5 HERSHEY ST - BUILDING INSPECTION r
IAUST-BEf1LfB-li Afl Pfx`ROVED BY T44E
U PI:CT.Q1. ,PFWR TD.A.PERMIT.B,EWG GRANTED
CITY OF SALEM
'kA � Date
N6 CAyI:.
Is Property Located in Location ofr!/
the Historic District? Yes_No—.Z\— Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, R Install Siding, Construct eck, Shed, Pool,
Repa Replace, Other: P)C /,;Z-
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 J/ 10M614 citi 4�1.
Address & Phone i71rr - 4?oV S
Architect's Name
Address & Phone AX ( )
Mechanics Name 1f PO /P r N/ r LM d/ 4
Address & Phone Y 4_ (9J�i 7qG/' 3
What is the purpose of building? /
Material of building? /1!/PJa C/ If a dwelling, for how many families? �—
Will building conform to law? ? 49 Asbestos?_ki)
qqq������ Estimated cost r`, > .� _City License# N 1, state ' se
Home Improvement
�� ` \ `` Lic. f �630(aS' xta
VJ Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
fie C Z!L e,X 1
MAIL PERMIT TO: 1.2 de; (NA P
I
•t
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2- � 6S-
APPROVED
SP CTOR OF BUIL INGS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Officedinmtlmom
600 Washington Street, 7`a Floor
Boston,Mass. 02111
�y�lWorkers'Com ensation Insurance Affidavit: Buildiu lumbin lectrical Contractors
name: ,�(r
address: U t't Jin e S J
city state: liV019,70hone# 7
work site location(full ss • ek 17- ,-o t1�
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
am a sole ro rietor and have no one worki ity. El Buildiniz Addition
❑ 1 am as yployer viding workers' compensation for my employees working on,this job.
a9asr�telnC' (r �Y'l/ ��I i'J t-!/!'.r •'/ w. ('0„� ',�, ,;�. s''�-xh'}. y �. �'� `4'v� } �zn?
address' r .> fl#x:doted S 4y
city: .-,. ,. . ._ '..?� ,f't t 4a. ;3C,j,, y,
insw4u,e
I am a sole pro ietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following wo ers' compensation polices:
com an n
address: - -
ci
in ran p� , : -w, ,�:��,k
,: ..w+,< _ , ,K ,,.... ,rr-..,::., y H t , rev h• w ;.:.'.:rs ,+}
ap, rSk,
coma nam .
address : . .. .
.. ..
s
.. _ t*..... '
Failure to secure coverage as required under Section 25A of MOL 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me, 1 understand that a
copy of this slatem be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby erttfj a tr ai is nd pe es of perjury t tat the information provided above is true and orrecit
Signal. Date D J •D
Print name A4 A Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit/license p ❑Building Department
❑check if immediate response is required ❑selectmen Board
❑Selectmen's Once
contact person:
[]Health Department
phone f/; ❑Other
treeseJ tape oxen
2
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHIN6TON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL (976)745-9593 EXT. 380
40 FAX (976) 740-9646
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 0 ,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 e
Location of Facility
Signature of Permit Applicant Dat
FULLY complete the following information:
(PLEASE PRINT ACLEARLY)
Name of Permit Applicant I
py,94 M� Aavt (J \ Sew Ciro a-iiC
Firm Name,if any
l 1� rI c� ?,*
Address,City dt 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 cHL S150A, and the building permits or licenses are to
indicate the location of the facility.