20 WEST AVE - BUILDING INSPECTION (2) tJ T-BE fflL-EG-*NO APPROVED BY T+IE
.WPEXT-0-R PSJOR T-0A.PERMIT.BE1NG GRANTED
CITY OF SALEM
No.'?;,l2-ZCxO A ` .. 'r\ Date
NE
Is Property Located in Location of
the Historic District? Yes_No Building 4;20 (,J�ST / f e
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) eroo�nstall Siding, Construct Deck, Shed, Pool,
pa' eR place, OtheqQ 4 Q C-NTS
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 C l �es �n �
Address & Phone S coll�M1s SrScl�rvf`>f1 f93) 88� -66�
Architect's Name fO S , Avtna N (NYC
Address & Phone p ( )
Mechanics Name 1 ' 094SC0LL l-lomj ( A4 }� z
LLl pkt oLz % �j Lb
Address & Phone M Y3 r.ti rp ( )
What is the purpose of building? R E R00E- Ilp,&f AI-L S k t( L 1 C-H TS
Material of building? If a dwelling, for how many families?
Will building conform
/�to,� law?
��'� Asbestos?
Estimated cost 5 —7 ` City License # N�A State License # / S z_
I 16-10✓ Home Improvement
o Lic. / 13
Signature of Applicant
1 Z3 [F500 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
_ R RooF 7o?AL MAjW RnoP CS'TRfP)
tRA-MF OJ AQE�A rFc)&yhTt-: F7rJj? SK�LiGNTS
(V BE PLACL-D AT Rt6-91- sIbe a-F yaus6-, RI"T fhy�
LEFT S/aF O'F Do& &S. 11WMEk)
MAIL PERMIT TO:
No. 31 Z ^Zoo"
APPLICATION FOR
PERMIT TO
LOCATION.
do
PERMIT GRANTED
AP OVFD
✓✓//^„��Gr6�2, / //AAA
INSPECTOR OF BUILDINGS -
Y
"j OF •SALEM. IYkASSAGnUaci L
PUBLIC PROPERTY DEPARTMENT
° • 120 YwASH%NGTCN STREET, 3RD FLOOR
9ALkM�MAO1970
shy TEL. (97 8)7 45-9595 EXT. 380
FAX (976) 740-9845 _
;TANLEY 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 .
govemed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c7II,S150A.
�/e Z DiSPdSA
The debris will be disposed of at: Location of Facilrty
3
�Z
Signature of emit p .c
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
J
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 c1II, S 150,& and the building permits or licenses are to
indicate the location of the facility.
s� Cornmonwt:alth o� llla�eac�useffe
S n
Sjv
�eparbua� o/.Ja�riaf..�eeiasnL+
�amesJ.Camooel talon, /!/atasc�iata.W 02111
C01--dwsstona
Workers' Compensation Insurance Affidavit
,aa...a..rr,.e.•n.e)
with.a principal place of business at:
s t�s� Call��s Sfi 4�a1en M
. roer/a.ar.rsar)
do hcreby'certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my cmployees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
Q I am a sole proprietor,�rnisanyaaor, or homeowner (circle one) and have hired she
m
contractors listed below who have the following workers' compensation policies:
1-9 DRISC LL
Contractor Insurande Company/Polity Number
Contractor Insurance Compatry/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all she work myself.
I unotrsun.0 tnit a COP/of this suten,tnt wig bt forwar"d to tht OffKe cl Inreifnauom of the D11. Ion co. ate •eAkaoon*,no Drat Wwf to a00we
co.erate n rewreo unoa Section 25A of HCL 1 52 can kid to the i MOSWOn of cruninal otni iks corsutins of a fwe of aro 041.500A0 ands one
yean' in wn,,ent v ,u at ri.i otnaitiu M the torn,of a STOP WORK ORDER ano a 6"of S io0.00 a oaf against ME.
Signed this ,r. � . /Q��day of
-iccnsct/Pcrmittae building Gepartrrent
licensing board
Seiectmens Office
Health Department
! 7-7 -goo x c_ < =0�, T,t