6 FEDERAL CT - BUILDING INSPECTION IM-*#QSIAOST-EIEffL-ED-A O Aff)ROVED BY T*IE
,=PI=CTD-R ,PRWR TO A..P.ESIAIT BEING GRANTED
CITY OF SALEM
No. I b U-Zpo,-j F-." ..� .\ Date
Is Property Located In / Location of (r r? L
the Historic District? Yes_VVV No_ Building nJ l Q SAL T.
Is Property Located in / ��d? (�N P7• h�� �q
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, �eroofInstall Siding, Construct Deck, Shed, Pool,
Repaire, 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: 0Pw_c 1p�
Owner's Name m a• Peck 60
Address & Phone s3 Q, r\A ` S7reQ-%" 1
Architect's Nameo
Address & Phone Iva L )
Mechanics Name
Address & Phone 6L p4�arcu Sr- �� L i`c S ' gZLf S
What is the purpose of building? n Q S ow w, I_ ,
Material of building? 3 If a dwelling, for how many families?
Will building conform to law? Asbestos?
S �Z1Zt,2oo �
Estimated cosh OL=City License # N P State ' arse # J�
c�3So Home Improvement
Y Lic. I
CK 3(ogz Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
-S,vSTfAILL NPW fZ�oK— CN15�2ic �I�sT� tc,r�
V7 vl� �HONE CAI"-t- ;
L 5
MAIL PERMIT TO:
't
No. I fo -20 oL�
APPLICATION FOR
PERMIT TO
LOCATION
!o �
PERMIT GRANTED
APPROVFD
J�l
INSPECTOR OF BUILDINGS
(02. 0c>
oq/
she raids or intends to reside,on which there is,or is
or dctached str wWM acoessory to soeh me andkr
one home in a two-year period shall sot be coasidaed
the Bonding Offreial,on a form aaxptabk to the
such work performed order the building pemdt
bilhy for compliance with the State Bmlding Code and
ML 1
she undcrstards the City of Salsa Building Department.
is and that h/she will comply with said pmcedwa sad
�a OF SALEM, MASSACHUSETTs
v6� PUBLIC PROPERTY DEPARTMENT
° ® 120 WASHINGTON STREET, 3RD FLOOR
g0 SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
�Grnra FAX (978) 740-9846 .
STAWLEY 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,S150Ap.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY 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 cIII, S 150A, and the building permits Or licenses are to
indicate the location of the facility.
Porn rwnwaaa o/ 1/lw3ackwetb
a
5 �eParlmutl o/9r Giaf—.7MOA U
.fames 1 CarnVOO &,I , YY/as,adLaaattf 02111
Contrrussicew
Workers' Compensation Insurance Affidavit
I,
— (afeerearMf�iuee)
wich.a principal place of business at:
ioer,at,,.raa1
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.
Insurance Company Policy Number
I 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/Polity Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I understand cut a coon of 0h4 natenrcnt vn"a De fonvaroed eo the OrKe of 1m 6gawns of the DIA for coeerate+e6ko6on VW cut lame to Secure
coverage a:[vireo under Section 2SA of HGL 15 2 on itad to the :nooSnion of cruniro,ocnmtin corsatint of a fru of w 904I.500.400 and/Or one
rears' 'vaxuonment m.Sect a civ+i txnaltiea in he loan of a STOP WORK ORDER and a fine of S 100403 air nainst tne.
Signed this. day of
Licensee/Fennittee Bui ding Departr-cnt
Licensing board
Seiectmens Office
Health Depar-cment
1C VERI`rY COVE2J.GE INFGGtri-" iON CALL: 6i7-727-4900 X407 , 404, 40S, 409, 77S