48 GALLOWS HILL RD - BUILDING INSPECTION V # ,
r
c ; _
: i "' "'fi�E D �I OVEO BY T44E
v WS,P>ECTO#I ,RI A O 1 PEAICAJT BEING GRANTED
's i
' 'PITY OF SA'LEM
No. ` w� 3 40o Date 0�— 7 —Q 3
fx, . 3
Ward
\A �' Zoning District
Is Property Located In Location of 1 1 ,
the Historic District? Yes_No_ Building-- L\2 is A LLc,u,1 N < It (Zn
Is Property Located in
the Conservation Area? Yak_No
BUILDING PERMI"APPLICATnIO FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOIp 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 AtiD 9-04v f�n I j rn L
Address & Phone t4 8 CA LL ,,cu c 14E 4 L ) '� (4 1 - O 4 R o
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost b 72-6 a'City Licenses 7 3 2., state License s I d n f I
Bowe Improvement
Lie. i OSg,y D
Glc T Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Z.. .s -r-A LL S 1 o ,,Ljc
MAIL PERMIT TO: b, L{� Coo �.c
1 y 9 MA r,j .ST
ru <i;id., t a . :z3 !.i. u+"^•r t u.t-.t.h;+a �
r wJ r� �i Elr+lith h.,'{ $1. � �{s'Ul.2sE tt :"i C,Yin}14^, i.,,r'>� a 't , 1 A,t > °ed `s:<Ail i(9 1 iir) ^a1• tL"AI��"V�fl t�"
IO )7'.M.�r$lU 00 (I"�r`eaiU: MN]S%'rtY„'si✓Saik
`h. v Af A G J«:e.'
'iS'f} dy.tiR S ➢.h�!`. d yx i�:e.^ rr�s, .. � «, .._ '
1 0
LL
co
cc cc
aa,a to F_�,I M� ry A bl.
w aco
$ a ¢ z
>a (fomrnonwoahli 0 /411a»acnctaelb
w 31 LP A
�a0arimeni G/9,dwlrla�_rr�ct�rt�
,. . pp 600 VVatf la,'Sliaal'
-
• Barnes J.Camooeu tr oalon. M4=cnl .alb 021 1 1
. Commissioner .
Workers' Compensation insurance Affidavit
with a principal place of business ac:
I fI 9 AiN
(cJcr,sua.,ua
do hereby terrify under the pains and penalties of perjury, that:
1 am an employer providing workers' compensation coverage for my employees working on
this lob.
Insurance Company Policy,,Ntiinber
O 1 am a sole proprietor and have no one working for mein arry capacity.. .
1 O 1 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 Numb"
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number.
O I am a homeowner performing all the work myself.
I under02na out a CODY of ft summem wrw oe lorwarceo to the OfrKt of Imesuratmnt of the DIA for coverage Yem6ex B and inat fakwe So"CNN
coverage at reaurm uncer Secoon 25A of MGL 152 can teas to the a ocn of m nmm oenamea conmung of a few of uo w g 1,500.00 sndeer am
Yeas'►noroorenem as wee u crvw ocnatuea m the form of a STOP WORK ORDER ano a fine of 100.00 a oav steer:one.
Signed this j day ofv r[,S T r
Licensee/Permittee , Building Department
Licensing Board
Selectmen Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL. 617-727.4940 X403,. 404, 405, 409, 375
r- ��, l'1i tj IIalplll. � a5�aznlYzr
1C�Ji� �ublir �mptrig �t{�nrtmtAi
L:
;ll11D1nq U r;mrtmrn1
(*at erdrm barn -
S�B•7-15=9595 Est. 380
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance. vith the provisions of MGL c 4,0 , 554 , I acknovledge that as a
condition of Building Permit tlI I , all debris resulting from the
construction activity governed by this Building Permit shall be disposed of :n
a properly licensed solid waste disposal facility, as defined by MGL c Imo. ,
S 150A.
The debris vill be disposed of at : _
location of lity
gL
gnature of Permit plicant Date
Fully complete the folloving information;
(Please print clearly)
Name of Permit Appiicant
rz1-4C wG
Firm Name, if any
Address ; City b Scare
The above statute requires that debris from the demolition.. renovation , retest
or ocher alteration: of building or structure be disposed of in a propexiy
licensed solid waste disposal facility as defined 'by KGL clll ,' S150f, azui that
building permits or licenses are to indicate the location of the fxr~l ty at