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43 APPLETON ST - BUILDING JACKET -ft-* SMOST-BE filEG-A+40 APPROVED BY T*IE ,i' pjXTD_R PFUDR TP A.PEBMT BRING GRANTED CITY OF SALEM \\ 5 - F_ 0s No. -� �� Date s ��NINB OPT! Is Property Located In Location of the Historic District? Yes_No Building y f Is Property Located in the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) 9,004-QsuxQnstalI Siding, Construct Deck, Shed, Pool, Repair/Replace, ther: 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: Owners Name �� ,t Hf k,4 6 l PA Address & Phone 4J3 fqpp1 eJ-0A)f ST (928) 945 - 601� Architect's Name A/_ A Address & Phone ( A ) Mechanics Name ,A-,ej 53 fJ6 On OLLUC*01V Address & Phone 0 ffm etC 6� �qq_ ?6 �1 _ja e-rn What is the purpose of`building? Material of building? Lc)Dob If a dwelling,for how many families? Will building conform to law? 4 Asbestos? A20 Estimated cost o24 ISO, JLf City License t N P' State a sex Oo)3)13_ Some Improvement Lic. i 100272 I a ur o Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE p SJ C r1n, ) MAIL PERMIT TO: /c/o 6 (10akk- -g I Al /,? C0mm trCI4/Sf S?1-1Er01 A- 9 D t an No. APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED APPgbVFD 11//) „4, J INSPECT OF BUILDINGS Page No I of Ppges. 1036 i = SALEM: (978)744-8641 DANVERS TEL:(978)TT7-7310 PEABODY EL:(978)535-9968 CONSTRUCTION FAX: (978)744-8647 18 COMMERCIAL STREET WEB SITE SALEM, MA 01970 - 3917 httpJAvww.MDB-Construction.com PHONE 7EI TO Mr. S Mrs. Miraglia 978-745-6016 9104 43 Appleton St. JOB NAME/LOCATION Salem MA 01970 Revised from original dated 8/5/04 & JOB NUMBER JOB PHONE 1036MIR We hereby submit specifications and estimates for: Installation of partition walls, and miscellaneous work so as to re-define bedroom spaces to consist of the following items: DEMOLITION: 1) Selective demolition of two interior door units to be re-used in other locations. 2) Demolition of existing closet wall in the spare bedroom. 3) Demolition of ceramic tile floor in new hallway. 4) Demolition of existing partition wall so as to relocate door unit- 5) Selective demolition of vanity to be re-used in other location. 6) Demolition of two fan units, one track light, and miscellaneous wiring as per plans. 7) Demolition of existing exterior window unit- 8) All job related debris to be removed by MDB Construction. FABRICATION: 1) Installation of approximately 34' of 2x4 plastered partition wall so as to re-define space, and infill openings. 2) Re-installation of 2 interior door units, and one new unit. (6 panel pine) . Note: Moulding heights to match upon completion. 3) Installation of re-used vanity in new location as per plans. 4) Installation of 2 Anderson tilt wash window units. 5) Installation of all necessary mouldings to match existing. 6) Installation of 1 closet shelf and clothes pole in each closet (quantity 3) - 7) Installation of pine shelves in remaining space at vanity location. 2 Qcou1Z TEL_Fc-ot-> op t(Izq(o4, INCL.vbcS , Co J5-rf_WCT(C (1 OF NtW C-L-05GT OL1 OF 4, PANTS- 'b'n"L - INSTMI�t FFTtot1 of Nam" tSr0 R f�naownbOvQ (NS•M�-L-h-TfoP3bF Iw S2z7�+Koc fLac�iVl1JDC'2 Pzt2 o-at6rt-plc- fErote4eb Sr!E�_CCEE 'DRrZt) 3c,&JE ak, 2-004� W(D IPIItIDgGi3e hereby to furnish material and labor--complete in accordance with the above specifications,for the sum of: Twenty Four Thousand One Hundred Fifty and 00/100 Dollars dollars($ 24,150.00 /Payment to be made as follows: - Payment 41 - Upon Completion of exterior roof $500.00 Payment #2 - Upon Start of Main Project $6,000.00 Payment #3 - Upon Start of Framing $6,000.00 Payment #4 - Upon Start of Plaster - $6,000.00 Payment #5 - Upon Start of Hardwood Flooring $3,000.00 Payment #6 - Upon Comp. of Project - $2,650.00 All material is guaranteed to be as specified.All work to be completed in a professional man- ner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders,and will become an extra Signature: charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tomado and other necessary insurance.Our Note:This proposal may be 30 workers are fully covered by Workers Compensation Insurance. withdrawn by us if r2 accepted within ACcSepQA race of 1Pr0p Mfl --The above prices, specifications andconditions are satisfactory and are hereby accepted.You are authorized Signature: to do the work as specified.Payment will be made as outlined above. JJ 0' U