118 HIGHLAND AVE - BUILDING INSPECTION (2) r
.9►4PS Si�£fiLf� id{� APPROVED BY T44E
.WSPFXTDR ,PFDR T-D.A.PERMIT.BFING GRANTED
CITY OF SALEM
\ V ,,
No, l � ��" '� ''t Date
5
Is Property Located In Location of
the Historic District? Yes_No,_ Building i
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, (nstall Si in 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 `se 0 r `6� Pc nR. n , 3 , h,2
Address & Phone 1 1 3 N, c h Lam.. �v-e (CIM R R
Architect's Name
Address & Phone )
Mechanics Name L v b_o LYCa, Cr-
Address & Phone U_�1A(>J S`r- era lr)nV 1Z) qIt 1-2,Z=3U
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost S4� City License # N P State License #r1 S-0 `1 S Z
LHome Improvement v r
v 0 Lic. i l ,�11 a_nar+
. Signature of Applicag
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
I
lLYL
s
r
MAIL PERMIT TO:
Li
�� g � 0 .0 MA ac � b �
No.
APPLICATION FOR
PERMIT/TO
LOCATION. J/
� S
PERMIT GRANTED
APP D
INSPECTOR F gUILD114GS
w
P
1 ✓/N
Mu�llb9 6ds1482
I; tr,no; , 21208
r i
otter �j ... .
�� �anv�izovuuea/�/ p�/ aaac�iuoet�lop Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration\100811
Expiration 6/23/2006 1
t
We PflV8fe Corporation
LEN GIBELY CONT
RATING CO.,yINC.
Leonard Gibely
149 Main Street " _
Peabody, MA 01960 ��--; ✓
Administrator
t
� � C�ommanwuat°Ui o� /�at�aacnccaaf�
1Jeuarlinent a/���triaL.�teiai�i ..
600 VVaJ�iin9tan' treat
11
ntwtts`02!
i �/�olton. ///a!!ac . . � .
JaTlS J.CdT00811'
Commissioner qI
Workers' Compensation Insurance Affidavit
6� Lv
with a principal place of business ac:
1 (-i 9 MAIN t 9 6,0
tagwawa4
do here c . and penaldes.of.periury; than
mr emfY` P
under the pains
I am an employer providing workers' compensauon coverage for my employees working on
this job.
Q�87a� c� ae4
Insurance Company Po. cY Number
O 1 am a sole proprietor and have no one working for me in any capacity.
1 O 1 am a soie_proprietorr general contractor or homeowner'(cirde•one) and have hired the
contractom.ljsted below who have the following workers`compensadon polidest
Contractor . 1 Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor- "Insurance Company/Policy Number
O 1 am a homeowner performing all the work myself.
I wWerume alai a coot of thb sum nRm ww be forwarata to the Ofraa of hweweafom of the OIA for comatt tnrAcloon ant Na bkwf w Maw
cartage a rmw"under Secoox:2SA of MCL 152 2.can wad to tnt mcoaoob of crtnana oenatw'Conmunt
r' of ri IYte N ua a>;I.S00.00 aosttr or
rea mom mrse w in as ea a ow oemues m the brm of a STOP WORK ORPER,ana a fine 04Ie10.00 a an ataer or.
Signed this SY day of S® r C3 a
- �
Licensee/Permittee Building Departmen
Licensing Board
Selectmen Office
Health Departmem .
TO VERIFY COVERAGE INFORMATION CALL: 61.7.727 4900 X403r,404r 40Se 409, 375
Otu ITf �j' air ' �)ilia�aaznu��i
. • ,� I �ublir �rnperip �r.�nrimrAi
Euilbing $r;rnr=rut
(Oat t}vlrw Strtn
5D9<7Q5=9595 Fct. 3aD
DI5POSAL OF DEBRIS AFFIDAVIT
In accordance• with the provisions of MGL c 4,0 , S54, I acknowledge that as a
condition of Building Permit A all debris resulting from the
construction activity governed by this Building Permit shall be disposed of :n
a properly licensed solid waste disposal facility, as defined by MGL c 1I1,
S 150A.The debris'vill be disposed of at: �.1_�L ��•�r. Mo" i� S k !) o CAti� i
location of facility
57
=T Date
o
T � Signature of Permit plicant
Fully complete the following information;
(Please print clearly)
Name of Permit Applicant
�_o �. Yl b 2L�/ �aN!IZ 4cT LNG
Firm Name, if any
Address: City b 5tare
The above statute requires that debris from the demolition., renovation, rehat
or ,ocher alteration; of building or structure be disposed of in a properly
licensed solid waste di4,0391 facili-ty as defined 'by. MGL• cIII,' S150A and that
building permits or licenses are to indicate the location of the facility at