63 WINTHROP ST - BUILDING INSPECTION w
♦ i
�IHST�f fiLff;�fJD APPROVED BY T*IE
.=PXT'D13 ,PFWR Tp A.PERMIT BFJNG GRANTED
CITY OF SALEM
No. I I S- 2cDO-� �.`� °�\ Date �1 •�� '�3
5
Tr
�,it !ram
Is Property Located in Location of 1 I
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
RepaidRep ace, ther:
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:
Owner's Name L 1�,r r, w, 1 i,-t,r
Address & Phone le3 (✓ ..11.YaR SI- . (fI18)55L(- 5043
Address
Mechanics Name R KAr 4pm t _S,.rw tr_S Inc .
34S Cxru,nwooA ab. 4
Address & Phone woc-LzsEcc- MA. OI601 09(-)) L4r -)-3IZ6
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost J 3,000 City License # N A State Lic ns #
Home Improvement
Cr- 5O3s � g Lic. f t-L684'3
X Signature of Applicant
SIGNED UNDER THE PENALTY
3 OF PERJURY
DISC- RIPJLON_OF-W K TO BE DONE II //
62S, Rp Q'ac. ew.t .,� U ,a. F� LAi mlewc, rlh Jr' CrucJvral
ClNC, ngtS ' � � -�la��t a • �
MAIL PERMIT TO: +46W irw cc 1
No.
APPLICATION FOR
PERMIT TO
INa �PIJI�i�a W�
LOCATION
JPERMIT GRANTED
-
,APPR D _
INSPECTOR O BUILDINGS
m.,manwoa Be�� �j� & ol Y4a.3saCLUtb o
6 �Jepa,lraas,tl o/.J�Irinl 4eei1.�
nn 600 Ulaala: �.S1 ..I
James J.Camobell &alon, /!/aaaa L.w 02111
CorrmrsSWW
Workers' Compensation Insurance Affidavit
I, Patel � A- � 2 S 4 � M- ul 'Ges
— tay..ee..r•a•e1
with.a principal place of business at:
\ nn
Ieaeriaeat.n4)
do hereby certify under the pains and penalties of perjury, that:
wzl l am an employer providing workers' compensation coverage for my employees working on
this job.
CD'rnNntrc,e,� �r���r� ��5 . .Co U0Lg6 � URl
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
Q 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 unotnunc mat a cony of the s ,e t w•fe bt iory zrovo to the Office of 1mrsd{avons of the D1A for coverall verik2d0n and tut Uk" to aacatre
coveralr v reovrro unoer Section 25A of MGL I S2 can lead to the 6,1mudon of crv+inar ve"ties corsvdnt of a the of we toi 1.500.00 and/or one
rcan' v.a uonmmt w _6 x cei oenaldes in the loan of a STOP WORK ORDER ano a fine of S 100.00-a am stivdt me.
Signed thi 3o 4, day of
Licensee Fermittee building Departn ent
licensing board
Seiectmens Office
Health Deparrmer.t
TC: VERIFY e-0S, 409, �75
CCVEP�.CE 1NFORI-;F-,T101.' CALL: i- i7.7'7-4500 ` 0 A&5 ,
=_ OF SALEM ,- MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHING70N STREET, 3RD FLOOR
F. m SALEM, MA 01970
3,
TEL. (976)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,, S150A.
The debris will lbe disposed of at:
Location of Facihty
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of P`eArmi�t Applicant
Le�
Firm Name,if any \
Address, City &State A O
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.