10 AMES ST - BPA-05-223 DECK' �s�sr��.fe� �ov� ar r+�
JeI�PFcx�,��lpR rD a ��eR�w� c�►n�rEn
CITY OF SALEM
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9UILDING PERMIT AP�UCA190N FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Inetall Siding, onatruct peq�,��hed, p��,
RepeidReptace. Other.
PLEA8E RLL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCEgg�Np
TO THE INSPECTOR OF BUILDINGS: '
Ths undersigned hereby applles for a permk to build accordi��g,to 4he.following
specfftcatlona: .
owners Neme ��P i s�ti�vP /1 i ��(�,r •
Address & Phone 1 t� �l�i�� _ j �
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Archkect's Name ' �
� Address � Phorre ( 1
Mechanics Name 7�,� � �. �,�,�.e�-��.,, � vuw.,� �} ,
1 �a- sy/„�,. st �
Address & PhCn��•�,,�.,� c u� � O�a 2 3 (�735 7 G.2 8'�� 7 I
Wht la ar purpow ei huildkig7
�„�a b�l�np� �'Jo� e ror now m.►y lemlfes4��
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WIN 6uYdnD to Isw9 �S A�bMtos? h.�C'�
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Eerin�Ud ��• qly Lk:aw N 3ht�LlC�rw N�`S�'S q�
8aM I�ro�et
i.ic. i - �
ipnature Of pplicant
SKiNEO UN ER THE PENALTII�
OF PERJURY
DESCRIP'TION OF WORK TO BE DONE
_��?d� c�p,��..��D 1�.,�1 --� ���k
MAII PERMIT TO: ���,s�we, Y� � ker /6 I�w�eS S {--
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PU9Uc PROPERTY DEPARTMENT
�- 120 WA/HINOTom STREIT, 3RD FLOOR
9AMM,MA 01970
TEL (979)745-9595 EUS.360
FAX (679) 740-9946
STANLEY J. USOVKZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
Ia accordance with the provisions of MGL c 40,S34,I aclmowledge that as a condition
of EWding Permit g all debris resultmS from the c mutnwtion activity
governed by this Building Permit sW be disposed of in a prapcly licensed soH&wmbs
disposal facility,as defined by M($,c OX SIXA.
The debrs wM be disposed of a.& khrAsA. 00,(-�%N CA � (.e p, M04.
Location of Facility
Yo
Signature of P Applicant
FULL( SE PPRRI T CLEARLY) meson`
.7T; W
Nave of Permit Apphamt
Ae: ( (�nl 7✓fir -eJ ` 41 w J
Film Name,if any v
lad Sy/�aN sk �ww�wers :Mrd oi4a3
&Sten
The above statute requires that debris from the demolition,rawVation,rehab or odwr
aherstion of building or awcture be disposed in a prvpaly-licensed sOH&waro disposal
facility as defined by MQ cHL S I50A, and the building pamits or ficeoaa are to
Mica te the location of the may.
��,,II' yy� II •
ComnwAw laLLft of Maddach4 ad
1Jtpariweef e��idrefrial�etilieb' .
boo waAL16 �f eel
AMM t Casend 80010110, 7lbeeeJ.& 021 If
eenaae.oew
Workers' Compensadon Insurance AAidayle
. . w10.8 principal placed bosloem ou
f '
•S
,do(hheerebr'cerrify under the palso and penil" of pff*ys %hM
`s �an p�� nsi workers' compeossdon coverate for my employees working on
tki via( WG 5- 37fS- 15J611 01N
Insurance eompaw oro Number
I an a sok proprisier and haw no one working fir me in any caPatiq.
() 1 am a sale proprieser, general comrataor or homeowner (circle one) and haw hind da
contractors Based below who-haw chi following workers' eornisawadoe pollelm
Cesmrsetnr Insuranu Company/PolkW Number
Consraaor Insurance Company/Po Nun bar
Concraccor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
•1 wnssrrsae own s cavy sf di amour We k farwarsed ■ an Ofhe a knuegswas of dnt DIA fr corwase WWWA M Me*A fines a sive
ww.astr r rtsnrto hoer Sanaa 21A e/r1GL 152 can laid mow studs cotwdes of a W d av n4LSM wafer oar
tcsn'is�a ws a dd etssida in dnt Alas as STOP WORK ORDER was Also of 5100=s err*"aw
Signed thiss der of L s, ,
Y As
censeei crmncee eimldsng Gepartrs.ent
1iccnsinf Ecare
Selectmen Office
ricatth Deparmer-
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