41 GALLOWS HILL RD - BUILDING INSPECTION 1
-MUST-SE fiL{-f;-:sirD.APPROVED BY T44E
W5PtCT.CI.3 .PWR TA A.PERMIT $,ENG GRANTED
CITY OF SALEM
.Aul `
No. 2� � ZC50� �;3f" ,, '�� Date
Is Property Located in Location of
the Historic District? Yes_No_ Building 4/ 6 4-1 Ws A/1 A
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, on truct De Shed, Pool,
Repair/Replace, Other: Ki
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
permit build according to the following
The undersigned hereby applies for a pe t to u d g o g
specifications:
Owner's Name /,l/A1Z fw
Address & Phone 41 C A I Iow.6 Ott ( kgb , ( 2 M 711 211L
Architect's Name
Address & Phone �/ )
Mechanics Name S//A I '�M2
Address & Phone �� CC��jliye" +V,�!-_
What Is the purpose of building? S ( a,�7iN c'2
Material of building? W, o?3 rAA-Akv-�u a dwelling,for how many families?
Will building conform to law? YES Asbestos? ry U
Estimated cost F Q u J City License* N A State License u
.\I
o J
�2GJ?v r Lic. i Home Improvement> fir`^ ` \\ all
X Signature of Applicant
G� l o S ao SIGNED UNDER THE PENALTY
OF PERJURY
DE�'S�/CR�IP/T-ION OF ORK TO BE DONE
ER ciez, lam- Src� C x-ei
�OA�l �e-4,6
MAIL PERMIT TO: .' ( G A-& w"S P ( R1 SA--�uik
N(2Q8-2 OO
APPLICATION FOR
PERMIT TO
LOCATION /p
PERMIT GRANTED
' APP VF%D
INSPECTO OF BUILDIN S
s
OF SALEM,, MASSAGtIUnci +
3 PUBLIC PROPERTY DEPARTMENT
• ^ 120 WASHINGTON STREET, 3RD FLOOR
p SALEM,MA 01970
a }
TEL. (978)745-9595 EXT. 380
pp FAX (978) 740-9846
;TAKLEY J. USOVICZ, JR_ -
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
,all debris resulting from the construction activity
of Building Permit#
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:
DPNIV K.('a,IrApaj Location of Facility
1 0� l t� et .-
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARS-Y)
R )J T
Name of Permit Applicant
Firm Name,if any
v � (��2t Cf if- , V 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 cM, S 150A and the building permits or licenses are to
indicate the location of the facility.
COmmORWt1ahk 0l MaesaCLaftd
6 Jepa.lmanl ol.Jadaskia( �eeiaar�L+
x 600 ryWasL16-311--1
JarneslCarnooel Uo�1on, }yfd,,,c�,a,.lts 02111
Coramssiona
Workers' Compensation Insurance Affidavit
VV-Q- Tnn�P�.;
with.a principal place of business at:
Cgs- �LRL►Vt� �� f� '
do hcreby'certify under the pairs and penalties of perjury. that:
(� I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Poliq llumbet
1 am a sole proprietor and have no one working for me in any capacity-
0 1 am a sole proprietor, general contractor or homeowner (circle ore) and have hired the
contractors listed below who have the following workers' compensation policies:
�'G ISX .
Contractor Insurance Company/Policy dumber
Contractor Insurance Company/PoliCY Number
Insurance Company/Policy Number
Contractor
() I am a homeowner performing all the work myself.
I unoersune wt a coot of thu avtvm (w%bt fora aroso to ttu Orftce of Inre kauorts of me DIA for ce*eratt.eri KWM aetl am fakee to WOWt
co• ate m retrueeo unaer Section ISA of MGL 152 on kao to the in don of criminal otnatties cor-Wdnt of a (rat of VC 04 LSM4DO MWOr oft
yeah'iraruon t v !trt u drii txr idv in the loan of a STOP WORK ORDER anc a fire of S 100.00 a 07y apint mt.
Signed this ,
1(a HA. day of Qwf p ZC' r 2 ,)
` building Geparcr.+ent
�iccnsec/Fcrmittee
Ucensing board
scleetmens Office
He2lth Department
i ' 405