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38 BALCOMB ST - BPA-2004-388 REPLACE 10 WINDOWS tiw t 4 14riSIMOSi' APf)ROVED BY T*IE PFWR TP!A PERMIT 13,EWG GRANTED v CITY OF SALEM Nib No. Date t.. Ward a , r \"crnrnco°'�. Zoning District Is Property Located In Location of the Historic District? Yes_No ✓ Building yV 0,91romB Sr Is Property Located in / the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool, RepaidReplace, 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: Owner's Name /ii y" r /jyER Address & Phone 38 8,fZcolh9 sT, SAlFm ,jf4 (?7P ) Mr- ©!?e Architect's Name Address & Phone ( ) Mechanics Name 4`014AIa1 G'E4-PIR041 Address & Phone (fin 1?41(or,11 XT, S41,1A, MA What is the purpose of building?/kr:S loIEwCE Material of building? 4/0 drA If a dwelling, for how many families? A Will building conform to law? )yS Asbestos? {/O Estimated cost dP 6 0,VOCity License # 06/3 State License # 04 0rPa Home Improvement Lie. f /OSo GO Signature of Applicant SIGNED UNDER THE PENALTY l D I OF PERJURY DESCRIPTION OF WORK TO BE DONE iPEP�BcE /O ��,'rTivG urhr/ow s cvr'T// y,ryyL �Ei°�i9��r,�w T /�/� is C!JQ'FQ Gs�7�.Qrd/Ei CA.fin,GSr ETC 4/i � �CNiM�iY(r/ri MAIL PERMIT TO: /116E1q7 DyrA 60evm0 S7� /yl,q Z m O o CD mGI a a M�. W C � OZ r pti 46 �f � M d ! t ^ r 3°r i�F 19".93�v�F'4 kG..' �"�.:a "§?tx••;u' A 1 'Shi,l..n!'y«�:. I, . ,i':r10 #" ,�:.tC J,➢t}e« � r.t2';;P,N 11 . ,' n S«!�^" a �,^tY.; ! > . x'x r W F "$$,.J'.''M0 t'jSOq+'A ()'T : cv. .' F.. �r ...i � ! 'Sn,•tli i K Xo CITY OPr SAE_EM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR a rp SALEM, MA 01 970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. UISOVICZ, 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, S 150A. The debris will be disposed of at: d✓oR ru t- Location of Facility 4 ./ _Oa�� /0/d o/0 3 Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) ✓l 01'gwc/ Gtiyallqwi Name of Permit Applicant G�- G Co /yTI-mc Ms Firm Name, if any 40 941coehD ST , S C---M /)M 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 cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. aai''. `\ Common MAk o/ Il a3.6acL ft6 aJ' c•�, n/ 600 -1-11m S1 ..I James J.Camooes Uoaloa, ///as�ae�i�wfG 02 111 comr ssww / Workers' Compensation Insurance Affidavit 1, RoG9n�p GEC?o�v GtG �ovT/1�9c7aRS wich.a principal place of business at: �o OAIc©�,� sT SAI�� r�i�Js- pl9?a . lOq/fur✓1M) . do hereby'ctrtify under the pains and penalties of perjury, that: 1 am an employer providing workers' compensation coverage for my employees working on this job. C/V1�' //✓SuR�9AiC6 ��5.5�911' c-S�k ?7�-�-03 . Insurance Company Policy Number I am a sole proprietor and have no one working for me in any capacity. () 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/faolicy Number Contractor Insurance Company/i oliq Number Contractor Insurance Company/Policy Number () 1 am a homeowner performing all the work myself. I uneencana wt a coot of the autenrtnt r."a be forv.aroee w tht Orrce of Imvccn om of the DII. Ioc corecare •eri&adon ano MX(aa,rre 1O smwt co.erajr v readfeo uncer Section 2SA of MGL 1 S2 can lead to the inoosroon of cranitm oe"em corsotint el a fine of w tei 1.MaQ angler one lean' i'aruommml M tro u cmi "nalun in the Porn+of; STOP WORK ORDER an0 a fnc of $100.00 a er! arairat mt. Signed this 7k day of 0C—oebt uccnseuFerriuet building Depanrnent uce:-t:ing Scare Selectmens Office r,,,;1rh Department - - - - - - 7cC o