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2 HARRISON RD - BUILDING INSPECTION L4YfiSlAtST-BE f4L-E irfl Af PROVED BY T44E =PZCT0-R ,PWR TP:A.PERMT.BEWG GRANTED CITY OF SALEM iVN No. IS$ 'ZOOkj H.��;. "� �' � Date s ��YHINB DO�� Is Property Located in ,, // Location of the Historic District? Yes_No V Building l�AkRlSO�� Is Property Located in 31— ©O O S the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, eroo Install Siding, 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 14k tir1270/`,) Address & Phone f2 Architect's Name Address & Phone ) Mechanics Name lfllcP019GJ�dDJ�U2 J 4 Address & Phone j✓o AdV 2/3 CG4�ys'/i A/ (O' ) 5?b�/ 7530 What Is the purpose of building? lk,nMT Material of building? (,dC.L'tl�2 If a dwelling,for how many families? - T- Will building conform to law? Asbestos? / Estimated cost ti City License # N A State License # h�-7i�7 Home ljImprovement lj� V Lic. # rJ /A� f t ignature of App icant `l SIGNED UNDER THE-PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE E t i i MAIL PERMIT TO: .nIZLZ- y t No. 158-Zoc�y APPLICATION FOR PERMIT TO LOCATION. PERMIT GRANTED APPROVFD INSPECTOR OF BUILDINGS OF 5ALEM. PUBLIC PROPERTY DEPARTMENT 2 • 120 WASHINGTON STREET, 3RD FLOOR < SALEM,MA O 1 970 TEL. (978)745-9595 EXT.380 FAX (978) 740.984ra STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,SA I acknowledge that as a condition activi of Building Permit#ILL"ZO a all debris resulting from the construction ty 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: ca on ofF StY Location of Facility ' Signature of Permit cant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant C.ic�c?13 crN5 7e?uC I. 'U Firm Name,if any A a /3d 1 2- 5 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 cM, S 150A, and the building permits or licenses are to indicate the location of the facility. �--Ommontul:aAk of V4a6.iacL6¢f16 JaPar[man[ a/ J [r[af 4 .lob boo Woski-11m-Sb..[ m Jaes J.Camooes 9Wctaaalt.4i 02111 Workers' Compensation Insurance Affidavit 1, wich.a principal place of business at: do hereby certify under the pains and penalties of perjury, that: O I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Policy Number 1 am a sole proprietor and have no one working for me in any capacity. 1 am a sole proprietor, nen�con%ractor r homeowner (circle one) and have hired the contractors listed below-v?+ wing workers' compemsation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor insurance Company/Policy Number 0 1 am a homeowner performing all the work myself. I unotnuna we a cotry of tKU wtemtnt wiA be ion area to the Orrtee of Imotitaoons of the DIA for coeeeate eerWK&den anti we hive to secure co. att w reaurea unaar Section 2 SA of MGL IS 2 can kao to the inoopdon of criminal ot"ties corsatint of a rase of uD to-S 1.500.00 moor one years' iraruon t v.,U a Chi ""Ides in a loan of a STOP WORK ORDER ana a W of S 100.00 a oar agaeat me. Signed this � day of t Licensee/Fermittee 6u�it ing Departneent Licensing board Selecamens Office Health Department TO VERIFY CCVERAGE 1NFORtnATION CALL: 6i7-7L7-4900 X401 , 404, 405, 409, 375