CG O/,- �. Signature: U Date of Acceptance: LJ Ci Page No 1 of P?ges. r 10362 SALEM: (978)744-8641 DANVERSTEL:(978)777--7310 PEABODY PEABODY TEL: (978)535-9968 CONSTRUCTION FAX: (978)744-8647 18 COMMERCIAL STREET WEB SITE SALEM, MA 01970 - 3917 http://www.MDB-Construcfion.com PHONE DATE TO Mr.. S Mrs. Miraglia 978-745-6016 11/9/2004 43 Appleton St. JOB NAME/LOCATION Salem MA 01970 JOB NUMBER JOB PHONE 1036MIR We hereby submit specifications and estimates for: - Continued from Page 1 ELECTRICAL: 1) Installation of 5 receptacles, 4 wall sconces, one 3-way switch, one fan light unit, relocate one GFI receptacle, 3 smoke detectors (hardwire) , miscellaneous deletions, re-switching of existing, and one vanity light. Note: All light fixtures to be supplied by owner. HARDWOOD FLOORS: 1) Installation of hardwood floor (oak) in both bedrooms, hallway, and stair landing. 2) Installation of 12 oak treads- 3) Installation of one coat of sealer, and two coats of clear finish. Note: Color staining will incur additional charge. ROOF REPAIRS: 1) Installation of roof patch on building bump out. 2) Installation of ceiling patch on damaged area of ceiling. Note: This item is for patching only - EXCLUSIONS: Painting by owner. 'We IPIIGgO1e hereby to furnish material and tabor--complete in accordance with the above specifications,for the sum of: Twenty Four Thousand One Hundred Fifty and 00/100 Dollars dollars($ 24,150.00 Payment to be made as follows: '.. All material is guaranteed to be as specified.All work to be completed in a professional man- ner according to standard practices.Any alteration or deviation from above specifications Authorized - involving extra costs will be executed only upon written orders,and will become an extra Signature: charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary Insurance.Our Nate:This proposal may be 30 workers are fully covered by Workers Compensation Insurance. withdrawn by us if njqt accepted within day ACCCCCr°pftimce of IPII't pwd--The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature: to do the work as specified.Payment will be made as outlined above. Date of Acceptance: OI bCC yt Signature: (IcA , Mlragua �(� 43 Appleton Street Salem,MA 01970 • Construct new hallway 3l3"=1'(approx) walls. Remove walls as Storage Room June 24,2004 required Existing Closet New Closet Hardwood Revision 2 • Relocate 2 existing doors O New - Floor from bedroom and Door Closet bathroom. Bathroom • Construct new closet ExkIng Tile similar to existing In FR wallway. ove Tile Hardwood • Install door for storage ebcatednstall Floor New room Doordwood Door • Install all trim and ----� i moldings. Finish all surfaces and prepare for w°ib painting/staining by am°u+• Old Chimney owner. Closet _ • Move Vanity as required - • Reprove rug and the and Install hardwood floor:. Preserve the In Relocate i. l a bathroom. Replace 1 Door I • Install new double Window with window In small 2 Windows Bedroom Master bedroom. 2 Individual Room Bedroom windows to facilitate AC Unit. • Remove track lighting. • Relocate a single clleing Optional fan to room center. Hardwood Hardwood • Add stairway and Floor Floor wallway lighting. • Install receptacles in wallway and new . bedroom wall +c<ms. • Relocate Ilght and fan 1 4 switches appropriately. Y 77� r �✓i�" �q�. , • f yj)Po I/ 1 r "0.:.'''.r, ' �...--- ... •. � ...'...'� a '. '.. :, ..L ..1. �JOi .•.. -1 .J':b}:Y n+VLL..Y jr.��+l' . bp i �11 11 1. • � Fi f is{n ..•." it � �: {:. :A �' .......... � ...: .. .,.r'.::�... 31 C ' �.GwiANY "t { i; .'. �, , {t yf,i+,dZ"�r+yi1(i,�) �ae..$. P. w: t- en LL= uLrA v , ; Z. LLL- U `� U [L 1 6 DATE: 9 •a b 7 v Citp Df �arPnt, JRaE;E;arbU5Ptt5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Location of Building _ J I e�p Building Permit Application For: '(Circle whichever applies) Roof, ro , Install ct Deck, Shed, Pool Addition, Alteratio air/Repl ,Foundation Only, Wrecking 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: owners Name:_ pn yn Isp Pi Taal I Contractor: A > A 5erV'IGe51 ehn5 Dr7 Street li3 Anvil d6 4 City, llen street;115 Mnt'4h City Ism State, Phone (99g)_qq 5 -(001 C� State Mfl Phone• M's 7.91 -_M A�q Ambitect: City of Salem Lic# I�-1 D5 Street City State Lic b 57 HIP# I D I to 09 State Phone ( ) _ Homeowners Exempt Formes—Lno Structure: (please circle gle Family, Multi Family# Other Estimated Cost of job S3D, D/OO, 00 Will building confirm t law?