0011 1/2 ALBION ST - BUILDING INSPECTION MW Ti9E fiL-EG-ANG APPROVE{) BY T44E
.MPECTLIB ,PRWR T-O A_PERMIT BEING GRANTED
�
L:_ CITY OF SALEM
No
Date
' iiI,�� Ward
\�c�mnsoo+D Zoning District
Is Property Located in Location of
the Historic District? Yes_No— Building 1 L1 t
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Constar c,� t De c, hed, 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
Address & Phone f 111�,f�, (7,4 1 t4at -?t'7D
Architect's Name
Address & Phone n A
Mechanics Name
Address & Phone (4m
What is the purpose of building? yo t
Material of building? If a dwelling, for how many families? /
WIII building conform to law? Asbestos?
Estimated cost City License # State #
Home Improvement
Lic. 1
Sig ture of Applicant
SI NED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �r Qt�L�✓1Lo
No.\\ ' �
APPLICATION FOR
�j PERMIT TO
T ���i V�f d(w� ✓Y�l'1/✓��
LOCATION
no
PERMIT/GRANTED
o y 19
APP OV�D
INSPECTOR BUILDINGS
• � Commonwrsal[fs of !I/n�athWsl�b
�, .1/.pa.laMat al�.faid,;.f'�etio erL•
600 W.1.11.e SL..d
Jaeeeq 2.unea+ &d, M..AruA 021 1/
eoarnearear -
(� ` p�--Workers' Compensation Insurance AffdWk
. . wfch.a principal place of business at:
do hereby'certlfy under the pains and penildes of perjury, duc
I am an employer providing workers' compeasatlon coverage for rrry employees working eel
this job.
rN
Insurance Company Police Number
1 am a sole proprietor and have ne one working for me In any capacky.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and haw hired the
contractors listed below who-have the following workers' compensation panel=
Contractor Insuranie Company/Police Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
1 rrrwenun.our a core of dre aurerneee wa be fora woed ea sir Ofnr.el Lwoipoae of dr DIA for co.s ate.e.fhad..and cur!iw M Mesa
ce.eratr y reeurr.anon Sedan 2SA of MGL 152 can kae eo ax inoeraio,d arirbaar oenade eoriaiieq of a aae el w wi l.SOOAD older err
mare'nror.aarnenr a tact a es.i Deasia r n the loan a!a STOP WORK ORDER ane a Srr d S 100.00 a M arairre ar.
e---
Si this day of r
.icc scciFcrmitcee ouiiding Depart ent
uceriSing Ecard
Seieamens Office
=e:tth Depar.^Men.
t PUBLIC PROPERTY DEPARTMENT
1120 V{I'4iHINGTON STREET, 9RD FLOOR '
Y SALEM,MA 01970
TEL (976)745-9595 EXT. 880
FAX (978) 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
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,SI150A k� _
The debris will be disposed of at
Location of Facility
---§j'gnmq6 otPirmitlApplicant D
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�lclr�lr��l It3h�
Name of Permit Applicant
Firm Name,if any
OqSLC<� L,07
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
I� I