183 FEDERAL ST - BUILDING INSPECTION (2) &, ;;7
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4 INV
Is Property Located in Location of
the Historic District? Yes_No_ 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: A SQ WIPm l
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:
Owners Name -:�£i F SL{lAaD7 `f ��)f��r /)-Z7`/z..0 kiU.fl 1
Address & Phone l�3 f �S�g L S Sq lam, (�'7K 591- //a t;
Architect's Name
Address & Phone AAA
Mechanics Name
Address & Phone f
What is the purpose of building?
Material of building? If a dwelling,for how many families?
will building conform to law? Asbestos? I�(
Estimated cost Clty License ft N�A License �/
gg'- S "f )4l
�/ obb to Home improvement 1L�11)C
Lic. t 11,V,5- e-
/ \ Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
S,s7'e �z i�ya-r,�s. �'�dd LvL
MAIL PERMIT TO:
S r�i:c�lr~
OF SALEM. tYlAs�fa�.nv��
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
< yp SALEM,MA 01970
�s�-s_✓�' TEL. (978)745-9595 EXT.380
ti pmra FAX (978) 740-9645 -
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
that as a condition
In accordance with the provisions of MGL c 40,SK I acknowledge
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,S150A.
1f
The debris will be disposed of at: SiAP CA-
Location 10
Location of Facility
Date
/e
Signature of Permit Applicant
FULLY complete the following information:
(PLEASE PRINT yCLLEARI Y) /
�C-U
Name Of Pemvt Applic�am
����4- Ce �S7�IJ�t�onr
Firm Name,if any
br L)CIA t ICL , S� 1I �1
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 c-M,S 150A, and the building permits or licenses are to
indicate the location of the facility.
Com\-monwi:1ahk clI l'7(a :[ acLaffi
� ` � Jelsnrlmutf o/J�✓ia[�[ei6aI1L1 - '
S� (7
600 ryw�nJwylon...)lr.a(
James J.Camoees r�oalon /!/asmc�wfG 02111
Ctsr.-mrss*W
Workers' Compensation Insurance Affidavit
54 eft�
with.a principal place of business at:
to zo 6
ltsn/aot✓na)
do hereby certify under the pains and penalties of perjury, that:
frT 1 am an employer providing workers' compensation coverage for my employees working on
this job.
11W �97070s`
Insurance Company Policy slumber
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 polities:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/policy Number
O I am a homeowner performing all the work myself.
I vbzn "we s CM of the wummt r be ion+arpd to the OnKe.7 In.esurawns of the DIA 1« co'eiare that lairs to,ewre
eoa'een, a rewrm unoer Section 15A of HGL 151 on lead to 0.:n�of a4ninai ce"ats eorstadnt of a free of W eei I.SM.00 abler one
roan'i.a wnmmt x _rh u cir4".160 i+the form o!a STOP WORK ORDER ab,fm of 5IOD.DO a aar aProt eras.
Signed r is �t5 f S '� day of
sic nscelrcrmittce building Deparrrrent
Licensing Board
Seieamens Office
H,-2jrh Depariment
40?, 77C