68 WHALERS - BUILDING INSPECTION �-• DATE: 0 C)
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR TRIOR TO A PERMIT BEING GRANTED
Location of Building . ZZE
Building Permi4tApplication For:
-(Circle whichever•appfies) Roof, Rcroof, Install Siding, Construct Deck, Shed, Pool Z - VaU 3T
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other: g S
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOm DELAYS IN PROCESSING
To the Inspector of Buildings.
The undersigned herebyrapplies for a permit to build according to the following specificali—s:
Owneri Name: V&j t Contractor:
Street 4.0- `4 4 A-t0'City Street City
State_ Phone ( ) State Phone
Architect: City of Salem Licq _
Street City State Lic# HIP #
State Phone ( ), Homeowners Exempt Form yes no
Structure: (please circle) Single Family, u ti Family ~Other
Estimated Cost of job S 40902
Wiff buildiug confirm:tolaW7,, y s no
A&WAoa' ves no
Deserip�tion'of work't` be done:
Drawings Submitted: es no Mail Permit to:
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X rya
Si azure of A plic#'Iio6;+$I( MfED " DEtRTFI PENALTY OF PERJURY
CANS F1iUC I IQNZ2 LETED WITHIN SIX (6)t MONTOS OF PERMIT ISSUED DATE _
Department use,only P601O O—Z. fIning Map/Lot
Permit fee S_ZC/ cb GK,) V U 19go
COMMENTS:
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No.
APPLICATION FOR
PERMIT TO
LOCATION
4,0L-6u d-61
PERMIT GRANTED
5 - 1rdD93
APPROVED
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INSPECTOR OF BUILDINGS
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n/ 600 r�yy��a.+Lgi.n SW-1
James J.Camooee f>dslon, ///assae"M 02111
Cor-.mrszaxsa
Workers' Compensation Insurance Affidavit
. tda•.erver.ut.ei
with.a principal place of business at:
iotytsrawLp
do hereby certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
/i,//z(,
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/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I underauna mat a cony of[his wtement"a be fora aroed to the Office of Imatitatrom of the DIA for coveratt veriecation and 03C Ware to"we
covvatt as reoured under Section 25A of MGL 15 2 can lead to the:nowrdoe of crin+nut oenartiet corsatint of a fne of w m-S 1.500.00 and/or one .
years'wwoomment as Kta as civi oenafdes in the lorm of a STOP WORK ORDER and a fine of S 100.00 a dar ataintt M.
/Signed this day of Cti G[
Licensee/Permitted Building Department
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 775
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (976)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,S34,I aclmowledge that as a condition
of Building Permit# ,all debris resulting from the construction activity
governed by ste this Building Permit shall be disposed of in a properly licensed solid-waft
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: �(� ��`'� LC
Location of Facility
3
ignature o Permit Applicant
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ame 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.