12 WOODSIDE ST - BUILDING INSPECTION I
fL'11tlt3iN!l6i"^BE {$ti4ND , OVEfl BY T+IE
L
JNSJ?FLI1A i !!QR 7D J#.P IEWC GRANTED '
CITY OF SALEM
No. 01 W Date �I
� �
Is Property Locam in Location of /� �
the Historic District? Yae_Nlo Building �� C�t/O(f"i
Is PropwW Located In / �l
No Conservation Arms? Yeses
BUILDING`PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, In I Sldl onstruct Deck, Shed, Prool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCEBON'G
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name iil i � _�/✓ ,)
Address & Phone //� //darn/ s./ 3 3.e�0
Archkect's Name
Address & Phone 1
Mechanics Name
Address & Phone �� �����m r� /� 11ir/(�/� g 2 2
What Is it*pepoms of Wining?
Alateritl of Wilding? `�T l� n a dvrelrw,for tow many Iamliss? i{
WON txrildbrp oarfoml to law?
Estlmat CBy umm a fJ P' sta M -?Lg
�U �U rnpro.e.ent
X o Signature of AP t
SIGNED UND THE PIEIN� � i,
I:
OF PERJURY
" DESCRIPTION OF WORK TO BE DONE
t
ry f
MAIL PERMIT TO: //0'm -e 0 wkm /1 r /
—
_i-
APPLICATION FOR
PERMIT TO
r / .
JIV
LOCATION
PERMIT GRANTED
AP PR 11D
INSPECTOR OF BUILDINGS
s
PUBLIC PRyPPERTY DEPARTMENT
120 WgSHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL. (978)745-9595 Err. 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 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 defjned by MGL c III,S150A
The debris will be disposed of at alz / vim
Loc 'on of Facility
2a GL
Signature of Permit App " ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
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.
ffi
focc�mmonwr aeo1 M' Ill fminAt ¢
t � ..UeparGnaal e/.J.del4ial J�«;d.a�s
b
600 W- :-j1m.3I".E
�atnesJ f:atrtoosr CL,t.�, ///auoe W 021 It
Comnas+atsf
Workers' Compensation Insurance Affidapit
. . wither principal place of business at:
. . fue,uwrafrf .
do hereby'certify under the pains and penalties of pedury, that:
�am an employer providing workers' compensation coverage for my employees working oa
this job.
Insurance Company Pol'fcy Numbe
r
I am a sole proprietor and have no one working for me in any opackye
I am a sole proprietor, general contractor or homeowner (circle one) and have hired tlst
U D D
contractors listed below who have the following workers' compensation P0611i s:
Contractor Insunnde Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I Ynae ne tnat J copy of"wivrmnc wia be ic, +3roed W ax Office of Imatita"M of the D1A for cc. are V"Vi aoen and Ytal laiu,e m ere we
co.erarr v fronreo under Section 2SA of MGL 15 2 cm kao to the inoontton of cra+anat oenarpes coraatint all a fine of w=41 SOO=m Wer eete
ycan'irwt,onnent n v0 as chi pe"Itief in the forth at STOP W ORK ORDER ano a fine of S 100.00 a ace/ ari.et aae.
SI t is U day of /
Liccnseei'Fermittee cuilding Gepartn+ent
'�ceruing Eearc
Seiectmens Office