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35 FORT AVE - BUILDING INSPECTION (3) _ a Z''14 aV 1MzVfS*NJST°BEf$. '_''PPROVE0 BY T*IE p ?� .WS,P;FCI,pF1 , UXOR �fL A.PF�1 BFJNG GRANTED CITY OF SALEM N& — ;`� ~� � � Date Is Property Located In Location of the Historic District? Yes— Bailding ng---t Is Property Located in the Conservation Area? Yes_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof Install Sidin Construct Deck, Shed, Pool, Repair Replace, Other: .P Q o aF a- V t L Y 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: Owner's Name s z/n��L✓n a N s k Address & Phone 3 7 cl q 7 S o Architect's Name Address & Phone L Mechanics Name .Q a r 5 0 CL Y C6.v.ST' Address & Phone 4 R NIA r� �i 9,PA (mat( 1k:1 What Is the purpose of building? Material of building? If a dwelling,for how many families? ph; Will buildng conform to law? Asbestos? Estimated cost 7 0 city License N N " State License e S 9 L18Bo , !i Lie. i [70�'lI r U Signature of Applicant SIGNED UNDER THE PINNIA !Y ��111 OF PERJURY DESCRIPTION OF WORK TO BE DONE I , Ni! d ,h MAIL PERMIT TO. �f _ 1- � . . . 10. -� APPLICATION FOR PERMIT TO /Ipp °. LOCATION PERMIT GRANTED /©/ V/o y �� AP .wovfD INSPECTOR QF BUILDINGS the CoMmonwealth of.Massachusetts Depar6me'ntofln'du'sir'iaiAccidSent'�-! s;I�! Offic a o InyustigatiollS 600 Washington Street, 7'Floor B so A lice Wei Co e sifilYnIni Affid Bljfldi#�11'�mlil I&cc 1, 1 R� in us rance 0" ical Contractors a A name: Address- 77l city "'i lz state Zip,- phoi work site location(full address) L:1 I am a homeowner performing all work myself. Project Type: nkruction E]Remodel p]am a sole pro Actor and have no one workm many ca achy �Buildmn Addition A. hone citi insurance co: 971 ❑ I am a sole proprietor,general contractor,or homeowner(circle arse)and have hired the contractors listed below who have 4 city: . . ...... ..... phone insuranci N4MAM=1111111111111IR11110 Will] companyharne- Address: 16 [l r, 't V city: I" W I I. .;i phoi a olIcI MMIMWVA�� i Failure to secure Ltu mppsitIop:At.F!!M!PanAJt' -coverage As required undir.Section 25A of NqL,3 52 can lead to Imposition Of ..Mes of a fine up;to Syli And/or one years'imprisonment as well As civil penalties in the form of a STOP WORK ORDER and a fine of SI 00.062 day against me. lunderstarl a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify e thepoins and peniallies'q/perfury that the linforinati provided above is true and correct. Signature— Date, Print name ). -Oei, C( b—ol, L Phol Al -7 1�_W"2 1 1� official use only do not write In this area to be completed by city or,town official city or town: it.... permit/lIcense# OBuilding Department t"iii .I, '. ii I t []LIcensing Board 0 check if immediate response is required tr.o ",i; xl; [:)Selectmen's Office i E)HeaJth Department contactperson: 1 U phone#; L(.=i.d All 2003) DOther W MMW� ^�i �. utz�� Dz ,�Ai�m, �,�Fl��iaLi111kiYllta ' Publir Prnpwt 33rpnrtmrui Wuilbing Urp nmrra (Oat tdgltw (Sum V Sos•HS=9595 art. 3BD DI5POSAL OF DEBRIS AFFIDAVIT In accordance•.vith the provisions of HGL c 4,0, S54, I acknowledge that as a condition of Building Permit 9 " , all debris resulting from the construction activity governed by This Building Permit shall be disposed of _n a properly licensed solid vaste disposal facility, as defined by MCL c lll , S 150A. The .debri:5''vill be disposed of at: �-��r' r'Vo!L� S l o Cq�c C t location' of facility 2 9- a y Signature of Pe� pp icant Date Fully. complete the following information; ,. (Please print •clearly) s.. Name of Permit Applicant Firm Name, if any Ro .,a b E IA C) ( S 6Z address; City b State The above, statute —requires that debris from the demolition,. renovation, rehab or other alterstion, of building or structure ' be ,disposed of .in a proptrly licensed:.,solid.vasci disp,os'al fseili•ty as def•ined 'by• KGL- cIII,, S150A and ttut building`permi'ts or license's are to indicate the location of the facility at ❑FSCRIP nKi AC utnov Tn=nr nnur