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22 WHALERS LN - BUILDING INSPECTION IM-*fQS M0 T-BEfiUEG-A+M APPROVED By T44E U PEGTDR ,PF, ORTDA.PERMT.B,EWGGRANTED CITY OF SALEM All No. 23 Z0(DO �`� � �� Date h .a�;. �'i�• his Is Property Located in Location of 1 the Historic District? Yes_No_ Building aa, W1-A x.5 Lr� Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, e air/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 Tare �� Saa�SK-i Address & Phone 11 WV%aA r - a e. (Ont ) -I41 - S a tFn 1 M o.. pl 9�0 Architect's N & Phon Mechanics Name V\om2. 11Scrv� cZS ,L r,L Address & Phone 311E �C� w() oodl SV. (Wb) -156- bb66 wort-t5Vtct M o- • o ibol What is the purpose of building? q%-- - Material of building? If a dwelling, for how many families? IU - Will building conform to law? Asbestos? Estimated cost b. p� 00 City License # N P state Uftenn # Home Improvement a, Lic. 1 I-L609 X Signature of Applicant LK- cv'a �3 SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE n o e S�fuc, u aI C-HartreC V - UaIL)e� 0 . 3N o MAIL PERMIT TO: �Aorng bw(ve - I No. 28 7?2,©off APPLICATION FOR PERMIT TO LOCATION. V l 2- PERMIT GRANTED /4 �l3 AP ROVFD y INSPECT OF BUILDINGS Commontutaahk o/ maaaachtac tL n 4��- cc^��y� _G.Jepa 1.1 o/ Jaa lriaf 47c,iaanLt n/ 600 wyymLll.n Sirdal James J.Camooes I. , /!/waeL.us 02i if C armrssaoner \ r Workers' Compensation InsuranceAffidavit I, Pt v� V p-nkft, �� M�4 Aarf-I L I nC . totarevtrer�iv.el wither principal place of business at: j 3 a o0 Co�� &a11 .Y, u < r>✓l.koD A y l a,n ya, G,l—I� . 30339 canfws.ftaq do hereby certify under the pairs and penalties of perjury, that: W'11�I am an employer providing workers' compensation coverage for my employees working on this job. Coww�unerc e + 1,z6vC W Lcl 616621 Insurance Company Policy Number I am a sole proprietor and have no one working for me in any opacity. 0 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 0 1 am a homeowner performing all the work myself. I unaerwne tut a cony of this mtetnent wis tot iorwarceo to the Office of Imzuitavons of the DIA for coverage weekatien ano mri fahice to lean coveratf a reouveo uncer Section 25A of HGL 1 52 ran Wo to the imoo>,tion of criminal otnaties coravont of a fine of vo t*41.500.106anafor one ruri lnlpftl0lMrlen{L-A as cka oeuiaes in the form of a STO P WORK ORD ER ano a fie of s 100.00 a an against site. Signed t "s . day of _ A-f, r �t73 Licensee/Permittee Building Departrment Licensing Board Stlectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 40S, 409, 375 �oxn - . OF- SALEM. MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 3 3, yA $ALEM,MA 01970 TEL.(978)745-9595 EXT. 380 �Grnu 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 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: R S n 0.0 GU S Location of Fac•L—t —' 'ty q 1"1 03 Signature of Permit Applicant Date FULLY complete the following information. (PLEASE PRINT CLEARLY) Name of Permit Applicant �t� A homer Se,�yiceS Firm Name,if any 3\-I5 a« e owood Woac NA ck - Olbo� 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.