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0025 WASHINGTON SQUARE NORTH - BPA-98-2004 �?QS1*11.46 -BEfiLf� APPROVED BY T44E LNSP XTDR ,PRIOR TAD A_PERMIT BE1NG GRANTED CITY OF SALEM No. �`� � �`�\ Date � 6 Is Property Located In Location of the Historic District? Yes_No_ Building � Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Rero Install Sidi Construct Deck, Shed, Pool, Repair/Replace, er: 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 442 r6 Zak, Alm` 5 Address & Phone �� �Y»� 0 -291 Architect's Name Address & Phone 1 1 Mechanics Name E Address & Phone ( r6AZ '`'� (9rhL 7d LS34 What Is the purpose of building? /�✓�zCr�� Material of building? 1o> c �f a dwelling,for how many families? I Will building conform to law? -�. __Asbestos? N4 4 Estimated cost �Zt 'r"' City License # A�state License # 0 i Home Improvement e. X Signature of Applicant ClI< 75 qp SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE Q� P /vt MAIL PERMIT TO: ,i No. 96 l2-o ©,-- APPLICATION FOR PERmrr TO �cr 2 z/lJ LOCATION // 1 ,2 T �4 i PERMIT GRANTED 7f J5lo 19 APP OVED u+,4 INSPEC,TO OF BUILDINGS :C s v Salem Historical Commission ONE SALEM GREEN,SALEM,MASSACHUSETTS 01970 (978) 745-9595 EXT.311 FAX(978) 740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ , Construction ❑ Moving 4 Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Washinglon Square Address of Property: 25 Washington Square Name of Record Owner: Debra Nemschick Anthony J. Delre Description of Work Proposed: Replacement of shingled siding to replicate existing. No changes in color, material, design or outward appearance. Non-applicable due to being in kind replacement/maintenance. Dated: July 16. 2003 SALEM HISTORICAL COMMIS/SION By: The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work. ji .co OF SALEM,- MASSACHUSETTS ' PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR ap SALEM,MA 01970 TEL. (978)745-9595 EXT. 380 ��nru FAX (978) 740-9846 . STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,S34,I aclmowledge that as a condition of Building Permit# ,all debris resulting from the construction activity govemed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S150A. The debris will be disposed of at: 11 Location of Facility Signature of Permit Ap licant Date FULLY complete the following information' (PLEASE PRINT CLEARLY) Name of Permit Applic 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, S150A, and the building permits or licenses are to indicate the location of the facility. � aet�II /� I-- � COm-monwt:afik of M66acL6aff4 5 �ePc�lnsa,sl a/9,�,Giaf..�«iatn�, 600w.Ljl..,Ararat .lames J.Camobes it>o I , ///assachusalfs 02111 Commssaner Workers' Compensation Insurances Affidavit 1, S o with.a principal place of business at: sico . - lGar/sr+aN3M1 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 )lumber 1 am a sole proprietor and have no one working for me in any opacity. () 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/Policy Number O I am a homeowner performing all the work myself. I unoersono wt a cony of the statement will be iorwaroed to the Office of hrvestitatons of the DIA la coverage werWcadon and Wt Wure to wart coveratr AS reOUeeo under Section 2SA of MGL 1 52 can lead to the i nooution of criminal oenatties corxsunt of a foe of oo w4 1.500.00 and/or one rears'enoruemment u..rd24k-t oenalua in the loan of a STOP WORK ORDER and a foe of S 100.00 a am against me. Signed this . 4� 01`� day of . _ �J 44- Licen'see/FermitAe I Building Departrment Licensing Board Selectmens Office Health Deparzment TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375