9 GLOVER ST - BUILDING INSPECTION gMtST-MffLf� APPROVED BY T44E
=PECT,I-R PRX1R TD A..PERMIT B•EWG GRANTED
CITY OF SALEM
No. / 71 Z vb Date 5 �j 3
.ill.•
Is Property Located in Location of v�
the Historic District? Yes_No_ Building qo
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/Rep ce, 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: n
Owner's Name v.Ul
Address & Phone q 6z=:t4a (97&) 7k —.(-8 V-G
Architect's Name >wn 2®w r,c�ewpCo
Address & Phone l�f 7 �i�P�KP ZP-4 If -dG`/93
Mechanics Name
Address & Phone ( 1
What is the purpose of building?
Material of building? It a dwelling, for how many families?
Will building conform to law? Asbestos? /
Estimated cost City License # N�A State License #
Home Improvement X
� � d Or g G r , Signature of Applicant QlL—
C 172_2,4�)O SIGNED UNDER THE PENALTY
I OF PERJURY
DESCRIPTION
{ OF WORK TO BE DONNE
MAIL PERMIT TO: �i��� 1,
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APP OVPD -
INSPECTOR OF BUILDINGS
coe_."'' OF SALEM. MASSACHU5ETT5
PUBLIC PROPERTY DEPARTMENT
° ® 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
a TEL. (978)745-9595 EXT. 380
�grma FAX (978) 740-9646
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,S150A.
The debris will be disposed of at: � "
—'Location of Facility l� ,
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
, kk'eQ L�
Name of Permit Applicant
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 c1II, S 150A, and the building permits or licenses are to
indicate the location of the facility.
�_Cc^f}rm onwaaltknnol 1lla6aacL6efL6
'--� J.JeparGnanf al.J,tlaiaGiaf�eeiaenlJ
1 600 W.LUIfat.Slraal
James J.CaMIX)a &L. , /!/a,ssa L.uj 02111
Corsmrss*w
Workers' Compensation Insurance Affidavit
1,
- itivrwetrer.it.e2
with.a principal place of business at:
irJtrrseas✓sMr
do hereby certify under the pains and penalties of perjury, that:
O 1 am an employer providing workers' compensation coverage for my employees working on
this job.
sWC
Insurance Company Policy Number
I am a sole proprietor and have no one working 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 Number
O I am a homeowner performing all the work myself.
I underwno vet a coot of this statr m t ril be ion arced to the Once of tmudtaoons of the DIA for corerate wriRadon ana Nat Wire to severe
co"eratc v fevrrra under Section 2SA of HGL 1 S 2 can lead w the irnany{on of CMWl oersmtses corsatint of a ""a'tao to-S 1.500.00 arW w one
rears' imxuonmmt as.,a u ei.3 oenaldes in the form of a STOP WORK ORDER ano a fine of S 100.00 a am aP+tst me.
Signed this TGri 4" _day of g'-,/ —
R
Licensee/ ermittee Building Department
Licensing Board
Selectmens Office
Health Department
T0 VERIFY COVERAGE INFORf-itATION CALL: Ei7-727-4900 X403 , 404, 405, 409, 775