13 ANDREW ST - BPA REBUILD STAIRS & DECK "K-ONS11AtW-OE f♦Lf4619 APPROVED BY T4IE
J SPECUIR PWR W A.PEAWT BIKING GRANTkD
CITY OF_SALEM
Dde
` ward _
Zoriq DWW
1h�Webilc DhddG?„ Yw No
Is f aMly Loud in
: dN C UNVa lon Ann? Yet—No_
Permit to: BWLDWG PERMIT APPLICATION PORK
(Circle whichever apply) Roof, Rehr 1—Instal Skft Construct Deck, hed, Pool,
Rspai 0t1»r
PLEASE RLL OLRT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCESSMq
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accord4ig.to the following
specifications:
Owner's Name ?A A15 Q& ti e KA10
Address & Phone )Rb dj c T A ox F cAg .ts,e
Architect's Name
Address a Phone r
Mechanics Name )A A v I C& H.4 rT
Address & Phone ti f,4hnpi v n d . A QV,`A ( 4 ys-)
What is sr prsPoM it W~ n t-VtACA- d�ctr �— $TA1g e
humor of 1n11rarq? v 7- n a dwt+anp,for how mony hmUm? I
Wo NWldlr g corMorm to low? 1'-*-s AatNatos4 A/Ga iL'
EslmsMd coat Od0,1"d CUy llrarrfa• 81AN U0o r G 5 0 2 3 4 y 3
�1\� Lair IA 7 1s ) 7 t n '
V L1C. e l67 r l 7 , r /Y2&
Signature of Applicen
SIONED UNDER THE PENALTY'
OF PWWRY
DESCRIPTION OF WORK TO BE DONE /
MAIL PERMIT TO- 4 :�c �� �� �,✓ o �zr
APPLICATION FOR
PERM TO
77y,��
MIT G TED
/l� D
INSPECTOR OF BUILDINGS
,
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON amsEr, aRDFLOoR
8AL[M,MA 01 G70
TLL(975)745-"95 EXT.380
FAX (&76) 740.96"
STANLEY J. UaOvmr, JR.
MAYOR
DWOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34 1 aclmowledp that ar a ca n"m
of Bm7di4g Permit 0 .all debris resulting fire&a conouc&m acdyty
governed by is Bui th lding Permit"be maposad`of in a propWy licemed aOH&wasla
disposal facility,as defmad by MUL c Iq,SIX&
The debris will be disposed of at
Location ofFamft
SiignatmeofPermit licmd ate
FULLY complew the&DOWNIS(PLEASE PRINT CLEAR msos on.
I?AVYL )G� GATT
Nam ofPesmrt Applicant
Firm Name;if any
if 14 A m ZI c,
Address,City&State
The above statute requires that debris from the demolition, rmovadon,rrbab or odw
alteration of building or atTimun be disposed in a properly-licensed soli&waste dbporat
ficility as defined by MCI cIq S150A,and the building permits or licenses are to
indicate the location of the facility.
' .1Japaalwsal d��ar✓rdria��aralids• .
boo waILA16e Sbad
mastweeas Boodow, Mumajr.b 021/
c«w.aafw .
Workers' Compensation Instsrance Aflldavk
. . w101.a prindpei place of business an
do hereby•cer* under c)n pains and panilties of perf.my, clow
U � anplftw providing workers' comm peatke cinftfte for my daploYeea working M
146
Insurance Cempasb reaw Number
1 an a sole proprktor and have as ens working idr me to asry capaedq.
() 1 am a sek proprister, eneral cemrs or homeowner (drde owe) acre how lied d a
cemtactots listed bekaw.w o•have the following workers' conwessaahm poNdan
ComraeteK Insurances Company/re Nuw6w
Comracsor Insurance Compasry/re NU"W
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
•1 raaanu"sw a CM of di waaasawWit be fer..aroad as dw clue a M.a#aaom of ow D"ter carers"rwncodw am an barao a asvo
aowrap a rrea►rs~Saba.SfA d WU 15 2 ran kse w ow ira- -iaa of- I - oeaasfn coawsdaK of a saw of a ni I.NO asNer am
rem'iwoo.wret a vs a d.t araaoia in dw wm*to STOP WORK ORDER sae a far of s iciaAc s ssr spba ace,
SiEncd this, day of ��, g�o +(
6S3 99 7 N-1 1 o 11 7
.iccrsctiFermintt cnlldnn{ Departn.ent
Licensinf Ecard
Seiectmens Office
=faith Dtpsr:mer,:
- --.eFCC ='e - : 4ee ape qpe 775