27 WILLIAMS ST - BUILDING INSPECTION p ' .
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flE ;ipmVLZD BY TIE
A IQA D P. BRING GRANTED
"CITY OF SALEM
No. �
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BUILDING PERMIT APPLICATION FOR:
Pwmk to:
(Circle whWMW apply) Roof, R m
, Install Sid Construct.Ds&, Shad, Pool,
RepaWlepls ,
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROD
TO THE INSPECTOR OF BUILDINGS:
The umlemood hereby aWlas for a pwmft to build aocordhp to tho %&oft
speormatbw
Ownses Name t)v 6.2
L�aGC�_l
Address A Phone 2 7 /r ( • ) 9
Amhksct's Name
Address 3 Phone ( )
Mechanics Name L-Al a _IrLL
Address A Phans AAoev�,AJ fA (976'1 13 7 i -V
wrW k sr pu mo d busargv • Z
malow or, jiA gl a_^...7,for how mmr lw~ ! 1 a
Wo bjlq=An,111 to IMIr
tag 6 -cod/L, ' op umm o N P6 Qv&'Z._'j 4:
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7 n
ature of AppNcarif
SIGNqD UNDER THE 106110",
OF PERJURY
DESCRIPTION OF WOf'1K TO BE DI
/L `
MAIL PERMIT TO
APPLICATION FOR
PERMR TO - '
LOCATION s :
PERMIT GRANTED
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
a ' 120 WAENaNGTON STREET, 3RO FLOOR
SALEM, MA O1970
TEL._(976)743-9596 EXT.380
FAX (079) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
III accordance with the provisions of MGL c 40,SA I aclmowledge 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 M(33,c III,S150A.
The debris will be disposed of at !z
Location of Facility
Signat ue of Permit Applicant Dow
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
NameofPermit licant
19 cAv�- A I�Pr
B°nm 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 WK cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
Ccmmanlut:a.Uh o� �.lae�a[�ai�
b 1 boo eyWosi-jlm-3L,, t
ism"ICatntod f)esloa, ��/uwe�uwlls 01111
Cdaayaassnow
Workers' Compensation Insurance Mdayit
. . with.a principal place of business at:
. . iuta•1se�unvl .
do hereby•certify under the pains and penalties of perjury, th=
() I am an employer providing workers' compensation coverage for my employees working oa
this job.
Insurance Company Policy Humber
1 am s 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 worker' compensation policies:
Contractor Insurance C.ompatry/Policy Number
Contractor Insurance Compatry/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoee tared wt a twin el dto-aiaaert,em w N be i,aroed o, the Offct el Imadrawtd of the D1A la ca. zle werikadon ano Mae laic'm teeate
w.erart as moored um,Section I5A of MOL 1 5 2 can kad w the:noowon of cararrtat oenxota conaastint of a Gen of so R-f I.SCD.OD+octet oft
yean'k.°reotrntnt n A at chs otnaltitl in the form of a STOP W ORK ORDER ano a ire of S 100.00 a clap atwnat tee.
Signed this day of -
LiccnsctiFcr•tnitttt Euilcing Depamrwt:nt
'_3ccnsing E•oare
Seiectmens Office
,t<fLh Gep:rmer.