5 GARDNER ST - BUILDING INSPECTION fL*NS1MXT9E fKf$#ND APPROVED BY 771E
INSPECUIR PWR TD A PERW BEING GRANTED
CITY OF_SALEM
No. Data
waM
ZonUg DMId
Is PrOPWtY Located
ftHht ftDWdcf?� Ya No= Location of
Is Property locdad In
f Conearptb,Area? Yes No X
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) _800fRewat, Install Siding, Construct De(*, Shed, Pool,
Repair/Replace, er: n�� loGf
PLEASE FILL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCESSWG
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accord4ig,to the following
specifications:
Owners Name TfwlH c sffIL&I4?
Address & Phone S 6,q-RDNi✓1Z ,�T, (97d 1 7ys a99d
Architect's Name awzy 4,•�r i .9r9�vriC ?� �Gr✓
Address & Phone /9 DCeelil ,9YE /+9/)G ywiil LW) So?S— "y
Mechanics Name _
Address & Phone ( )
W W is ft purpose of WNW A�7tN�i✓ %9CF /fT L DFT
mm"of tadldYtp? N a dwafYrg,for how mmy famaas?
WIN huNdkw cordon,to taw? *6 A@bW N.4
Es*rwM wd ov.,pp"y Uc•w r o rk stag uc«w r /'C oS/1?W
am Improvement
Lit. / /37YS7
S' ro icant
UNDER PERJURY THE PENALTY'
DESCRIPTION OF WORK TO BE DONE
.LITCI+F(,J Coal rS — iy // S,1j2gl cPr2iiCl' ff —
91ap LJ-7 Fm 6F-Fi c
MAIL PERMIT TO-. S' AlbL & TT cs/>tiCFNJ r Nsif� ///97D
e
No.
APPLICATION FOR
II A PERINT TO
tip; �- 3
LOCATION
PERMIT GRANTED
19
A7PMVfD
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
1 120 WASHINGTON STIIaaT. 3NDFLOOII '
SALKU.UA Ot S70
TEL (978)745-D595 EXT.360
FAX (97e) 740-9/4O
STANLEY J. USOV=r, JaL.
MAYOR
DISPOSAL OF DEBIUS AFFIDAVIT
In accordance with the Provisions of MGL c 40,W I WJMDwledge that as a cwdidm
of Bm'ldiM Permit f .as debris raolt[gg from the 0010MCbOn activity
governed by this Building Pemrit shall be disposed Of in a properly licensed aog&wuw
disposal may,AS defDed by M(X c ll;SIX&
The debda will be disposed of at A/o fzl*xl DE f1.TiN to
Locatim ofFacBgy
Si ofPemidApplioaot Date
(PLEASE PRW CLEAM) meson.
Name ofPeamtt AppHcm t
c79(4�n1 /o crn IA-MA)
Fi m Name,if any
Addreas.City A Stft
The above statute requires that debris from the demolition.rewvadM rehab or other
aheradon of bWkiing or struMm be disposed is a propaly-licensed soli&waste
to
s«>ity as defined by MG,cIq S1SOA,and the buildarg permits or licenses we to
indicate the laation of the hazy.
Cof)VBbAw" of Mamse"mi
adpa�e��./adrie!�ai�la
boo U UL.0. 31,. i
.�n..lcaasta &don. )11esa.J.aA 0.2111
Workers' Compensadon Inman= Affidavh
b 7� EMDAI - 9,9aw Ccw.f w
. . with-a PA14W pba of btuietets an
S FIDTC�NCF Sl SALEry ge D/97D
/ %
do berelry'centy under tjn palm and padh w of peky, done
() 1 M an empl"w providing workeH' compeuwtleo cawra fe for my etuple"no working M
t�1�L fir. ,0 p4SOC. hystifivec wCS- �/S 28D3D—i33
insurance Compaq P Miunaber
1 am a sole proprietor and haw no ono workim fir ate L saw capsdq.
() 1 am a sole proprietor, aenesel comiraeter or homeowner (di one) sad how Mood din
coninaaen listed below who•have the following workers' conwensashm po6dess
Cosnracler Insuran" Company/Po Number
Consraaw Insurance Compaalr/Po liuittbes
Contractor Insurance Company/Polley Wv bw
0 1 am a homeowner performing all the work myself.
•1 VeftnL ed am a Baer of di ruwner N be ferwaroed act or Once a MvC*nae of da MA br ce+erate nAkair Me*A Base r rase
eenaaq a awned Ma Sense SSA N MGL 152 can Mad r ow Wasoden of wiiwa deaai,ee nndm .f a Me of w a.i I,t00A0 aaefor een
ream':avrewn,a ye a*4 earns in the brae of a STOP' WORK ORDER aw a fee of S 100A0 a an ap4a dr.
Sinned this • 3/ a1- day of W7- 700
ricers iFe tee culldlng Gepartn.e t
!ictnsinf Eaarc
Seiearnens Office
i rieslth Gepariner:
"e : = 404 tpc ape 179
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