39 WARREN ST - BUILDING INSPECTION 'P APISAIII fGT4E"Mill AND APPROVED By TW
JdSPUMR PWR TD A PERMIT WING GRANTED
CITY OF_SALEM
No. ` v� \ Dab 7
j.
ri �c Ward
Zarwg D13W
Is PMPWtV Mistato OCaNDistdo In Yw NO Location of
Doildias 3�Q-nJ S] +
Is P OPNIy L.ocalad In
Cn C nnrva*m Ams9 Yaa Na�„
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) R , Reroof, Install Siding, Construct Deck, Shed, Pool,
Repa' splace, Other:
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accord„ig,to the following
specifications:
Owner's Name onvi
Address A Phone -9 Ake-0J Sri ( 1
Afchltecrs Name ))r-/C'GC) 114-
Address & Phone '/ ( )
.Mechanics Name W" T, lAc v 6se} � (YAFrs vk4f j
Address & Phone S -b6,e,2 k LT 4(k ' 9 y W 22
What is to P Rpow of bl Ud 1 /�o S NCO c!✓Tt 41
Maww of buNd W F�41 C L R a dwaft for how many famaas4 /
wo txA*Q conform to law? Aabaetoa4 vo
Erimatad cog 00 o GN Licarra M 40 g' shb Ucl N
Hawn Ispso+sant
Lie.
Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
CJ
MAUL PERMIT TO: S- et)C-
1
No)�)
APPLICATION FOR
PERMT TO
4As����G /Qe ,ems
LOCATION
PERMIT GRANTED
VfD
INSPECTOR OF BUILDINGS
Pusuc PnOPEm DEPAm'MENT
t20 WAsHsmaToN vmwArr, 3NDFLooN
SALaN.NA O1 a70
TEL (979)745-MOS EXT.360
FAX (P79) 740-96"
STANLa:Y J. tJfOVICZ, J11.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(Z c A S34,I acknowledge that as a condition
of Building Permit N_ all debris resulting ftm the dam wdyty
governed by this Building Permit shall be disposed of in a properly licensed solld-waste
disposak facility, as defined by MGL c I%SIISOA.
The debris wfll be disposed of at MA [I
Location ofFacrlty
6
Sigoatme of Permit Applicant D
FULLY complete the following mk=&Wm
(PLEASE PRIMP CLEARLY)
Name ofPermitApplicant
� C cc cc
Firm Name,if any
Addreaa�,GYty dt S�e�
The above statute require that debris from the demolition, renovation,mhab or other
alteration of building of structure be disposed in a properly-licensed solid-waste disposal
facility as defined by Ma cIq S150A, and the building permits or liceoaes are to
indicate the location of the facility.
�`� �OI7►/riOMUc>�fA � ///d10GC/ufOfiLO -
•
600 w.4;.#Swa
,.ate 1 cnam.a lees Os///
caA..4aow. -
Workers' Compensathm Insurann ANideyk
. . whh-a prhsdpai place of bodes ac
do herebr'cerdy under s)n pains and p emildes of palmy, they
U 1a as employer lnovWing workers' compensation Coverage for my eiaplryeea wwkbS on
Insurance Compegy pollm Number
�— 1 am a sole proprksw and haw no one workbW fir sne L saw eapedW.
p 1 am a sok proprksor, general comsaictor or homeowner (drde one) and how hind the
conoraaon lined below who-haw tbi folkowkg workers' coinpensatkan po9dul
Conasaor Insurance Comparry/Poft Hum"
CommClI f insurance Compa=y/Po Nsm*w
Comrsaer insurance Company/Poky Number
O I am a homeowner performing all the work myself.
I aaawlHwa mm a nq 0111111 AMMM wa be 1on.araee w ew OHaa it la.aelwwo d ew DIA fir tolwaer•wiiraew aft wa(iw a mere
eowgry a reawn loll Seerac 2fA el MGL I S 1 can kee r ow irweneaa a1 tririnir asnseas sarwiq a/a ane el ee�{I.S00�00 areler w
Teen':aaraenacm a td a der MMWW in the hvw a!a STOP WORK ORDER area a few a1 s Io0A0 a ew+p4c we.
Signcd this . day of �0 ( �o
W
.iccrscciFcrmiicee Building Depsrtrwent
ucensinf Eosrc
Selectmen Office
=nith Gepsrmer�
s