6 HAMILTON ST - BUILDING INSPECTION •' i
STYE f bf��APPROVED BY T44E
UPcCT4 ,PFt10R TPrA'.P.ERMIT B,EII•IG GRANTED
CITY OF SALEM
No. $ ZUo I .` �' Date /
Ward
/ j\dtvmneo° Zoning District
Is Property Located in / Location of
the Historic District? Yes V No Building
Is Property Located in /
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Retool, Install Siding Construct D ck, hed, Pool,
Repair/Replace, Other: wm w // t 4.
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: l
Owner's Name O'` ee''ee 6 �� I
Address & Phone
Architect's Name
Address & Phone
Mechanics Name /
Address & Phone J r� 117 ) ?'IV bd 74
What is the purpose of building?
Material of building? u a b If a dwelling, for how many families?
Will building conform to law? b Asbestos?
Estimated cost City License tt State License #
Home Improvement
b4 S Lic. f
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONErtbo I /
lQ � oh 6 l 1�� l�cZ h I kd ]�/�--
a cv/Lh / hodF hov
MAIL PERMIT TO: 0�I 46tr >U rbu
cn
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r ta�� -113 q All elYAJ3G (ROVA O7" Y 3ITIMAC),'s A Yj gr Tc.z° j 6� ..fir*
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) 1 :Sta4'`3
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600 ryw�askujim-3b..I
J.rnesJ.ealrooes �.b�, //lassoe 02111
CDMJMisona _
Workers' Corn
nation Insurance Affidavit
I
witha principal place of business at:
Our C<1- �
I�r,aeaeJa.)
do hereby certify under the pains and penalties of perjotya that:
() 1 am an employer providing workers' compensation coverage for my employees workhnt on
this job.
Insurance Company Policy Number
1 am a sole ro rietor and have no one working for me in any capacity.
O 1 am sole proprietor, eneral contractor or homeowner (circle one) and have hired the
contra who have the following workers' compensation policies:
Contractor Insurance Company/PoLcy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I un0ers:anG WI 1 CM of Cho wig D< fOMafotO t0 the OrrK<cl Imestgataont of the DIA Ior co'hceate+r*+&aOo"WA MX Uk"to arcwt
co. arc x reouree unorr Section 25A of MGL 15 2 can kad to the:noo>,tion of errr'nai ottwties conuatint of a to,of w w-+I.So0A0 an0ler one
rears'roeuorvnent v .cru v tivi , i�in the form of; $TOP WORK ORDER anon of S,a0000 a m 313'e at.
Signe his ,
day of '�jA1�-
License i"rcrniuet building Deparcr. en
licensing board
Seieezmens Office
He2lrh Dep2mment
- - - - - cc00 "= 50� , tpc -mac
1 .
-- OF $ALFM; It'1A55Acnu=�
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STRE'£T, 3RD FLOOR
< • y SALEM,MA 01970
TEL. (978)745-9595 EXT.380
FAX (976) 740-9846 _
iTANLEY 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
ate
Signs of Permit Applicant
FULLY complete the following information:
(PLEASE PRINT CLEARLY) i
<,'\ hio
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 cIII, S 150A, and the building permits Or licenses are to
indicate the location of the facility.