75 BOSTON ST - BPA-2004-272 CONSTRUCT GARAGE CK I
10�IdeST-BE f11L-Er A,PPR0VEI3 8Y T44E
.I1�ucuiR ,PFDR TPA_PERMT.BEING GRANTED
CITY OF SALEM / J
No. ?'-7 Z 'ZG c7 `� �+• ���� Date
—�L
r
J
NK .
Is Property Located in / Location of
the Historic District? Yes_No Y Building
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,
Repair/Replace, Other: Ceh A�, -/
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 NameA
Address & Phone fU70.1�
Architect's Name
Address & Phone ( ( )
Mechanics Name
Address & Phone ( )
What Is the purpose of building? .0 c n
Material of building? Q)n n r-> r/ If a dwelling, for how many families?
Will building conform to law? Yyr Asbestos? L /0
Estimated cost .1fi'6�City License # N P' t7fft:
Z—12-2 C�o�( Home Improvement
Lic. i p
Zg �= Signature of Applicant
C-V- -7 2-9 SIGNED UNDER THE PENALTY
URY
DE -R PTI ION OF WORK TO BE DONE 7EEOJ-_
bo C o s
Pt° 7 i
M ERMITTO: li. � � Yd.
No. Z-1 2-2cc-,-3
APPLICATION FOR
PERMIT TO
/�
f(/D C/O fo
LOCATION.
PERMIT.GRANTED
APplmOvFD
INSPECTO OF BUILDINGS
k
- A
i
i
- 3avbo a3
o
V1'.'JLWV3 Fit
O�Z']L O7TONIMt Lt.1 �. .� P
lo
WIZ)
b9wb0Q'
L1::- TRIt'1 — '\
PL)-'U D.
PMWEL (T)'P)
� El -
4 n
JR,
--------------------------------------
,
p Li
FIRONIT
4 �'
In -
I
> I �
_p
GRA'�-EL :FILL
SECTION A /A
SCALE 31,11,11_oll
I
i
i
�O%J 4Z- . �lkRA9 a
I
ca•.0 PAD
OL ldS
I
I
r.
0
� o
/go 03 f/c #7/ Z
V. (9`C f B` rYP)
\ BS
6 /
Z `r
c
m DEED REFERENCE
Booms /7 393 /A�/G 2_PG GZ, /7/
PLAN REFERENCE.•
�g3,, PC�aIB
I CERTIFY TO
PLOT PLAN
7NT TI'E DX�� OF LAND IN
ocArm r� AND is sRouN
77 REsuL T G- AN r EY. SALEY, MA
a/cs MICHAEL
0.
?laa
• sowo H MARCH 3 2 00 3
NO
.34609 SCALE: 10 = 30 1
COASTAL SURVEY
AADS70RTH YIVAGE — D11YURS BUILDING
T� FROF I NAL LA S V� Y R 130 CENTRE ST. — DAMRS, 31A
(978) 774-990
U 30
77Y OF SALEM.
�o.36 PUBLIC PROPERTY DEPARTMENT - -
• ° 120 WASHINGTON STREET, 3RO FLOOR
< $ALEM,MA 01970
J, 7
TEL. (978)745-9595 EXT.380
py� FAX (976) 740-9846
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge 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,13150A.
The is will be disposed of at. l b'v`
Facility Location of
ignature of t App 'cant Date
complete the following information.
E PRINT Y)
Name of Permit Applicant
Firm Name,if any
Address, City &State
The above statute requires that debris from the demolition,renovation,rehab or other
disposed in a ro erly-licensed solid-waste disposal
di o P
alteration of building or structure be sp P
alter € O
. . building
Permits Or licenses are t
defined b MGL cIll, S 150A, and the b g
facility as defm y
indicate the location of the facility.
• fottrrnmonwaafi 01 I,` CU6acL.tf6
s . ��J
Jepa lmant ./ Jardusl.iaf s«ia.rri�
600 Waa�iopfae
James J.Canatloe� f)osion, /!/a»aciaua.W 02111
Ctarmrssroeatr
Workers' Compensation insurance Affidavit
I• _ t NP A- 'JU y c l---ti
(ivrwgeeaa.sn)
wither principal place of business at:
�do/hereby'ctrtify under the pains and ptnalties of perjm 1, that:
t� I am an employer providing workers' compensation coverage for my employees working on
y this job.
Insurance Company Policy dumber
1 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:
/� nrucric;yC � t�
f Contractor 1 urance Company/Poliq Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unaerstane we a coot of weemenr wal be ion arota to the Ottce of lmctgat m of the DIX JW co. sre eerWaden ana Yari laietre to aeaan
cc• atf sr rewr<a once 5 don 25A o GL I S 2 on Ioa to the:r oovdon of crenirwi ocnatem corsodnt of a fine of ao ae-S LSDD.00 anta/x one
ream' rarwnment a+ of cii ""i the I [a $TOP WORK ORDER/ana a 6"of s IooAO a oaf a[wroe •
Signed this -e4_ c day of
:.iccrucci Fcrmiuee building Dtpartn,ent
L censing Board
Seieetmens Office
Health Department
��,i , �G'.rEF -.�� �NF Lam_
-qOO X4Q= 40< 40z, 400 z?t