7 1-2 GARDNER ST - BUILDING INSPECTION kN 1
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INTLSTii?7E�CIA131�� JA yPPR OVED BY
T71GWTLD Rip� P T BEING GRANTED
CITY OF SAiLEM
� y �c Date b d
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Is Property Located in Location of l
the Historic District? Yes_No Building 7 2 6 fit Sr
Is Property Located In
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Con truct Deck, Shed, Pool,
Repair BplaCe Other> �s�rvt�h r <;lirl/Jo ✓S
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
Address & Phone 7X&I (W 1 7yy 95;��
Architect's Name
Address & Phone j 1
Mechanics Name Lam' 5'S�icc`�'hG � ST
Address & Phone ����s � Gr��a� ( IySZz
T [j
What Is the purpose of building?
g y�o/� If a dwelling, for how many families?
? N/Material of building? ng 41 i'•
i
Will building conform to law? Asbestos?
M
Estimated cost JL O(J Gty License • N A State License
�\ home Improvement
xx V Lic. if Z
S' nat of Applicant it+�
S ED UNDER THE PENY VLf
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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ii
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MAIL PERMIT TO: &126i 1�477-/I
l
No.
APPLICATION FOR
PERMIT TO
C,K
LOCATION
1 PERMIT GRANTED
APRR �D
TN-SfSECT0R O BUILDINGS'
E
COmmontul4W` 0 I+Iad6acLatt0
s1J,Pa.lnwlo/9,�f�«�.�
5 n600 ,ywaJiaapfet,SWel
�amesJ Gmood Uoslow, //la.tne(uww 02111
T �/WAorkers' Compensation Insurance �drOt
///. . with.a principal place of business at:
. . foes/aw✓a4)
do hemby'certify under the pains and penalties of psrjmy, shalt:
() I am an employer providing workers' compensation coverate for my employees working on
this job.
/7
Insurance Company Policy Number
I am a sole proprietor and have no one wcrk'mg for me in any capacity-
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 Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Nu;ber
() I am a homeowner performing all the work myself.
1 vnoeruant oast.a coon of"rcaaement wa of for Aroeo m the Office of Inresetiwnt of du DlA la ce.erarnt .eho4 ofdn s d- S!hone b"core
co.eranf st ffwvca under Section 25A of MGL 15 2 can kid to the"rnoowion of cr'rrna oenaoes corsatSM of a fee d w do-S I.SOOAO Undlef sent
rein' raruon t x ■r0 x c'j j ""jcef in the loan of a 'TOP WORK ORDER and a fee of 5 100.00 a oar stirot day of die.
)y✓�� 2e�a
Signed this • _ —
Zia
liccrseei crrnitcec building Geparzn+enc
licensing boars
Scleamens Office
�,�Ith GeQar*me^:c
CITY OF SALEM9 MASSACHUSETTS
PLIEiLIC.RROPERTY DEPARTMENT
m e 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
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 aclmowledge 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: !A)467E7 IRA�4z fLff?
Location of Facility
63v�
Si lure of Permit Applicant % 4 e
LY complete the following information:
(PLEASE PRINT CLEARLY)
m*(J( �
Name of Permit Applicant
A&S p�j
Firm Name, if anyF
�.5��� s. �a sr�2 f+t� cel "7
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.