18 WARD ST - BUILDING INSPECTION (2) OPUM1611Atl6TISE f L494AD APPROVED BY T44E
ASPECTDA PWR TD A.;PEAWT BEING GRANTED
CITY OF SALEM
� � s Date
Ward
Is P0PN1Y L00010d in of lD�dii� nt), L oL 1
MeMNs1orIC DWrICt? Yts No�
Is PrOWY Located In
"m CaMsrve lon Am? YM No
LD UI Nst; PERMR APPLICATIONhR:
Permit to: ■
(Circle whichever apply) Roof, Remof, Install Siding Const�Deck, Shed, Pool,
RspaidReplsoe, Other I a
PLEASE RLL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSIM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build a=r&,*.to the following
Specifications. (�
Owner's Name ��.w. r� \�vJ y
Address 3 Phan
Architect's Name r �A
Address A Phone ( )
Mechanics Name
Address 6 Phone ( )
Whst Is ft purpose of b~
rr deft a buldrp? N a dwaflir n,for how nary%mars? y
wa ftedm arch.to low? 5 AsOas%s? f Y D
E*nr%d cW City Lamm r rib r
Home Isrlro.�..t �—
���a Lie. ,
Sign rs of Applicant
SILINED UNDER THE PENAL
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
o� hc�
ze-
MAIL PERMIT
APPLICATION FOR
PEIlrr TO i 0 Dn t i A
LOCATION
PERMIT GRANTED
19
7
INSPECTOR OF BUILDINGS
PUBLIC PROPffXTY DEPARTMENT
120 WASHINCTON STREET, aRD FLOOR
5 SALLM,MAOtS70
TEL (979)740-S595 EXT.360
FAX (976) 740.96" ,
STANLa:Y J. USOVICZ. JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 4%SA I aclmowledge dW ea a calodit"
of Building Permit fi .A debris resulting Dom the consuucdm,arvy
governed by this Building Permit shall be disposed of in a properly licensed solid-wsft
disposal facility,as defiDed by MGL c BX SIM&
The debris wHl be disposed of at }� _
Locatim Y
Signature of Permit Applipmr D
id
FULLY complete the following im&mut n:
PRIIJP CLEARLY)
Name ofPem h Applicant
Firm Name,if any
(,Y\ S
Addw,City A Stabs
The above#fatale requires that debris Dom the demolition,renovation,rehab or other
alteration of bmldmg or muctiae be disposed in a properly-licensed sO1id-
waste
m
Scility as defined by MGL cnX Si50A,and the building pernibfs or lieaoaa are to
indicate the location of the hcift.
; � � � ,`rommonuivaLU1 o f ma�aCl�J�d •
' .1JdPaalawaf a�.7alydriaf�ssiisis• .
�Irwa 1 CsaeM &don. ///ou.." 02111
workers' Compensation Is m ance AlRdayis
. . wi,<b.a principal piece of btairress as:
do 1lereby'certify under xjn pains and peulildee of pof.st than
Q Ia employer providing workers, co tton coveralle for MYeiapiry an
sas working m '
r-
JuL
Insurance Canapowir Pe Nura6se
1 awn a sole proprietor and hove ae ens working fir one in arty eapedey.
() 1 am a sole proprietor, general contractor or homeowner (cb oes) and haw hind do
cammcton listed below who•hove the follawitg workers' compenasth m pe6dat
Contractor Insuranu Cempasq/Po Ntrwrier
Contractor Insurance Comparry/Po Nm bw
Coouacrsar Insurance C0snpa8y/P91j Numbsr
() I am a homeowner performing all the work nryielf.
•1 Ywe.raLawd aw{J teey.f 6*AMMM Ma ae ferwweN 0 N Chia a te.'aadrmw of on CIA Ito toe.rirf.edasadea and M taalaa w man
ae.sarr ar rawrd too Sadao 2fA N MGt 152 cm load wow:noniron d adniwr eseada cdriedw of a in el as=41.lOOi00 aaaww eaa
veiny iaareeree.et awe a*4 me it in dw Iona of a STOP WORK ORD ER and a Iwr of 1100.00 a day apiet awe
Sirned this . day of
.IcerseeiFermittee culldlnf Department
jjcensinf Eosre
Selectmen Office
rieslth Depryrlerc
6 c '
A.
CITY CIE SALEM
BUWING DEPARTMER
HOMEOWNERLICENSEE MOMON
Pkwe pm
DA
• ,Hmkowmm
ADDRE"
HOIv1EOWl� � `t •�� . .
7FIFPHOMB
PRESENTMAnJNGADDRESS
71c nvrc -camption of"bo Kowoad"wm etacsded w bs:lade awoa•+Fapkd dweAio.[Two
Unto a ku aid 0 aDow and Domeow ma w C fst bdirrda *r un wbo does smt power t
lipp voided tossdo Wass►sa"apmvisM
DEFQaTWCFHO&ZCW!'=
Person(s)wbo owm a past of Iwd on wbkb be✓she usida a brende>o tedds,op wbkb then k w Y
rounded u lm.s one w"m bvdb dwcgn&snsclod a dcact ed Wucmu sooesam is sa!mesa.1R
find stroemm A persat wbo comtruets mat than aK Dome Irks two-year paled 5ba0 am%eomHu d
s boueowsm. Su*`hamowvd' sha4 submh to the Butldbtd OifxbL w s lhs;t acoqmbk to tb
Bw7dio{Oftc4 that bd she be aspotw•bk to an:a&work perfamed tmda the boll pm,=L
77rc wdcsipted"homeowad'aswna respomtbrliq for co pnw=wilt t w Suss Ba tp Code d
otha appgabk toes by laws,rules ad te=aistiaoa.
The wAcrsip ed'homwwoe ardfies that Wile wdastands the Cid of Salem Balidleg Dgwuma
rmmmtsn bupcWc m pmadwa ad mgtpremnss and b/sbc wBI tvitA sabd pioodws d
TeV�
HOMEOWNER'S SIGN.AnMil"C
APPROVAL OF BUILDING INSPECTOR
See mba side for Sam ads
• A 4 1
HOATEOWNER'S EXEMPTION
The cods Sara that: •wW hotmo.raa pulbrmI ag imA fa wWd a boDft ya>oh Is r q&W abal W
cxempl from dw Pro 1dm Cribb sccdom Okctian ltpal-1Jecnsiog of comracdoa Eopervio
provided that b a bcmccsrrra OV99S!Pcwm W for Um to do.smcb TAnk tort siseb I F n 'A P
ahafl eat
as rvpavlmm�- ,
MwW v&Q me thb campd mare unaware that they are msmobng the;e9ondbMdes dd
supavbw(see Appeodbr Q.Rules and Regulations for]Jezosl g Censtruetias Eopenhem Eeedn
7hb bsdr a[rnarawa dies results in aeries problsma.Paoeuia�'wbm ft Lm 'A +m bba
Urrlieeased pcts?me In tbb case pew Board amrol p=xcd agabat the mureeaaed papa n ll wwla via
Ikeased Sopatira. ne boaoeowfcr sahsg ns supervinr it oMisaose respwRld. ,
To came that the boracownrcr Is fully ssroe ed hVba ssponfUldea6 taarq nsg�:ns Tf�
of ON pcnWI applladm slat the homeow nu ecrdfp rh r bLWO mrdessCoda t>reapomibuldn ds
or.avavb You mq care to amend and adopt sae!a knakcilflatlm e perry Coausmd -