7 WALTER ST - B.P. APP i+LAMIifWT-BEf4L4-� APPROVED BY T44E
MPEGTDR PR DA TD A PERMIT.B,EING GRANTED u
_ CITY OF SALEM
No. V F�.`� '�f��'\ Date l9-/1-O2
ari� I ' r,'I� Ward
suoj° Zoning District
Is Property Located in / Location of the Historic District? Yes No V Building /7
u,JA '�e& Sj,
Is Property Located in
the Conservation Area? Yes No �f
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Iniielrr�:
Construct Deck, Shed, Pool,
Repair/Replace,
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: Q
Owner's Name CIPR I} I\ eAL $ + A}P
Address & Phone W At, eR ' 7f5 - 5795
Architect's Name
Address & Phone ( )
Mechanics Name `/ 1 D I O.v y nll LA
Address & Phone l Se �ZPr y
What is the purpose of building? P S ,' e ry C e
Material of building? W ooe- 1'RRrn e If a dwelling, for how many families? f
Will building conf rm to law? (!e 5 Asbestos?
Estimated Cost 0 0 v o City License # Slat ense
Home Improvement
Lie. ►
AAI-
signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
V L
MAIL PERMIT TO:
•t
No. �
APPLICATION FOR
PERMIT TO
LOCATION/ !, /L
7 �� 1/l�r 7�1
PERMIT GRANTED
19
APPF(O,VED
G emu,
INSPECTOPHOF 6UILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASH INGTON STREET, SRO FLOOR
SALEM,MA O 1970
TEL (978)745-9595 EXT. 860
FAX (076) 740-9646
ST&N' LEY J. USOVIC7., 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 activity
resulting from the
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL a III, S150A
The debris will be disposed of at S Al e-vv\ I ,M A s S
Location of Facility
0�
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ig" c PC k\M el eC
Name of Permit Applicant
Firm Name,if any
l 3 � Cw,ALL Sj ,
NA .* . ✓hA .
Address,City Bt 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.
� COmmoiuul:Q.Ci7L 0��CIDO.L�su.7 ,
5 �ePa.taaaa!.j.�.davtvf.araf.'.ab
eoo ryw�. ,,w�►ra
fames 1 comooae 0211 f
ccemnscow
Workers' Compensation Imuranee Affipit da
`
c '
. . whli principal place of business st: nn
13 S ewyA Ll L 5 d_�A� MIA .
do hereby•certify under the pains and penalties of pesIFry, thm
() i am an employer providing workers' compensation coverage for my einpioyees working on
this job.
IP.At leas
OF
Insurance romps" Policy Number
1
I am a sole proprietor and have no one working for me in any capadey.
() I am sole proprieto general contractor or homeowner (circle one) and have hired the
contra e w who have the following workers' compensation poiiefes:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner ptrfonning all the work myself.
• I wno"Waa cent a coat of Nb wo,"Nnt wo be io,,+ fta m dx Ofrace el k,,, aamm of dw DIA for co. art TWWXadon WA am 124ee b aaeere
COMM a1 rewaro oncer SacBon 2SA of MGL 15 2 can kae to Ow inoow oo of crjj r oeneda COr-Midm" e(a h"d se W41-500 D anerer em
roan'imwoorenrnc a va it cm eewgia in the farm of; STOP W ORK ORDER ane a sew of S 100.00 a en ndrse am.
CC 01ya 11
Sirn thi J�v2,J' ee, day of J N r
:i nseei climit' t01— Euilding eparin.ent
ucitric Eeare
Seieamens Office
=e:Ith Depsrmerc
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