47 WINTHROP ST - BUILDING INSPECTION A � � 0
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JNSPEXTL?l3 ,PWR Tp;A.PERMIT BUNG GRANTED
CITY OF SALEM Tamura J
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Is Property Located in Location of J '
the Historic District? Yes_No_ Building f j p� r
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, onstr ct Deck, ed, Pool,
Repair/Replace, Other: ;
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: n
Owner's Name alpk C 011 C)I-^
Address & Phone 47 tn•4�nv-04 07e) 7 72
Architect's Name
Address & Phone
Mechanics Name a6n
Address & Phone Pb G&A, 40iL QeveAi) (G7A P22 — 63Z
What Is the purpose of building? AP A V6OSP
Material of building? W hhh If a dwelling, for how many families?
Will building conform to law? Asbestos?
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Estimated cost )v' City License# N A State en # 3 3
QX e 4 (02 w Borne lmpro,osm�uc �( A
Lic. i ,
Signature of ADplicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO:_ �h /If
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No. 2-0 3-Zoc- �
APPLICATION FOR
PERMIT TO
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LOCATION /
PERMIT GRANTED
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INSPECTOR OP BUILDINGS k
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Workers' Compensation Insurance Affidavit
azernT4 . C1C i
with.a principal place of business at:
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Ichrrs.>,.n+a
7do her y 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 Dumber
I am a sole proprietor and have no one working for me in any capacity
O 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.
1 understand out a coot of this sugernot w�be iorwaroed to tact( ORKt of IttwtiPwns of the DlA la eoeerate'efiRcadart and 1.5l kin.400 as or o
[Ovefaar AS seo•+red unoer Section ISA of MGL I S 2 can lead to the ir+ooution of ervninll oe"tin eorsatint of a fine of W fo-S LSODAD irta/W Ortt .
rears'inoruonment v.eto as&A penalties in the loan of a STOF WORK ORDER and a fin,of rs i000..DO0a am nairat me•
Signed J�7this 7 a'Y of -� _-�=1--'
Licensee/Fcrmlitee building Geparzr„ent
Licensing board
Selectmens Office
Health Department
40E, A0Cr 27S
TG VF-rJF1' COVERAG"t: !NFc,; : lol� CALL: i. ; rI 00 X G3
OF 5ALEM. tYtFS�f+�-nv. � . . —
to� PUBLIC PROPERTY DEPARTMENT
• ° 120 WASHINGTON STREET, 3RD FLOOR
a SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
'&p FAX (976) 740-9646
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
govemed 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: 5 Or TOIPA VVI
Location of Facihty
Date
Ignatu l e of Permit plicaot
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
11�2h. k2)
Name of Permit Applicant
2) ��Oytn l�H
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.