1 GARDNER ST - BUILDING INSPECTION 0
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` ;-eE{ L WPROVED BY T44E
Own T BEING GRANTED
IPIT� OF S4EM
No. Date /b —
ji ry
Ward
1 \• Mnys°a } zoning District
Is Property Located In Location of it /_ ^
the Historic District? Yes_No_ Building I l J MP^ ` I
Is.Property Located in
the Conservation Area? Yes,_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: PL YtAlmDl,-i
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 ,Inillfit welyz&_L
Address & Phone 121#W s/ 07,q 7y5'� a591
Architect's Name
Address & Phone )
Mechanics Name 5144e0e O/ i�/9�fiNs
Address & Phone 36/ 11vxyZ1,1M0(!3/ //
What Is the purpose of building? 5%N .j& L2!V14x mall-e
Material of building? 14),90(9 If a dwelling, for how many families?
Will building conform to law?—� Asbestos? &6 9
Estimated cost /Z eDD. City License k State License 0
Hose Improvement
//J b Lic. f/ 6 i a
Signature of Applicant
p� SIGNED UNDER THE PENALTY
6 ' OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: ecr 7L t ec6i 65, e AnAL 1,,i Q/gb�
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CITY OF ScA1,.EM9 MASSACHUSETTS
• PUBLIC. PROPERTY DEPARTMENT
n
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
,pe ^^ TEL. (978)745-9595 EXT. 380
g' 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, S 150A.
The debris will be disposed of at: 14101ey4 .Sipe- z is 11�y
Location of Facility
T 7 03
'Signafure of Kennif Applicant D to
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
_j_0/v-_/
Firm Name, if any
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, S15OA, and the building permits or licenses are to
indicate the location of the facility.
i 111Mr1xnWl.1a& 01 Mwsackatb
is
61JeParimaato w 1,ttiaeafa
99
600 Wa1a9faa-311..1
�amet�.f�tt,00ea �a�M 9W.L" 1112f
Corrnrssrtaratr
/ Workers' Compensation Insurance Affidavit
1, 9CiiYowy4
witka principal place of business at:
here y'certify under the pains and penalties of perjurya that:
do
an employer providing workers' compensation coverage for my employees working on
this job.
Policy Dumber
Insurance Company
I 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 one) and have hired the
contractors listed below who have the following workers' compettsntson policies:
Contractor Insurance Company/PolicyNumber
Contractor Insurance Comparry/Policy Number
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I unotmane wt a coot of the st,rertrcnt rib De ior.+arotd m the orree of Inrafq,wm of the DIA for corerate+t'rlfitaYon
ana out faaun to saeare
co iratr v revived under Section ISA of MCL 1_S; can lead to of :noovu of crjrr r , oermats coexadn{ of a fiat of w to-4 1.50000 ander oat
reap' 1r..aruon t at vt as Ci6 oerulun ' t form or, OP WORK ORDER ano, of S 100.00 a ear at"%me.
Signedthis� �vG, day of 7 v �
iccnsce/Ftrrnittet: building Depanrmenc
1_3ctnsing board
Seleamens Office
c�ltfi Department
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wa7615 1s 20""6/ /
- BOARD OF BUILDING REGULATIONS
- I Board of Building Regulations and Standards
License: CONSTRUCTION SUPERVISOR
HOME IMPROVEMENT CONTRACTOR
Number. CS 053330
- Registration: 106127
Birthdate: 10/0211961 Expiration: 7/22/2004
Expires: 10/02/2003 Tr.no: 6162
Type: DBA
.-.. Restricted: 00
JOHN A STUEVE - STUEVE CONSTRUCTION
38 BUTTONWOOD LNJohn Stueve
PEABODY, MA 01960 �"� 38 Buttonwood Lane ���
Administrator Peabody,MA 01960
• Administrator
00-35,000 d enclosed space
(MGL C.112 S.601.) !
IA-Masonry only
1G-i a 2 Family Homes . tt License or registration valid for individul use only
4.'.
' Failure to possess a anent edition of the before the expiration data If found return to:
Massachusetts State Building Cade Board of Building Regulations and Standards
is cause for revocation of this license. One Ashburton Place Rm 1301
Boston,Ma.02108
DIG SAFE CALL CENTER: (888)3447233 l
Not valid without sianature