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70 WHALERS - BUILDING INSPECTION DATE: OK -07 -0'S T1 . Citp DfdYPm, Fi �ftjr�U�PttS i; PLANS MUST BE FILED AND APPROVED BY THE INSPECTORTRIOR TO A PVRMIT'BEING GRANTED/ , / Location of Building. 7D (.ti 12ALt6-IiY- Building FermitiApplicatioo For: I Z- fsb7b3 -(Circle whichever,appbes) Roof,Reroof, Install Siding, Construct Deck, Shed, Pool y Addition, Alteration, Repair/Replace, Foundation Only, Wrecbing Other: i. PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PRnCESSING To the Inspector of Buildings: The undersigned hereby„appties for a permit to build according to the followi g speeificaf;�"S: OwnertfNamc: // ` -�/y l /t lT_ r Contractor: / Street /Gi 2�. 1„ 7,h PAJCi1v Street �—Z Coo= City -G--fi State Phone ( ) Slate Phone( l�e6 e eErZ,3 Architect; City of Salem Lici( Street City State LicH O1�6�7Z-HIP H /7. 6�� State Phone ( ) Homeowners Exempt Form yes no Structure: (please circle) Single Family, i Family N Other Estimated Cost of job S WiUifbu"ildingconfirm,to,law' s no Asbei�oa'_ yes a Dead&. tiod'of woe done: Drawin Submitted: es no Mail Permit to:� X ` f/ 'Signature of Appl)cii_iony 4l WIED ' .:-DDR THE PENALTY OF PERJURY �"cUl!1STRUCTION TOT©'IVIPL TED WITHIN SIX (6)+MONTHS OF PERMIT4SSI,IED DATE _ Department use,only TO Yf`I�jl(,g 'ZAoyZgnip Ma of g p/L Permit fee S Za _ t l•Y q0 COMMENTS: 1 f No. Ito$-2cocy� APPLICATION FOR PERMIT TO LOCATION 7D GrJI,RJI e PERMIT GRANTED 6-3 - APPROVED INSPECTOR OF BUILDINGS II Ccrnmonwaabli, of Y&ie acLt6effi n rat /9, ;�iaf .?«< 5 agar ms o 600 �y�yymyton Last .fames J.Camats" F3oltoa, /!/aeaaeLuaatts 021 /1 Ca-.mrssrona Workers' Compensation Insurance Affidavit (Gvrwrtwrt�iwt) with•a principal place of business at: . Itaey/aw.,asr1 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. 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 undo w"wt a copy of this wtement"I be fenvaroed to the Office of Irrve,dgatgw of the DIA for coverage verification and that I31109 to ware coverate as reopeeg unaer Section 25A of MGL 152 can Ina to the inoourion of erimimt otnatties ecrauting of a fne of oC to-S 1.500.00 MWM one rnn'imorwmment as vrs0 as civi"naftiu in the form of a STOP WORK ORDER ano a fine of 5100.00 a Day agairot me. T Signed this . 1 Lj_-day of cl�-G[ Licensee/Permitcte Building Deparcntent Ucensing Board Seiectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375 OF PUBLIC PROPERTY DEPARTMENT ° 120 WASHINGTON STREET, 3RD FLOOR 2 ye SALEM,MA 01970 TEL. (978)745-9595 EXT.360 a FAX (978) 740-9646 - STANLEY J. USOVICZ, JR. - MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,S34,1 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: {' `'t I/ -C Location of Facility Signature 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 c1II,S 150A, and the building permits or licenses are to indicate the location of the facility.