24 WEST AVE - BUILDING INSPECTION POW
CcoL�
-Pt:AM IlMtST-Ef#L-E� APPROVED BY T*IE
U PECTpR ,P1WR TD A PERMIT BEING GRANTED
CITY OF SALEM
No.q 1e'Z0 O 1 H:`� '� �'g� Date
!if
NG�y
Is Property Located in Location of R r
the Historic District? Yes_No `� Building 02� 41-eJJ�
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo Rero , Install Siding, Construct Deck, Shed, Pool,
Repair/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 Name DQh 57
Address & Phone 4 ( ) gZ/Z/
Architect's Name
Address & Phone
Mechanics Name
Address & Phone `j£D£h � �u OPyv�2/ (?2j7) n99p9<jif��
What Is the purpose of building? 61
/
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos? �C)
Estimated cost .Z, City License# N �' State Licens
Home Improvement
U 1 C.l�SLd tic. 1 IJ6190 r,
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO-
No.
APPLICATION FOR
PERMIT TO
S��hP,Q rPrao�
LOCATION
PERMIT GRANTED
19
AP VED
INSPECTOR BUILDINGS
�.! OF SALEM- MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR. -
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SK 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.
The debris will be disposed of at:� ,�� ��,-s
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
f
`,ommonwt.aa o/r afseacki+seffi
y �epa,tmant a/.7,+duttrial sec.
boo ,wry��i.L.91..5b..t
James J.Cammee f�oatoa, ///aaaaaL.1b 02111
CarmrsttOna
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
? �D fti
(Utr/auW]y)
do hereby certify under the pains and penalties of perjury, that:
(n I am an employer providing workers' compensation coverage for my employees working on
this job.
,y�
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/Polity Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I undentand tnat a cotry of this uatement rral be for arded W ght Once of bnesdtatons of the DIA for coverage verilkadon and Mal faaure w Scare
coveratt L reaureo under Section 25A of MGL 1 S 2 can lead to the inooution of erinirtas oenuites ccrsmdnt of a tme of tm wi I-MIDI and/or one
ytarY inaruonrnrnt z Rol as cirri"naldts in the loan of a STOP WORK OR ER and a fine of S 100.00 a an stainst me.
Signed this , ili' day of _ �✓��
Licensee Fermittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375