16-18 ANDREW ST - BPA-2004-1073 RPR RAILS, STAIRS & DECK • c
yf
1 •4
. R VED BY T44E
P. =INO GRANTED
4.
CITY OF SALEMDft
Is Awaly Loomd In l"at"m of
n.Nwaio owbn YiR_No �ail�lai W r
M Awaly Loowd in
:- No Owwpalgn AmW Yq_No
BMLDII�Ki PERMIT APPLICATION FOR:
Pwmk tm
(Chb whW wr M*) Roof, In9d S( ft o w w Daok. Shad. Pool,
Other. �a
PLEASE FILL OUT LEGMLY A COMPLETELY TO AVOID DELAYS IN PROO11900
TO THE INSPECTOR OF BUILDINGS;
Tho
turd sVW hweby appow for a pwmk to bWid ao�p to tha /okswkq
Owners Name
Addrou d Phom f( 1
Amhknft Name
Addmu a Phone �p c
Mao =Ics Names
Addnaa A Phone eli c% /T(/p �c��r /LIa (r1 766 -04,6A j
7,
p.pm if arm8►
molm d, Adh of "a d' 4 for how arry W 0 1
Mlle edluiq oadam b YaN ;r ;
ab
Enarl.d ad. Od0 cly Ua r fU p` ew.t�ooma r oc� t k.
n of
SIGNF,D UNWIR THE
OF PERJURY
OESCRIPTKIN OF WORK TO BE DONE
�Ci A't • q j
AtR
MAIL PWAITTo IWa .� x* Pd f/r-7 � I,,'
R.
J
e�
k•.p'
A
r
e.
4
1A _
. . � �`. � �/� �ryYINR(Ynl!/P.LLI(/L p�•./��/.lF.M4[�6
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
i � Number. C$ 000311
Blrttidate: 04I0811930
Ez0ires..04109/200b Tr.no: 22149
Restrict®di,;00
GEORGE A AHMED
102 COLUMBUS AVE
SALEM, MA 01970 gcling C mis oner '
PUBLIC PROPERTY DEPARTMENT
` 120 WASHIN .TON STREET, 9RD FLOOR
' SALEM,MA 01970
TEL (979)745-9595 EXT.390
FAX (976) 740-9B46
STANLEY J. USOVIC7, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ,c 40,S34,I aclmowledge that as a condition
of Building Permit 0 . all debris resulting from the consftction activity
governed by this Building Permit shall be disposed of in a prupaly licensed solid-waft
disposal facility,as defined by MaL c III,S150A.
The debris will be disposed of at ��_ /�� S 1,14 Cj
Location of Facility
Sign of Penn Applicant Date
FULLY complete the following information:
(PLEASE PPJM C1XARLY)
Name ofP&m Applicant
Firm Name,if say J
�z eat/, ��� dill /.fir
Address,City&State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of bmldmg or shucture 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.
` E 0.l�O.Celt0
_ Camli10hfU A I i/ RF
6
JJepe.Gnewlal.7.duslriaf.r�eeia ala•
600 wU-jim.31,od
.lamp J.camood 02111
Comntslow
Workers' Compensation Insurance AffidrAt
t
. . wither principal) place of business at:
. . lavnw✓:+q
do hereby certify under the pairs and penalties of perjury. than
() I am an employer providing workers' compensation coverage for my cmpioyees working on
this job.
Insurance Company policy Number
I am a sole proprietor and have no one working for me In any capaaty.
() I 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
O I am a homeowner performing all the work myself.
I uneertf erne a4at a cm of"wg mere ri r..be foaroeo W dx Office of Inaodcaowd of ehe DIA la ca+erate .eelrnadott ano MX LUt eo"care
cce aft as teourro anew Section ISA of MGL 15 1 can kaa to ox ienooWon of ab*'^°�oana�do corAam4t of a fw of a a I.SOOAO+nOfae One
yeah'joroenn,enc n,va a eiae oenaltief'in the lom,of a STOP W ORK O`RIDER ano a fne of S 100.00 a am na.w WA.
Signed this
day of V (J Y! ,cam O
. iccrstt Fermittcc iiuilding Gepann+ent
'�ccnsing Eoard
Seieamens Office
&eS .CS, 7-7t
i I ke
-- L -- -- - -- - - -
T
I
I I ;
I I
i
I i
y
I ,
i lop 01 Der, i
O� I C i .�+ ': N i M I W Ifl I �p l� W � O d' I V' V R I NC � 'Y .I L`• 1 eX � d' i N I I!) I! IM/1 , N I l(1 I IIDj
' � I1
i
KEPAREDEY 1•'
DATE
i 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 J
21
22
23
24
25
26
27
28