4 WILFRED TER - BUILDING INSPECTION ,
1
1
-PL*" Mi18�•K f�Lf$-AND OVER BY T44E "r
lws$ :�B 7DA p RF.1IV0 GRANTED �
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J CITY OF SALEM
Date
S '
Is Praperty Located In , / Location of
the Histodc OlMdct? Yar_No 4/ Building �'�f� erg 2✓V
Is PropWty Located In
be Coruervatlgn AMR? Yes_No.�
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, C struc Deck ' had, Pbol,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROC11;8lIlNG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: ••m�►
Owner's Name AP J"c0441P.�-/
Address & Phone �i u'l ,�'o/' L I
Architect's Name
Address & Phone L. S
Mechanics Name 42A,� ����°%!/
Address & Phone fg3, r—.y I (71 1YL D oZ d s
What Is the purpose of brdwkv? ;IG
Mate"of txrlkEW n a dwaYYq,for how many IemANs?
iG!
i
WU1 bukkq cordorm to law?��P.S Asbestos? /U 0
Et*resled coslt. Cdly ticerrse r
xx Hass LaprorrensatLit
V . Signature of Applicant
SIGNED UNDER THE PId1sli
�
OF PERJURY
DESCRIPTION OF WORK OBE DONE
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1'►'IOL3� Ta ^ !) I ,
,T_'I Ir�li
R�moae tv, I.,07Ajri �A A n9rot)AA Peo l y
e. nir �Ilil ,��
A G
MAIL PERMIT T0: t
Cx
-
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APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APP /OVfD
INSPECTOR OF BUILDINGS
s
i - ;=
� Commanu,IfG.�0��0.»GCa^�SWaLL'f .
)r.
6
,' �Uep.rfanaal o f.J+drrl4ial J'�ccia u�t .
600 eyW..�:+yl aSimai
Jam".L Camood &,L.., Yn,..L" 021 It
Coremsaorw
Workers' Compensation Insurance ANldaAt
1, ><'! /L 69✓' //BA ALl h S/61/P LJ!>i COP Y
tom:
. . with.a principal place of business at:
. . 1Clcraor✓aMl .
do hcreby'ccrtify under the pains and penalties of perjury, thaw
(� I am an employer providing workers' compensation ccverate for my employees working on
�u this job.
Insurance Company Policy dumber
1 am a sole proprietor and have no one working for me in any opacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policks:
Contractor InsUranie Comparry/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner periorming all the work myself.
I unocrauno wt a cool of tWo ,jvm ►o be ion aroeo to &W Once of Imodrauom of du DIA for cote e"wcadon and ax biwe w weare
cc. jjc as reourco under Scotian 2SA of MGL 1 51 can kao w rnr invowjon of crir:nar ocrwuea coraatint d a fire of w c*41.500A0 wwor one
years•6-.ww n,nt a,.tr0 as civi "witw in tnc icr n of 57OP WORK ORDER ano a w of S 1oo=a ta7Y etArm art.
Signed this . day of — --
icc rot ei'Ferrnittet tuilding GeQartn+ent
ucensinf Eoarc
Seiemmens Office
re<It�r Gepan:rnenr
" PUBLIC PROPERTY DEPARTMENT
y ,. 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,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, S 150A. �/J
The debris will be disposed of at: ,� `d C r l/-A ` 5'Alli0t 1 L' 14-
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
JK/�'►� r9ar AJ/e
Name of Permit`Applicant // > �
A9,14h, 5) DrL- )6Ut lalw '
Firm Name, if any
63 C00 Ok)(() l�
m O/>o y
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 cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.