10 GLENDALE ST - BUILDING INSPECTION (2) IM.* }S M11:11 T- E+;&E� APPROVED BY T*IE
\,ISPECJOA PRIOA TO A.PERMIT BEING GRANTED
J CITY OF SALEM
Nu
No. `t�.. b�e�i'Ta�
Date
Ward
�Aesrmneo°'� Zoning District
Is Property Located in Location of
the Historic District? Yes_No Building J 0 ji'I�.�CC
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidin=Construct Shed, Pool,
Repair/Replace, Other:
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 / k (AWI L-0
Address & Phone �J Ill 3LWa42l.-
Architect's Name
Address & Phone ( )
Mechanics Name �L �.4C,GYgIur�IS
Address & Phone S.uR»�o �c�7 ( (�67��
What is the purpose of building? a✓s
Material of building? if a dwelling, for how many families?
VJIII building copform to law? Y� Asbestos?
Estimated cost �� City License# ense #� 0�
Home Improvement
��.�J Lic. a 1 �
Vignature of AOplicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
odd 7 X,.
x ' Sn -ro C lUo Ct, �s ���rr ,► l
,; MAIL PERMIT TO:
No.
APPLICATION FOR
PERMIT TO
LOCA TIO�1
PERVIT GRANTED
v� 19 0)
APPROV
INSPECT R OF BUILDINGS
� r
# � CommOntt/rtQ.Wt of /1J0.•I�nAG�l�d •
600 ryw��. Ly �G.S
/I/
carers l f anroaal Ace, ..A. A 02111
Comaaso.ar .
Workers' Compensation Insurance Aff'IdWk
. . wieb.a principal place of business ac
l)-� �,rn•G5' Qi�� ern= �� �' "�;�r,_-sty � i
• Icavaa..ratq .
do hereby certify under the pains and peniltiss of pw*y, shags '
() I am an employer providing workers' compensation coverage for my cinplorees working ON
this job.
� 1ooa .
insurance Company Polity Number
I am a sole proprietor and have no one working for me in any capacity.
O 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired she
contractors I•uted below who-have the following workers' cornpensatioa policies:
Contractor iroaranie Company/Polly Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
f veeruane our a caer of des aueenws we be fern wvod m on Ogee el hn,*aaere of Ore Mole for co.erate wrllcsdnr aft saw Ulm rr seem
cumarr as rewere oaoar Secden 25A of MGl 152 can kad to Orr inwweo Of ererdnar decade carv.dM al a ere el w=4I.S00.=arWer ewra
nan'ino wmwm a ya a e.: OeLsido it du loan of a STOP WORK ORDER arse a fer of S 100.00 a an ag*w an.
Sirned this , �U -r4 day of I7NC �
aj��'
.i n/jeei'Fermittee cuilding Gepart ent
Jcensinf Boar[
Seiectmens Office
e.alth Gepariner;
- _7 . =CC Y. 404 e05 eec 37c
r
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL (97S)745-9595 EXT. 360
FAX (978) 740-9848
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MOL 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 ID,S 150A > /�
Th debris will be disposed of at
Location of Facility
Si �
Signature of Peamlt Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
/ky (�qMIA4; 6,4/�O&
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 cI9,S 150A, and the building permits or licenses are to
indicate the location of the facility.
i