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10 CHASE ST - BUILDING INSPECTION i+t 9tiPSidl�iSi"9E fiL{• �4NDl iPPROVEfl $Y T+IE U�ISFFJrTL>A PADA �la PElIT BEWG GRANTED CITY OF'SA'LEM No. ��• Date b "Wit Is Property Located In V Location of ' O �L _� [� 1 the Historic District? Yes_No_ Building Ili J / Is Property Located In , / the Conservation Area? Yes_No V BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roo Reroof Install Sidin , Construct Deck, Shed, Pool, Repaid place, they: t3g''t k ROP E!2� 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 oLavrier w, goyc, h qrj O Address & Phone C hqs* S ( r7o► 7 ° 164' Architect's Name Address & Phone L Mechanics Name C u rT s Jb r h Address & Phone L A b6tt- SgAent Pill ((?79-) �71414 — h47J What Is the purpose of building? R e Poi r 84th !PO ")Material of building? If a dwelling, for how many families? ©� Will building conform to law? /�c7 Asbestos? 'nY O Estimated cost 9MO-00 City License it N P' State License r J� Bona Improvement c ,1 3 C ►� 3 i 3 N2-73 /1 Signature ofApplicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE R-eY►av4tf a tV o rotfS qt'h /'oo "l �CrH a(/t0 Fd t��eS 6valls Floa(s T CoeliA, .rn.S7��1yeyyll Ta ovT,Stie �f t ArSSI17irry a vT-er walls T C tl'r� �,., 2�,�,s rq 11 F-10W, "i—k Clet P T PQiA,)r' ' MAILPERMITTO: 6 gbbd-r+ &T S9I`eM i � 01470`6! 02- . i No.' 2c- Zoo g APPUCATION FOR PERMIT TO LOCAT PERMIT GRANTED -- 72—t � 49 0 APPROVf,D INSPE4TOR OF BUILDINGS aa.. ��jj II COmmonWtiafik 0 Y46ackwatb 5 �eParlm./t1 a/�RdYllrial �CCi6/.eAb 2 n/ 600 W u inylon.SIr..1 James J.Camooe6 C7 A. , ///asaach .1h 02111 Corhmsswur Workers' Compensation Insurance Affidavit 1, _ GurTS L ORtAC,O W 6 13b6 -n 87- s4lrnl nfq. 0197() with.a principal place of business at: U To 1P Sy' -• M14 0f9-)a (ratrrsw✓ttrl do hereby certify under the pains and penalties of perjury, that: () 1 am an employer providing workers' compensation coverage for my employees working on this job. fQrm r-am; i a0os �( 0b39 Insurance Company Policy Number I am a sole proprietor and have no one working for me in any opacity. () 1 ama s for encral contractor or homeowner (circle one) and have hired the contra ors 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 1 am a homeowner performing all the work myself. I undetw"that a coot'of the moment wa3 be for aroed to the Office i+7 bnesdpuons of the DIA for coverate.er;k3don and 03t Were to feeare coverate at reourea under Section ISA of MGL 15 2 cm Ieao to the invoRdon of crcninai oenmdes corsadnt of a free of tto mi 1.500.00 and/or ones reari inornonnrent v•ua a<eiA xnaidmts in the forof a STOP WORK ORDER ano a fns of s!00.00 a mr atainst me. Signed this .� �y, 4 > day of 7740- 03 Licensee/Permittte Building Departneent Licensing Board Seleeimens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375 i 0o r OF SALEM. MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT p e 120 WASHINGTON STREET, 3RD FLOOR SALE14 "MA01970 _ TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY 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 Id,S150A. The debris will be disposed of at: Sq i,#m -rf 4 K S Fet' s t4 tov J N1 d f 7 �SJ�� c 41c}k Location of Facility 49J,-Z� - 10 - 03 Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) PRACOry Name of Permit Applicant ai(T Leh tSCgrf -f- C0vN3TIvCTIoh) Firm Name,if any w4 D1470 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, S 150A, and the building permits or licenses are to indicate the location of the facility.