
. Itagasna✓aaq
do hcreby'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 Dumber
1 am a sole proprietor and have no one working for me in any capacity.
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policies:
d
Contractor Insurance Company/Policy Number
yp-eez
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoeri:.anC wt a Cory of t}iu araernxnr w� o< iorv+aroso m [he Offce o1 Imcceauc a of.the DIA for corerarc rW"don am ehit laaurt to$00we
co�atc ar reoarro unoer Secoon 2SA of HGL 1 52 o irraotm
n lead w thr oon of cr'rrinm otnaues corsotini of a fine of co te-S LSODAO ablo(one
reap' ir..oruonmtnl v.uo a cm oenaluu in thr loan of a STOP WORK ORDER an0 a fne of S loo.00 a dry ap:ot Mt.
Signed this i ��� /` ,day of er cro&d/z-
a�y3
�icenseei Fzrr et bu cing Geparir.+ent
liccrt:ing board
Seieczmens Office
r;cslth Gep:rmcnt
-mac
9Q° �Cc pc
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
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: r ef)H0." t<_lftS i�
Location of Facility
ignature of P t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
C.yeis GoY�TT�'
Name of Permit Applicant
Firm Name, if any
d le Cs3
Address, City& State oi�zi
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, S150A, and the building permits or licenses are to
indicate the location of the facility.