✓yes no Asbestos?___yes�no --Description of work to be done:_-t 1_ Vlnul s�� ina : SnSfizll Yi iP (�l re�la�pr��v� (Iag wro — hn12ar px14ro 0)mjev rm0 an C70C g� 1.0 i h ZI A '6a r n ry S ru W A&A SERVICES, INC. Draw�ing9b fitted:_des no Mail Permit to: 1 SgLEM,MA 01970 Signature of Applic on,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE Department use only: Permit# Zoning Maplut i Permit fee S 1 l The Commonwealth of Massachusetts 6 Department of Industrial Accidents' Office of Investigations ►� 600 Washington Street �& Boston, MA 02111 f www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber's _Applicant Information Please Print L blv Name(Business/Organization/individual): Q A Sot^Vi as 1 ,Tye La Address: 1 [� D r+h Stream+ City/State/Zip: tit p p 9-7 Phone O/A 9,N A reployer?Check the appropriate box: ployer with_�_ 4. ❑ 1 am a general contractor and 1 Type of project(required); es(fill and/or part-time).* have hired the sub-contractors 6. ❑New construction le proprietor or partner- listed on the attached sheet. _ �• El Remodeling have no employees These sub-contractors have S. O Demolition 4'` for me in any capacity. workers' comp.insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10•0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no insurance required.] t employees. 12.[v�Roofrepairs [No workers' comp.insurance required.] 1 ET'Other *Any upplicant that checks box#1 must also fill out the section below showing their workers'compensation'policy information. t I lorrs:owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contraetors that check this box must attached an additional sheet showing the name of the subcontractors and their workers-comp,policy information. " . I am an employer that is providing workers'compensation insurance for my employees,'.Below is the policy and fob site Information. —ft- insurance Company Name: ' r`e— Tiro VD 1 f y:s Policy#or Self-ins.Lic.#:�[(' q rli4 X 1 `oZ n Expiration Dater- 1Z p'-] Job Site Address.-A3 AV plfjMT !3IYP l City/State/Zip:��(IC Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date) . Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Id2de the pains and penalties of perJury that the information provided above!s trae and comcL Si nature: Phone#: �1$� /J OJJ7cial use only. Do not write In this area,to be completed by city or town 0 ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of He alth h2.Build ing De ar g p tment 3.City/Town Clerk 4.Electrical rtcal Inspector S.Plumbing Inspector Contact Person Phone#: jai h' DISPOSAL OF CEBRIS AFFIDAVIT f In accordance with the provisions of M L. c. 40, Sec. 54, a condition of Building Permit Number is th Itthe debris resulting from this work shall be disposed of in a properly licensed fi bility as defined by M. G. L. c. 111, Sec. 150a. The debris will be disposed at: Sale fioransfer Station owned by Northside Cardna _ f, Sign ! e of Pe it Applicant aid Date ,fig 1 e iI�I ki iF 7• JNIy ti Christopher Zorzv :M Name OfPermit Applicant A &A Services. Inc. , ,, Hrrn Name ; : 115 North Street. Salem MA 01970 1 1 Address, City, State, Zip Code i '+ a� hi t�' J BOARD D gUIML G REO Ng i- ' License: CONSTRUCTION SUPERVISOR ' + i Number, CS 057733 ' Blrttsleb:�05/26/'�958 I ! a9aa Ikpl __ 65R Tr.no: 12633 Rel� �H iij CHRISTOPHER :�f - 115 NORTH ST SALEM, MA 01976• - �� i Commissioner 1 I . :^ ✓�t¢ TJom'xa9utM�� O�,fGi.War./uwelG �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101609 Expiration: 6/26/2008 Type: Private Corporation A&A SERVICES, INC Christopher Zorzy 115 North Street «✓la...` ; Salem,MA 01970 Deputy Administrator Commonwealth of Massachusetts Division of Occupational Safety Robert J.P1ezwo,Commissbr!er ' Deleader-Contractor CHRISTOPHER ZORZY - EB.Date 04WM7 Date 02/OB/07 DC 0 DC000440 Mm to d C.O.NE.S.T. . 