31 WARREN ST - BUILDING INSPECTION -ft 19106TfiOEfiL-E�I APPROVED BY T+IE
wsplabB .p ljon t `A_PERMIT.B,EING GRANTED
CITY OF SALEM
No. 'J q-�c� f F" ,� �`'� Date 3
Is Property Located In Location of
/� ,
the Historic District? Yes )C No_ Building /,'/C /� ,
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, In Sid�sidingq onstruct Degkl Shed, Pool,
Repair/Replace, W 1Qe
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 1 �, e �fo1l"/�� �✓// IV �ZicTD�£✓
Address & Phone 3/ 0 LrWejo e (978� 7VS- /0 3,;71',L
Architect's Name /14
Address & Phone
Mechanics Name /bole/ 4?ed k1al. &-j- :tiz
Address & Phone 341�uf r +tom cfy S1/ ti oye
What Is the purpose of building?
Material of bullding? _A1,00,�/ IZ-1 YL If a dwelling, for how many families?
will building conform to law? A.S Asbestos?
Estimated cost-2saW 00 City License# N P' State Lic se # 1017,74
rob Rom Improveneut
Signature of Applicant
Gte-- 15L4G SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
trf2�1,1' ze
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I1 I its _I
MAIL PERMIT TO: / O /!�'.
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No. "Z-00`
APPLICATION FOR
�PERMIT TO
LOCATION.
PERMIT GRANTED
19
APPROVED
INSPECTOR OF BUILDINGS
OF SALEM, MASSACHUSETTS ~
6 PUBLIC PROPERTY DEPARTMENT
3 ° 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
�pMna 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 Pemmit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,
�S15�0/A.
The debris will be disposed of at:
Loccatiationon of Facility
AVr= ? .War
Signature of Permit Applicant
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
�p�pA°�,Lam' /aau,�,✓e�- ��
Firm Name,if any
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
k
f0rrmonwtia& 0/ MaesaclitvefL�
n F
oJl'.�„�ibinl �rccia.nL,
//��600 ryW&akinplon S1 ..I
4>oa J.mes J.Camooes loa, //lasaacL.Us 0211/
Commtsswair
Workers' Compensation Insurance Affidavit
wich.a principal place of business at:
do hereby certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company 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/Polity Number
0 1 am a homeowner performing all the work myself.
i unoeruano mat a coon of this w,ement wig be 10 aroed to the Offce of Imvdtaoons of the DIA for ccnwate.e*ircadon and that Aatre to some
cowate AS reaureo unoer Section 2SA of MGL 1 S I can kad to the iroendon of trim'utai at"ties corsadnt of a fine of oo to-41.500,00 and/or one
years inwaomnent as.ta of cw ""hies in the loan of a STOP WO RK ORDER ano a fie of S 10040 a an staintt me.
Signed this day of
=4�L�
t
Licensee/Fermittee Building Departra,10nt
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375