35 CEDAR ST - BUILDING INSPECTION (2) fL�MMT13E f R994AD APPROVED BY 744E
ASPJ:CMR PRIOR TO A PERMIT BRING GRANTED
CITY OF SALEM
d� \ Ode
\ I � ward
zorttrtg District
Is Property L.00ated in Location of
Qte FNstorto DISI t? Yes No )G a drains � ZT- �C--X qk S�
Is Properly Loaded in
ft Carteervadon Ana? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Retool, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other K,-rr, ite;tj L0A )A4c,3 - gri-, [--(x1kP-CrS
PLEASE FILL OUIT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '.
The undersigned hereby applies for a permit to build accordcrig.to the.following
specifications: /1
Owner's Name � 04-m C/In t Y I�a,ct/�� cvr)rJ-#P-D
Address & Ph e 11 h I�,L i S— ( 97g} 5 -)�y o
Architect's Name
Address & Phone ( }
Mechanics Name 1 2 YES 4 j
Address & Phone �°I `�O��CS fV�e �1QI'R HIS)
Whd Is ffte FXpoea of btdldktg? Q L s 1"-n n-(
Md eft of trt~ n a dweb ,for raw nmy famaes? 3
WIII btA&V cordorm to tow? S Asbeeaa?
Edmided coatf F L P) 0 G Cfy Licetw a sea U0W=e
'J Hans Iapso+eeent
Li .
Lie. /
mature of cant
SIGNED UNDER TH TY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ciJ Iz,�� l ei rg al fixkgvr,cs
MAIL PERMIT TO:
No.
APPLICATION FOR
PERMM TO
LOCATION
PERMIT
GRANTED
19
AP �O/VFD
GZtR,,.o
INSPECTOR OF BUILDINGS
m
RL �
BOARD OF BUILDING R IATlOti3
:tUcense: CONSTRUCTION SUPERVISOR
Number: CS 082483
Birthdate: 07/28/1968
Expires: 09/04/2006 Tr.no: 82483
Restricted: 00 ,
TOMASZ KOTAS
55 SUTTON ST#3
PEABODY, MA 01960 Administrator
�G/n/rSO/LlYg7fELifl of me�flclJd
w 31-ed
t canoe d [>'i don, Mumaa<.r.a 02 f I l
Workers' Compenudm Issurance AffMov e
. . wFdia pr6c%W place of badness an
.2�Y �YdL�>NG
do hereby•cerdy under t)w paha and penoA In of peri.maye than '
() 1aan employer pnWIdtni workers' couipemstlen covefte for nq dapieYeee woeking m
IMIL
ONE C ut,14 L•-Y J^0 `
Insurance Cbn*n r Poliq Nunabet
K I am a sole proprietor and haw no out working fir me In any opade,Y.
0 1 am a sink proprietor, general commcgor or homeowner (drde one) and Moe lid tM
contractors lined below who-haw the, following workers' compensation pofldw "
' Cenvaeter irsuranu Ceenparry/Po Number
Convaaor Insurance Company/Po Nundtee
Contractor Insurance Compasry/Polio Numbs
0 1 am a homeowner performing all the work myself.
• rna,nuM ON i see/of daY ANOOM.s be fern wend a ON Oise A M.adjaeew of du M Iv C~ap rafhados see an lira r soon
COMM r newts.aMa•Swdse 2IA N MGL 152 can 4ag w ow' . d akpiow eesade cengsdnt of a 6n of ao 041JODM ansi sing
rrn':wwo-mm a yo red aeantie in she Iona of r STOP WORK ORDER ass a 6n of S ICCAC a ass apbM ar.
Signed this , day of
:iccnseei'Fcrmitcse 6unl6nnf Department
i.icensinf Eaart
Selectmen Office
riealth Deprment
- - _-.ccCC Ye : _ 904 e05 405, !7r
PUBLIC PROPERTY DEPARTMENT
120 WAENINGTON STREET, 9RD FLOOR
SALEM,MA 01970
TEL(976)745-9595 EXT.960
FAx (979) 740-9"6
STANLEY J. USovICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the Provisions of M43L c 40,S34,I acknowledge that as a condition
of Building Permit g_ all debris resulting from the consbucdon sctivity
governed by. this Building Permit shall be disposed of is a propaly licensed soli&wsm
disposal facility, as deft ed by MCii,c III,S150A.
The debris will be disposed of at
Location of Facility
Sngaatlme of Permit Applicant Date
FULLY complete the following k&UAStim.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,city at state
The above statute requires that debris from the demolition,renovation,rshab or other
alteration of building or structure be disposed in a properly-licensed sOlid-waste disposal
facility as defined by MCM cIII, S 150A, and the building permits or licros are
indicate the location of the facility.
I