6 FOSTER ST - BUILDING INSPECTION (2) 14� MU t-M fiL-E-P fl APPROVED BY T44E
If PfXT.QFI ,PFMDJ3 TD.A PERMIT B,EWG GRANTED
CITY OF SALEM
No. ` ` �vV \ ``� .� �\ Date 1 )-YIO
���mnkp0��fi'
Is Property Located in Location of
the Historic District? Yes_No Building t p$'I+et 5t�
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, stall Sidin Construct Deck, Shed, Pool,
Repair/Replace, Ot err:
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 e W 2 T-
Address & Phone 9ro /UDI Si', S�'t It n , �178) ?�
Architect's Name
Address & Phone j
Mechanics Name f�O�
Address & Phone t3 S wu `51 (17t 67t ;a
What is the purpose of building? .�
Material of building? I j to Q If a dwelling, for how many families?
Will building conform to law? Asbestos?Estimated cost Du o City License # IV A Sy State License # 03 el yS 7c
Home Improvement R„ .
,, � /
Lic. i /�6 3SG X Signature of A pliiant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: C 3 S w1 R ev e as
No.
APPLICATION FOR
PERMIT TO
✓, —Q ` c
LOCATION
PERMIT GRANTED
APPROV�D
INSPECTOR OF BUILDINGS
/ E
_ l
4.>_ �ommonw,=L[h 0/r4wiacLdeltt6
I
y _ JeparlmaAL oJ.Jndua4ial Iccia AU
/�77 600 L11aaL.91aA-3W.1
James J.Camobea I., M .aaaa6 .1b 02111
Carmrssaptaa
Workers' Compensation Insurance Affidavit
(aa�rv►rrruw)
with.a principal place of business at:
�Otr�saawayf
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy plumber
I am a sole proprietor and have no one working for me in any capacity.
1 am ole proprietor, ral contractor or homeowner (circle one) and have hired the
contractors t ow who have the following workers'
compensation policies:
k'J �ti� RR05 vc (T/1A+vie SYatk 1N5, UJGal6Y2 (0D
Contractor Insurance Company/Polity Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unaeruana that a cc"of this statement wil be for arced w the Once of 1m ogatmw of the DIA for corerate reeiGcauan and ehat Wttre to 60=4
cowatc st reoarea under Section 25A of MGL 1 52 can lead w the irrtoaation of crhninat oenatties corsotint of a W of w=41.500.00 analor one
Yvan'imoruemment at we as civil denatlies in the form at; STO P WORK ORDER and a fru of S I00.00 a an ag+wt me.
Signed this , j y day of A , aUd
Licensee/Fermittee Building Departrnapnt
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
IL
OF SALEM,- MASSACHUSETTS
ANY.
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
j, SALEM, MA O1970
'?rt TEL. (978)745-9595 EXT. 380
�Gr FAX (978) 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,S150A.
The debris will be disposed of at: �/, l4�� L a4L✓ � C
Location of Facility
Signature of Permit App cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
BOG
Name of Permit Applicant
Firm Name,if any
l3 Ste=l( st 9,A-
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.