15 HARDY ST - BUILDING INSPECTION III
f..
13
P116ROVED
EW $Y TEEIR 0G GRANTED
�PITY OF S LEM
.INQ• � � .:.. I, ', ' Date
Ward
�\ Zoning District
IslProperty Located In Location of
lhji Mlsfbllc [pistrict4 Yes_No Building
�s,Proprly Located in
II10 Conagorvation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repair tie,ace, Other:
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name 1414 to civ�
Address & Phone a 7
Architect's Name
Address & Phone /
Mechanics Name k„ 114,v�.l CC&,1RON Ca G C0A iP1A0 L
Address & Phone 070 ) 7ti l'' ax49
What Is the purpose of building? FcIlrj.a) A
Malarial of building? f�(prd If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cosh s� City License # '3 State License #
Hama Luprovmant / 0
/y Lic. / /osozo
Signature of Applicant
�,� C SIGNEQ UNDER THE PENALTY
V OF PERJURY
DESCRIPTION OF WORK TO BE DONE
.S Li v lE r9yf/p Ey;I r. 1/10 A14140- S//'4,1�'/_FS
MAIL PERMIT TO: ki olAiygl 6 En alRon� Ac, eogteo ,g sj, . SA�r,'ivt D1970
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a m
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C 80
RK O Z
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DbY9'f$.Me.
'013t1`lt "E
1wf_i i....'ir.'): �,ta64rdei' lane'p,"1l; I{}oHfiaiP Ioor"i
Of -eYAJ30 010V.A OT Y s'Taj w; :P ,4. 5 i`UO J J t ':I A.�93"I
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r.:
,'ie�FIV"f7tn, `(Y9elr'9 Nti' 1,Yf jivYlBefat w;, Fl 1' :y f!�"i�,f„ (,'.- J'fu,!"iFJ91P�
:osmaaaL+ ., .r'. n pyf,:guilttlua;- tSi�n
h",MARM IV
�— fornniznumallhenolllla.sjacLafb
�<Parlmant o/.1adull,iaf 1+cciu.aL+
600 ryw� 611m.31,..1
dames J.Camwes 4�e,1oa, as>m�uu.lb o2111
Cora ss[oner
/Workers' Compensation Insurance Affidavit
1� _JSD��JN�'1 �ENC�'�Giv
with.a principal place of business at:
Sr
(eaeia.ar.,sU)
do hereby certify under the pains and penalties of perjury, that:
Q� I am an employer providing workers' compensation coverage for my employees working op
this job.
CWh kSUPAQf I'n 9Sd'X ? 70' 02
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() I 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/Polley Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Polity Number
() I am a homeowner performing all the work myself.
I unaen:anC wt cool of thu weemM[w9B D< ion+arosa m the OfH:<of Imadttuo[u of the DIA 1er coverare rer'kadon&race UM LAW"to Mcwt
coveeart of re0urea unaer Secoen 2SA of MGL 1 52 can lead to the invopemn of crrrinai oemtdes eoLsodnt of Erse of w mi I,SOOAO ands once
[ulu in the lo o OP WORK ORDER ono t fne of $100=a amatirottne.
L.u0 u Cive o< ti rtn
roan'ir:.JlWnrnen[
Signed this �� �� day of
l
tt -
�Iccnsee/Ferriittee building Geparcr.+ent
:accruing Eoaro
seieczmens Office
Y;t_;lth Dep:r-imcnt
CITY bF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
e 120 WASHINGTON STREET, 3RD FLOOR
j. , 'ro SALEM, MA O 1970
TEL. (978)745-9595 EXT.380
FAX (978) 740-9846
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, S 150A.
The debris will be disposed of at: St94c—n ?2r1n S fit STj T sv
Location of Facility 9A) 9 /D �
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
G � G Can.i R e'-fopy
Firm Name, if any
/fo JeJ966om/S ST SA arm , /YJ�9ss
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.