37 WINTER ISLAND RD - BUILDING INSPECTION (8) III' �^ � ��y�N�� •
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JIlISPA JlIQRpAFWp GRANTED �?
CITY OF SALEM
,.. ow � o
Is PRomty Loowd h roaatioa of
ha FNslorb labldol? YbC.N0 t� lalldiai 3 7 /eJ,;iI ER /SlA/�o�. �o�
Is ft"My LoaMd In
;r to COnmwAgon Am? Ysrf,_NO✓
BUILDING PERMIT APPLICATION FOR:
Permit t:
(Ckds whbhaver appy) Roof. Ramat Install Stdlnp, Canstrlrct k, Shad, Pool,
Repair/Replace,/✓llaa ��a<A« QAscti,k �� : "'clews
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCROWS
TO THE INSPECTOR OF BUILDIN(3S:
The undemignmi haraby applies. for a pe mk to build actor ft to ow t nw&*q
Owner's Name fa Qo ys
Address & Phone .79 w;4, g oval (974P) /099
Amhk@ is Namo W i l 1-i'ri m 4&9 s
Addnas3PhorN <PoL� FAv�i7Esr ��RfJ6FNf�„/ (7�/) 63/ 7039
Modanica Name R4hAn.ol Cfl-IRON yj
Address 3 Phone 4r) GALcan,47 sr. sA6F. , ,`n ( 97V) 7Hs-
Whd Is In puposa d ` r`I
tsllwlg4
md"of Wool _Ldn od N e dwrwq,for how mmy hmass?
Wo tM/- n nn do 111%Imp
11
EM1114admod ,f o o n CNyL:m"0 N A,638wouo 0 040.01,2
i
loaa Ia4sossarat ''
Signature of Applicant
SIGN40 UNDER THE PONOVO'
OF PERJURY
DESCRIPTION OF WORK TO 8E DONE
JL_L Y //�'✓rq Al.Oik-�q✓(.d a �ti 1Gh /.. O�IAw�/ '•+
d v
MAIL PERMIT TO• J ti
I
r
a
APPLICATION FOR
PERMMT yTO
LOCATION
PERMIT GRANTED
N7ifD
)4*�j
INSPECTOR OF/BUILDINGS
sJ
4.
Ir lL,
I
Commonwa:a� M o� 111aMathwaffj
6
600 eyWw ybe.3b of
�saaaet a aaa>awa Qa1M. /Ilauaelnaaalis 02111
co wnsataw
Workers' Compensation Insurance ATIdapit
I, PU/4A1 (7 /V IM/ G tLK (fO&LaAr f,gat
. . wither principal place of business at:
race/ h a SY/GF/i i In/f .
. . Itannw✓saq
do hereby'certify under the pairs and penalties of pa*ye thm
Q� 1 am an employer providing workers' compensation coverage for my cinployees working as
this job.
DNA /A.S41)A&C E ro Insurance Company policy Number
I am a sole proprietor and have no one working for me in any capaeky.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensotton policies:
Contractor Insurance Cornparry/policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
• I unoentane otat a Cary of the sutemwee wo De ic, . rwd w the Offwe of imeautriom of d"DIA for cer.enrte .erbacadea asd Nat bawl m S"N"
eo.vatt M etawra undo! Section 25A of MGL 15 2 can kid to u" .>+oQwQ;0R at Oer+nar drnattte cor"'r t ab a Rwr of m 104 t.5
00A0 anUor arse
rtan' a ew+ oeuhio in the form of a STOP W ORK ORDER and a ix of t 100.00 a 'm +Pest we.
Signed this . 7N day of
built g Depamneent
,ucnseer'F crrraucc
accruing Ecare
5eiectmens Office
�,e=ith Dep�r-mer:c
r.e5, ;es, 7,r
PUBLIC PROPERTY DEPARTMENT
IZO WASHINGTON STREET, 9RD FLOOR
j SALEM,MA 0 r 970
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# . from
all debris resulting the construction activity
governed by this Building Permit shall be disposed of in a properly licensed soh waste
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: /✓�ti a1 g,4/F Qo7' v r -Shh"
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ao�tlivw C.64A01V
Name of Permit Applicant
C d- G Gd�i`I'R�9c7'y��
Firm Name, if any
GfD (3/�L c�rn S7• ,S�6G/h M
Address,City&State
The above statute requires that debris from the demolition, renovation,rehab or other
akerstion 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.