3 1-2 WARNER ST - BUILDING INSPECTION (2) -PL-*fQS-MOST- E fiL{G--ANO APPROVED BY T+IE
UNSPXTDR ,PRUR Tp A..PEAMIT.BEWG GRANTED
11
CITY OF SALEM
No. O� -�." .L �� Date
GZ a3
h
Is Property Located in Location of '�.� Ph$I
zz
the Historic District? Yes_No_ Building /
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Ro f Reroof, Install Siding, Construct Deck, Shed, Pool,
Repa Replace, Other:
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 NameS,. �/`1�rJrl
Address & Phone 3 1 V f-,ny o7e) 7/ — IS0Z
Architect's Name
Address & Phone ( )
Mechanics Name r-,j 1l��wV�9J' y
Address & PhoneZ. T/l S �9 w �i7a -JO`��
What is the purpose of building? /:2S ie 7c-
Material of building? 1A)yC)C>1' If a dwelling, for how many families?
Will building conform to law? Y� S Asbestos? /v/o
Estimated cos t/T rW City License # N�A State License #
Home Improveme tt
Z� Lic. 1 r of Applicant
C.AS" S E UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
wcx
MAIL PERMIT TO: �Z r Yn�Y S � r�� e�/,970
1
No. 301 -Z c>o L-k
APPLICATION FOR
L PERMIT TO
LOCATION
/
' �nl� 57y
PERMIT GRANTED
21
APP OV�D
INSPECTOR OF BUILDINGS -n
.q
{o OF SALEM., MA65AGMw=r— ' i =
v6 PUBLIC PROPEGTY DEPARTMENT
• • 120 WASHINGTON STREET, 3RD FLOOR
qp SALEM,MA 01970
TEL. (978)745-9595 EXT.380
Gmin FAX (978) 740-9846 .
iTANLEY 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.
�rn YanS
The debris will be disposed of at: L,ocation of acility
4offeLt Applicant 44
Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�'L'V
Name of Permit Applicant
Firm Name,if any
Sz So�lrr- 'S u),4 - S� rn
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
MASSACHUSETTS
NU1Bet DRIVER'S LICENSE
012621251
UAiEumm gA55 HFST HE16Xi SIX
08-15-1965 n 9-00 N
Ou8 .;
-15-2008
GAUVAIN '
JOHN J
32 SMLERS WAY
SALEN,MA
0197H270 ..
�c
, � ✓die -�omriroru..w.a/l/ a�'./l�,onoru/aaoead
l
BOARD OF BUILDING REGULATIONS
'License: CONSTRUCTION SUPERVISOR
j Number: CS 069766 �
°•' - Birthdate::08/15/1965
Expires: 08/15/2004 TT.no: 10870
{ Restricted: 00
I JOHNJ GAUVAIN �f
} 68 WINDSOR ST _ j /
MELROSE, MA 02176 Administrator
L
4' C0mm0nLV0aft of 111a66acf"d¢ff
S I
n/ 600 �yW sLILm
James J.Camooes Wslern, ///asuc�..� 0.21 It
Cormrssiow
Workers' Compensation Insurance Affidavit
with-a principal place of business at:
. . CcagAbwBlp
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 dumber
/ Jl 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/Polity Number
Contractor Insurance Company/Policy Number
() I am a homeowner perform the work mys
elf.
all Y
I unoersunc we a coon of ehu itacemtnt wW be iory arotd to the Once of lmesutaoon of the DIA to co+ ate teeiJoadon am Mri(ak"to ueure
cot nc v reourta under Section 25A of HGL I S 2 can lead to the indo>don of crkr;nat otrwdea eorstadnt of a Jobe of w eon I.SOOCO mww one
rcan' inxuonmrnt W ' a Mint nc iorlmof a STOP WORK ORDER and a 16" of S�1000.00 o m ai.+cet �dD
Signed this day of
�iccnsee/Fcrniuee building Gepartn+ent
liccnsing board
Seiectmens Office
};catch Department
___goo �_ ao� cos _", ;,t