0004D FLETCHER WAY - BUILDING INSPECTION 1 J S
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P. wNQ GRANTED
CITY OF SA�EM
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ff�oo•�„ ideation of
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818LDNG PERMR APPLICATION FOR:
Pwmk UK
(Carole wh dWW apply) Roof. Renwf, Install Siding, ConaWW.Do* Shad, Pool,
RapeHRapka, Oftar:
PLEASE FILL OUT LEGIBLY Ik COMPLETELY TO AVOID DELAYS IN PROONM
TO THE INSPECTOR OF BUILDINGS:
sThe
peo mVdd hmW applies for a pwmk to bulld aoowft to fha foNswmftw
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Ownses Name
4JfN ka✓t -L
Address 6 Raw `f.[D, -i I e-I-C- ,. r We (�78► - f�ZS 93� t
Arohlto is Name I"l�—
Addnas a Phone L
Modanbs Nana R u�„c,[ j
Address A Phan Sat w& (IV ) "7Ks ScDc:o
v"Is"P.Po..d De c.jr,- EZ.e FA,(ZS
MrrW al tr/digf r s for law OWN bran?
kib4 b IrMIT
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Lia. / 2. 653
X SWmftre of A~
8N3NgD UNBER THE
OF PERJURY
DESCRIP710N OF WORK TO BE DAME
e Pi 2
r
MAIL PERMIT
. .
.51
40
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ocrym�monwi:a.Uho a6a �t�a
e JJepa,lmanl 01 JAr 44 `s J4A«;LA
600 U/.1-11m 31b1a1
James.Camoob (�o>tow, m a�ae�uu.fL 0s 111
CorrAUSSMW
Workers' Compensation insurance Affidr4t
fa.�...erna+al
. . with.a principal place of business at:
. . Icrri�w✓Lq
do hereby'ccrtify under the pains and penalties of perjury, thm
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
insurance Company Policy Number
l- ' am a sole proprietor and have no one working for me In any caWelay
01 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/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoe ^c we a cosy of the aucernnn wit bt icx+armd to the Ofhc*el Imodnaoom of the DIA le" co.ocane damn and M f7Wa m aaeore
w.erant >J tenured unorr Swfion ISA of MGL 1 5 2 can kao Lou"indotwon df c^^'n"cen ld"coraatint of a fim of me eo41.S00.G0 and/or om
roan'�.oruotrnent v ten a!ei.a oemiies it the lvrtn of a STOP WORK ORDER and a bw of S 100.00 a tray atwat trace.
Signed this day of
iccn5r t/F crmattt i slicing Gepartn crag
uccivinf Ecarc
Seieetmens Office
0S T G(1G G(tC � RL
PUBLIC PROPERTY DEPARTMENT
120 WASNINQTGN STRUM 3Ro FLoom
SALEM,MA 01970
TEL (978)7454595 EXT.380
FAX (979) 740-984a
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGd,c 40,S34,I acknowledge that as a condition
of Building Permit S all debris resulting from the construction activity
Vaned by this Building Permit shaft be disposed of in a properly licensed solid-w aft
disposal&cMtY,as defined by MUL c kIL S150A.
The debris will be disposed of at: _ oRTFFsIDP �grrr> sALs�
Location of Facility
igaatme of Perris S /y
Aplict Date
FULLY complete the follawinS in&M2&UM
(PLEASE FRINr CLEARLY)
1C W k -civ
Name ofPermit Applicant
De—C-kcF
Firm Name,if any
u LRvys ylrt J-
Address,City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or atrucdne be disposed in a properly-licensed solid-waste disposal
facility ar defined by MGL ca S 130A, and the building pamits or ficenaea are to
indicate the location of the facility.