1A HART WAY - BUILDING INSPECTION fL�lliMMIN PILAD4m APPROVED f3Y Re
XWAZ=@-PWR TD A 1 MIT'SElNG QRAWkD
CITY OF SALEM
zorwq owt
h.►I an co�M�Ad�7� Y� Loeatios or
— stas.s � C✓�
Is Pigmy L000tod in
*0CgwniwSonAmW YS No—
StXLDWQ PERWT APPLICA M FOR:
Pwmft tw.
(Ckda whWMw apply) Install Siding, Con VWOt Shed, POOL
Olher:
PLEASE FILL OUT LEdSLY i COYPLUEL.Y TO AVOID DELAYS N PROCESMIG
TO THE INSPECTOR OF BUILDINGS:The undws*W '•
hereby Opplhs for a permit to build eocordi ig,to the followkq
Owners Neme L cLc K < x]iV
Address Ai PhorM
ArohitWs Nmw
Address d Phoe N 1A [ 1
MetAenios Nam.
Address d Phone
Whet in ft piMm it e SMW
tdwm a NNW Lire v cl M.dws&q,for now mgny b~
wN twll�q aodown a wiry y e g Newow9 ill 14
Edmm oat C S
am Lgsoummt c
lag. i
svfttre Of pl"m
1111101011 MEW!THE PENALTY
OF PTAMT
oEscRlanoN oFwOacro sE osoNE
j
c i
MAIL PEiSAIT TO: r�
. ! -i
3DPN011f18 � mo3c I
a31NVV9lwrJ3d
NOILV
Oil JBWA d
UOd NOLLvorlddr
CITY 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 aclmowledge 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: — A
Location of Facility
Signature o9germit Applicafit Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
12o 64,,1 J. L-4 eLAr'C
UV-
Wam of Permit Applicant
Firm Name,if any
9 -3v
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 I50A, and the building permits or licenses are to
indicate the location of the facility.
I„ _
= \ The Commonwealth of Massachusetts
a - Department of Industrial Accidents
600 Washington Street, lu Floor
Boston,Mass. 02111
'¢ Workers'Com ensation Insurance Affidavit: Buildio lumbio lectrical Contractors
name: V. L�'7 a cA r-e.E�?e
address: 1 - r-i ail G W o-„
city Sea(-a^^ + state' M A Coo- Oi 9 7 0 phone# 4 7 d' 7�L
w /—A H a-4 G aj a Sw / H/3-
❑ 1 am a homeowner performing all work myself Proj Type: ❑New ConsauctionEklemodel
I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers compensation for my employees working on this job.
U::
chin
1C
insuaoa oo. . • iialer��. »...e.� "� .� a,;✓v..r-•.. . r
a'dd`
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
eomnanv game: - -
r.
address:
city:
g
'' {
e:':tt-max '•r n" '" 1-,fi ti.Fw "r,
a
l' ft r s
company muffie;
address:
�x'�� Ly��tia3Y:.n:v
* A 4fi�y%f h, X t ,oil
0.
s .r-
N
Failure to man Coveage n required under Section 25A of MGL 152 an lad to the Imposition of crlmbul penalties of a fine up to$I,500.00 and/or
one yesn'imprisonment m web es civil penalties in the form of a STOP WORK ORDER and a fins of$100.00 a day aping me. I understand that a
copy of this statement may he forwarded to the Office of Investigations of the DIA for avenge verification.
l da hereby cerd under the pains and peenalties of perjury that the information provided above is true and correct
Signature a M,4- 1 oLi✓G e.x_o pate
pp 62.e G J /)
Print name R D . L7 e,LA f-e t.r-,f Phone# 9'-:� ft'-7 Si S—6 f V/
official use only do we write in this area to be Completed by city or town official
city or town: permit/Iicense a
❑Buildtag Department
El check if immediate response Isrequired ❑l-ketmketm g Board
QSeen s Oflke
❑Health Department
contact person: phones; ❑Otber
."WSW =nut