12 FOSTER CT - BUILDING INSPECTION r
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CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to.
(Chas whWMW apply) Roof. R ' Instal Siding. Constnwt.Do* Shad. Poet,
RepakfiWolisce, Other.
PLEASE FILL OUT LEGIBLY A COMPLEMY TO AVOID DELAYS IN PROD
TO THE INSPECTOR OF BUILDINGS:
The nd=rs hanby applies for a permit to build according to fine following
Owners Name RO(Y�1U 1 11 C i� l�
Address a Phone 12 .\CL Chi 0`1
Architect's Name
Address 3 Phan ( )
Mo&mics Name r" U
Address A Phone / � `C.�
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- Mftw w t,ulsig4 l crA /•dwsiq,for now owM IrnMo9
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���CNylJowwsr N p` 8Wr rCS o$6�1�5 ',
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Signature of AppWnj
SIQNED UNDER THE *b .
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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Workers' Compensation insurance Affidavit
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. . wia�ha principal place of business at:
. . so.raa..ura+ra
do hereby certify under the pains and penalties of parjory, thaet
() I am an employer providing workers' compensation covsrage for my employees working tm
this job.
insurance Compa Popolicy Number
1 am a sole proprietor and have no one working for me In any o+smeky
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation policies:
T, �a�VQ�iu�4� `�I�ile�
Contractor
insurance CompanylPolacy Number
Contractor Insurance CompanylPolicy ldumbef
Contractor insurance Company/Polley Number
O I am a homeowner performing all the work myself.
• Of ax DIA Irn <o.erate` �°A arse am 1aRce m aware
Ian jjc w tot a<ppr w Sw on 25 ne f C (1 5 2 can
max Once oa -;OA W auob
<o.e<aee v reourra un°et Se<nan 25A of MGL 1 S I can kaE w ax i,000ien el 14"'3a'pennpei cpnaatiM of a roe ed we eoi 1.500.00 anNee owe
rean•mpr°°nnxn n tre as eoi o wi"in N+e loan at a STOP WORK ORDER a"a fax at S 100.00 a sal a l;fflw .
Sirzed this . \>( _ day of
i cn a Ferrniuec cuiidinf Geparcn+ent
Jctrcin€ FG7fG
seieccmens Office
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (976)745-9595 EXT.380
FAX ) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
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,S\150A.
The debris will be disposed of& G, M Q o
Location of Facility
Signature of Permit Arocant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
� dew OrV 3v-gef�
Name of Permit Applicant
Firm Name, if any
N Pk"� � Q Cn yQ/-� M(,\ C7 �123
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 cIlI, S 150A, and the building permits or licenses are to
indicate the location of the facility.