2 FELT ST - BUILDING PERMIT APP - FRONT STEPS 3 S'
IA gdwt-aE ffLf�N{it APPROVED BY T*IE
�P IW M
J R PR T-O.A.PERT.BFJNG GRANTED
CITY OF SALEM
No. 20 2-Zd0 Date
NB�y
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) eroof, Install Sidin , Con truct eck, Shed, Pool,
ir/Replac Other: /t/^t 7 G 5
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
Address & Phone oZ AQ#1*6./f St' Sim (9 1 ^ram- aq.2wB
Architect's Name Z4
Address & Phone 1194 l • )
Mechanics Name aw.o N dn'o-,
Address & Phone
What is the purpose of building??/^,/.4&!!e& 6
Material of building? If a dwelling, for how many fa " s?
Will building conform to law? ��� S Asbestos? -1�
Estimated cost 0 d 0 City License# N A State License d OC-
Home Improvement XX
�3 S��— �� o� ' natur of Applicant
SIGNE UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
i
I
i
MAIL PERMIT TO: j
i.
w
t
No. 2 0 0
APPLICATION FOR
PERMITJO r
LOCATION
PERMIT GRANTED
APPROVED a
i
INSPECTOR OF B ILDINGS
t
COf) mOnWs:aft o/ CU:5ackus¢tL
6i7i .
�.Jepar�mart� o1..7adu,lfri6f�teeiaertlJ
n/ 600 WosL-11orcSlr.a1
Jarnesi.campcel Uo�°'+� va6e�'�'�' 02111
corrmrssrona
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
ie+n„e.e.mq
do hereby certify under the pains and penalties of perjaryr that:
() I 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 opacity.
O I am a sole propriaor gen�conzrac�xtor homeowner (circie one) and have hired the
contractors listed below whlowing workers' compensation policies:
dOpheuAu
Contractor Insurance Conqf0anYIP0111CY.Mumber
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I undentan0 wt a coon of chit sutetnent va be icm woed to the Once o71- titatrons of the DIA for co+eeate werWicad nt and mat faatee to secure
coveratt as reoueeo under Section ISA of MGL 1 S2 can lead to the inoosriron of cririnsar oersattin corseting of a tare of ao to-S 1.50000 an616c ON
years'iraruora+xet v v_6 w cKj denaltiet in the torn o(a STOP WORK ORDER and r fine of S 100.00 a ON agirot me'
Signed this day/ --day of 5L�
ffs•,* t7y303$ Building Geparzrrent
Liccrsee/Ftn-M tee
Ucensing Board
Seiectmens Office
Health Department
ONCi Li: - 7 - =900 X4C� 40< 4oS, 405, 375
�o <._."Y OF 5ALEMI 1rtAZ=A%-nv.:.ca , .
PUBLIC PROPERTY DEPARTMENT
° • 120 wASHmGTON STREET, 3RD FLOOR
' SALEM,MA 01970
TEL. (978)745-9595 EXT.360
�G FAX (978) 740-9846 .
STANLEY,J. USOVICZ, JR. -
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
S34 I acknowledge that as a condition
In accordance with the provisions of MGL c resulting
' from the construction activity
of BuildingPermit# ,all debris resulting
. licensed solid-waste
governed by this Building Permit shall be di Properly
disposed of in a
disposal facility,as defined by MGL c M S150k {�
The debris will be disposed of at: /Yl��G!✓- ��l/8� ��sw�s � �� '
i ocation of Facility
1% d �3
Signature of Permit Applicant
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
GJ /v Cil A,4110>✓
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 clu, S 150A, and the building permits or licenses are to
indicate the location of the facility.