7 BOBB®®�� NN ��I�eryl I�'ryeB BB�Masss��sAp IAA .BB yppeeW�'nn�� IIH��tl��IN��IIYI�WM�I,IG��IAO BOSTON-RENEW ' —� o , The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State q Building Code, 780 CMR, 7th edition OF SALEM Revised January L' I Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008 �{ One-or Two-Family Dwelling 0 V This Sectio For Official Use COY Building Permit Number: Date Applie Signature: A-1/-711 Building Commis sroner/Inspecto of Build' g Date SECTION TE INFORMATION 1.1 Prope ty Addres : 1.2 Assessors Map&Parcel Numbers n tre-o 1.1 a Is this anaccepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. caner f R -/-) (/ /� � Name(Pri t) Address 41 �4p- 9�� X553 53y Signator Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) N1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief D scri ti n of Pro o ed WorkZ: n�rri l I OQ l,0_Yl SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ CD 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost' (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due: ISI SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 5 Is 3 5 /Q{ /� License Number E natio Date Name ofCSL- olde Cyt List CSL Type(see below) „ I sHae 3w Addre s Type Description U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling SignatureM Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition S. GRe ist a Home I trpro ment�gp actor(HIC) /6/ (009 I C mpan e or HIC is ra t N /e1 Registration Number Addres 2 20 Exi5iration q [e Si Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. C. 152. g 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 5k,0 04 M I roel / , as Owner of the subject property hereby authorize to act on my behalf,in all matters relative qorkthorized by this �ing permit application. � 11�13�1D _ a re of 0wner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION ] I, �� /r J / O[J kJ_ /-- z6rz cl ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoin plic ion are true and accurate,to the best of my knowledge and behalf. C)v r s Z�r2 Print Name Signature of Owner or Authzed Agent Date un (Signed der the pains andpenalties ofperjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 IO.RS,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ' y The Commonwealth of Massachusetts [ � Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 = ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):n c a p(uy i `'x S I t.I e. Address: 11b Mork sjtQL+ City/State/zip: I nh 6 19 0 Phone#: 9 Are u an employer?Check the ro riate box: PP P Type of project(required): 1. I am a employer withCA LI) 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.©r H///l ^'/n a Other t V (IU A comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t� C Insurance Company Name: �QI fI T �� Q�V� y��r�� Policy#or Self-ins.Lic.#: f l(� I ��t Expiration Date: Job Site Address: U S&pu-- City/State/Zip: Attach a copy of the workers'-compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify an e the pars and p nalties of perjury that the information provided ahove is/true and correct. Signature: Date: Jd �I ' Phone#: I V _ 1 vl O �I 1 01 u Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 2 WIVED BY TiiE NG GRANTED ICITY OF sALEM r: No. o.a Ida Dldlld'1h yM lip ioestloa of a s -`3 PppIE7 ft CpnAr9nMN'! Yam_No BUILDING PERMIT APPLICATION FOR: Permit to: (Grote whWMW a") R I S �ontquM. -Deck. had, Poe, epaidRaplaw e: PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROl 1M TO THE INSPECTOR OF BUILDINGS: The t undersigned hereby applies for a permk to build according to the bNwA*p Owners Name ! I +Z t tf PIS Address & Phan III � Arohheces Name Address A Phone d 1 Mechanics Name Address & Phone rlww a midlg4 W©n'l) I a dmft,don how nnrly km1w? t Wo bul"nonfarm to U e S n.e..as7 a3 DO0 t�aanwpd aok. or uc �• N A llorw r ■a.. t y ' Sigma ure of t SIGNED UNDER THE OF PERJURY DESCRIPTION OF WORK TO BE DONE to rA MAIL PERMIT TO: I�I1� P� ConS'IleyC-� ��p�(J �� CD i..,, aVY"erC.lA,-1 ST - • -3` APPLICATION FOR fio �P�✓ oec(C oec��° ,. . LOCATIo,N s y=n/� � PERMIT GRANTED 2.0 t _ INSPECTOR OF BUILDINGS L� y 7 ' PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM,MA 01970 TEL (978)743-939E EXT.360 FAX (976) 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 constriction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MQ,c S 150A. The debris will be disposed of at S i --A� Location of Facility Signatlue of Permit App Vate FULLY complete the following infomiation: (PLEASE PRINT CLEARLY) l M -b-�!:) . Co, Name of Pez=t Applicant Firm Name,if any f r ('0 n'Vh21LCi P,( Address, ty&State The above statute requires that debris from the demolition, renovation,rehab or otber alteration of building or stricture be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S I50A, and the building permits or licenses are to indicate the location of the facility.