8+8 1-2 BARR ST - BPA-2004-957 WINDOWS t . "
11
�L'h}tbiNl�Si'8Ef�-f 4�lD� "ROVED BY T+IE ryd"r r:
Jila xuis ,P+`$1!!aR 7D;Y# PER IT f3E1NG GRANTED a
CITY OF SAtLEM
1
,, "� Date
No� S O v
;,� - -�
Ii Nki I s Building
/✓'
by is Property located a
Location of /
kn, the Hilatodc District? Ye No ��812
;r
is Property Located in
me Conservation Area? Yes_No
,I
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Install Siding, Construct Deck, Shed, Poo
Repair/Replac , Other. eti _!
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PR=C'W 11o11+Jt
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name LOUrS?
Address & Phone fP?r ax 2,
Architect's Name
Address & Phone L
Mechanics Name 4J L "
Address & Phone
Whet Is tfw purpose cf bulldinpt �Si/J�nnc� ?�
Materal of brdiding? 141 neO If a dwelift for how many famYles? Z— , . a I g
J�/ I
WIII building conform to law? �3 Asbestos? /c
Eadmated cost. �J SGZ� city Ucerwe• N A sate ucanse s
�Q (� Bowe Uprooe ent X a� Ii
N�" v� i L — r , i n e ofApplicant
S ED UNDER THE PENAiM
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�o44'II ;
Alv
Prl
�f I{,i l
fill
�o 3YS' �c€r�lwo� S� El MAIL PERMIT TO: � - ,
h � ,
rl
I
i
n p ,
,
R d9
Tit
v
o p,h€
I
if
_ iW �tr
'!, ;!:
s itat•'1
I
t� Iia !xln
I
I lull
r �3
i '
cc 4b id�1�
O
cc
rI, W C7 00
I' t, 2'�,
a,a i-
Q W 4b) a O � k' �' i��f:
UU 1 a Z `Irl ��: i
_
' --� Cornmonwaahk of 1 a66ac"af
s �epac(eu<t101.7.�akf 47ccla a1.a
600ld wkji«t.�L..t
�amcs 1 Catnooal 4�eka, 1•, 021 1 1
ctvr+trtttOnC
Workers' Compensation Insurance Affidavit
with" principal Puce of using" a
G 3d 3
. . lCAtri�tat✓ai)
do here ' crtify under tht pairs and penolties of perjnryr than
i am an employer providing workers' compensation coverate for my employees working on
this job.
Insurance Company Policy Humber
I am a sole proprietor and have no one workasg for me in any capaelty.
Q 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' comptsation polieks:
n
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
Conte ttor
insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I vhoe he wt a coon of tKe ua<mrtm w,,t t i0ry aroed to the Ofrwt cl Inwtirawtts of th<DIA for ce.e<att +elrrttstion att0< {ti/t t°xea<e
i otnattxs eorsotint a ttnt d w tag 1.500 GO anoler ow
coverall as rroireo anotr Section 2$A of MGL 1 52 can kat to the inoo>.uon of cret:na
v ttu m eiri ""Intl M the Ioen of; STOP WORK ORDER ana rnt of S 100.00 a GM apittat Mt.
Signed this , day off - —
nscci crr,lltct Euilcing DePM1 ,cnc
licensing Eoar[
Seleetmens Office
-,�tth Geq:!-mcn
�, ,. • yr �rny v .— T-.��� . - �
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (976)745-9595 EXT. 380
Adnre FAX (976) 740-9846
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 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, S150A.
The debris will be disposed of at:
Location of Facility
✓�S� 1J_
S' a of Permit Applicant D$te
Y complete the following information:
(PLEASE PRINT.CLEARLY)
Name of Permit Applicant
Firm,Name,if any
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 cM, S150A, and the building permits or licenses are to
indicate the location of the facility.