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0005 HARRISON AVENUE - BPA-4-68 -Pis ­M41ST-eE fILf�';AiHPPAOVED BY T41E 1AIS7L fI1DA 7D P T R•EWG GRANTED CITY OF'S .LEV No. (A' lr:: Date 1 U b Is Property Located in Location of the Historic District? Yes_No Building Is Property Located InEM /Ltd the Conservation Area? Yes_No 3 �, y BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof,( nstall id g, Construct Deck, 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 kIy-k4/+27 + ) -Q( ,j Address & Phone DW LINE h ,S'1- ELL q )-7- Architect's Name Address & Phone ���/f/ 1 ) Mechanics Name I \i L[411V D Address & Phone ZF (Z At At a Aq S 1— f 9 X What Is the purpose of building? y Ul jt 1� Material of building? 1 R-1- If a dwelling,for how many families? Will building conform to law?-eS Asbestos? Estimated cost Z Gty License s N P' State License rt Boma Improvamant $Z oo Li`' # X Signature of Applicant ZZ SIGNED UNDER THE PENALTY OF PERJWRY DESCRIPTION OF WORK TOPE DONE MAIL PERMIT TO: I No. © y e. APPLICATION FOR PERMIT TO LOCATIM, PERMIT GRANTED 19 APP VD : INSPE Ti,R F BUILDINGS 1. OF SALEM- MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR '. SALEM,MA 01970 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,S150A. The debris will be disposed of at: -A-t,r M I� v.�c Location of Facility Signature of Permit Applicant Da e FULLY complete the following information: (PLEASE PRINT CLEARLY) ^-4 D E .a :UCS Name of Permit Applicant Firm Name,if any 2rP ✓� �vtN�� ( -S — i3C—vEic ( ci 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 clII, S150A, and the building permits or licenses are to indicate the location of the facility. C0rr-m0nfun:abk oPY&6.1achcvelL LF o/9,L,I,if.,7Ca;"nU 600 LVauLVi.n S1...I James J.camcces &sloa, ///auandlu .ib 01/ l f Ctaa-mrsmrw Workers' Compensation Insurance Affidavit (do�..vearwe) with.a principal place of business at: ltnr/Swds4i do hereby certify under the pains and penalties of perjmy, that: () I am an employer providing workers' compensation coverage for my employees working on this job. 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 under m out a cony of Nit sucement wM be ion arced to the OnKe of In odgaoam of Nt DIA for co.erate.e WKMion and wt faaare b secure coMatr y reooeto unaer Section I SA of MGL 152 can lead to Nt inomaon of criminal cenanies corsatint of a the of go toi I.50D.00 wo/or one reari imxuonment v A as ciei"naftio in Ne form of a STOP WORK ORDER ano a bu of S 100.00 a say against mc. Signed this �vr�e `�, day of U( U Licensee/Permittee Building Depa ent Licensing Board Selectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375 I