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45 FEDERAL ST - BUILDING INSPECTION (5) 'PL71lNSiMIl6T9EfILaWMI) APPROVED 13Y Z414E ASPEC IR PWR TO A PEBMff BEING GRANTED 1\\ CITY OF_SALEM Dah j. Wad ZOF*q D1*1ct 's PMPNtY Located tha Miataic Dhddct?� Yes—No ✓ Location of Dai7eins 4 5 feDe-g^t- Is Pmparty LocaMd in sw Consaroadon Ann? Yn No Permit to: BUILDING PERMIT APPLICATION FOR: (Circle whichever apply) Rqaotr4WvooLjnsWI Siding, Construct Deck, Shed, Pool, Repair/Replace, er: PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: ' The undersigned hereby applies for a permit to build acconLig.to the.following specifications: Owners Name Address & Phoneme S 1 o Architect's Name Address & Phone f ��IZD Mechanics Name DEN _ Address & Phone /l G) AA%:- 40, S'WIZ y What is in pnp of tsdl W P-05 i D eTCT/ A L MdWW of tarld W tLtO t 1 1 fZoAnu6 8 a dwawq,for how m, M(amass? Will hodhq Cal A W. to law? Asbntos? Esirns ad cost D b 6 © Csy Ucww t► shft Ucww HIapro�nt S f Applicant ED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE (-45nte- ? C �nf� /fsrfFLir �� &/I � 6 MAIL PERMIT T0: 4' l� i 5gi_t�r i /-kA D f $ D APPLICATION FOR PERWr TO/n�J LOCATION PERMIT GRANTED AP�V�D �, . INSPECTOR OF BUILDINGS PUSUC PROPERTY DEPARTMENT 120 VftSH1HGTON STHff T, 3RD FLOOR SAL.EN,MA 01 S70 TEL (978)748-S595 EAT.360 1 w FAX (970) 740-9046 STANLEY J. USOVwx JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions Of MGL c 4%S34,I acknowledge flat ea a condition ofBoilding Permit g— .aII debris resulting from the conatinctim sed y rzrgoverned by, this Building Permit shall be disposed of in a properly licensed sorWd waata disposal facility, a defined by M(X c n7,SIM& The debris win be disposed of st i tAjo o p 7li!ge-,7-Lr- ?Zc TT Location of Facility �/3 I d ¢ ofPamitApplicra Date FULLY complete the fomS mbrw&m (PLEASE PRIRr C .EARn ) _C 1 WAU- f Name ofPem*Applicant Firm Name,if any j /� n�w/�( TLC StJI rJFIi' �U� 0 Address,Oty dt state the above statute requires that debris from the demolition, renovation,rehab or other alteration of bml&g or structure be disposed in a properly-licensed aolid-waate disposal facility as defined by MG.cIII,S I50A, and the building permits or licenses are to indicate due location of the facility. lroee��n�mansoea�hol Maaachu dd i .2.P.A d 4 / �1`.�r 'ai"- boo W.A416 Ad 1 ceaoa.i Sodom. Me.eA—& 0.2111 ceae...a. Workers' Compensacia Insurance Affldsyk 1, S' L Plle- / Z>eFlzo N`z-o . . wkb.a principal Pba of budnew au �96 � S, Lxsrjj;�z JZA ; olg?-6 do hereby'ter* under t)w pafas and penihla of perl.ery, slows employer pnwk g „'o►kasc cerrpingaden cmmrafe for my eiaploreaa working a% dik Insesranoa Company Pon q Number I am a sole proprietor and hove no one working fdr me in any capodey. 0 1 am a sole proprleter, general contractor or homeowner (circle one) and how Iced tke cornracton listed below who•baw the. following workers' conspensatlon poGdm Contraaer Insurancs COOMPIMY/Polky Number Contracto► Insurance Company/Po Nun*w Contractor Insurance Company/Polley Number 0 1 am a homeowner performing all the work nMedf. • ee.c,.se.am s gaol of 0*Ammon"a be fer.areed s on thin is hm o taeete of dN M kr co.erane eer kodon a"an Uetee r.smon; ce.ecgc At re0wed.aoer Swdo.2sA of MGL 152 tan kw se w bwetin of arnina ee.ode coroodnt of a am of es w4 I.sOQ�00 anWr e e +rM•iaorrnnens a ya a dd sari.in L%c lone J s STOP WORK ORD R sees fun of s ioo.M s an wbox or, Signed ibis . 3 ' " day of :iccrs free eullctng Department ucensing Ecarf Seleesmens Office c.slth Geparmer: