17 BELLEVIEW AVE - BUILDING INSPECTION (3) v
-PL-AMqdtISTeE f4L*D,4W0.APPROVED BY T*IE
P TQ1T ,PFI DJ3 TD A.PERMIT.BEING GRANTED
Z?q CITY OF SALEM
No. "Z C>v H�:`� "� '' � Date q -) 3
Is Property Located in Location of '� 8�,�� eu e1 '
the Historic District? Yes_No_ Building I W Q
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R roof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replac 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
Address & Phone 1-1 �ie.1��.vier�J Ave. (11b) -lLiq -Soso
Saerr, , Ma . 01 `rio
Architect's Name
Address & Phone pp ` L )
Mechanics Name ( MA- \bbo 5Pwl e-S,
345 Cz•czt(\woo S .
Address & Phone lk)oc-c . Ma. (sob) -IS6 - 6686
What is the purpose of building? �:a`M,14
Material of building? If a dwelling, for how many families?
WIII building coptonn to law? Asbestos?
Estimated cost 1 a. OD City License 0 N A State Lic e q
� W" Home Improvement
` �/ Lic. i 1 lb8 "'
S gnature of Applicant
C 1G S�33 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
J16S n0 b
3
a� fUC,A-Uco. 1n G'na e s U - Vvck e O .3y
v
MAIL PERMIT TO: Coo Vf Cpw nr
1
No. 2g o
APPLICATION FOR
PERMIT TO
LOCATION.
I7
PERMIT GRANTED
INSPECTOR OF BUILD GS
Y
. DM lj
ommanwaafik 0 V46acL6eU6
n t7� n I
,y ePar ma O
nn , /600 � .ki ylon S1,481
.lames J.Camooe6 f�O I I/asue1uualla 0211!
corrmrsmorw
Workers' Compensation Insurance Affidavit
wich.a principal place of business at: n 1
�a00 C.o� 2-D�
3�33�do her y certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
Comm rC -� T Us�l-� w c cm �6a l
Policy
Insurance Company plumber
1 am a sole proprietor and have no one working for me in any capacity.
() 1 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 underwnd wt a coot of this wtement WR be for aroed to the Offce of Inv"dgaoom of the DIA for coverate•eAkaton and wt Wure to wave
coverall at re0uce0 unacr Section 25A of MGL I S 2 on lead to the inoouton of cr'vni=ot"ties corsvdnt of a &u of Oo t081.500.00 wwor one
ytari+ttxuonmmt x.A as ciri"wiaa in she form of a STOP WORK ORDER ano a foe of s I oo.00 a oar against tile.
Signed this —] +6 day of S t✓��PIfVI er, a�43
Licensee/Permittee Building Department
Licensing Board
Seleccmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
I
QF SALEM: MASSACHUSETT5
`O PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
$ALEM, MA 01970
, I K. TEL. (978)745-9595 EXT. 380
�Gmu FAX (978) 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 Pe
rmit# 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: �� QU A lJ 5 Q CU
Location of Fac '
01' �1 'D3
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
QM� rr,� �erv� �e5
Firm Name,if any
311s GAY wo�a s�
A )orC . M a . oibc)-
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.