122 HIGHLAND AVE - BUILDING INSPECTIONr
V 1r
. fL1M11s VED BY TiiE
8fJNG GRANTED
CITY OF SAOM
Deb
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sa MMaro cmft?
M Rawly Lamm b �C
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OINLDMKi PERMIT APPLICATION FOR: '
Pemltt tm
(Ckale whWwwr apply) Roof. Rsroof. Install SkH% CMOW Shad. PoK
RspaWRsplace. Oh r: /79�tc e Kew sarG .
PLEASE PILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PRODMO
TO THE INSPECTOR OF BUILDING&
The umWIWW hereby applies for a permit to build acwftV to the lain
spoomadow
wlrlE
Owners Name C � 1, : c!/r r! tco s
Address A Pin I , 2 jo u,;l,lgad -7 yo- a 7(e C--,
Amhkeat's Name
Address 3 Phone ( 1
Medanlp Nam C 4�)r L7 n
Address & Phal 8'I 477^ 'ilS
wlrl 1.sa pupoN ar 4is�nst ,;1y� •
Mmi"al laftqt r a d for raw WAN hmftl
vrr eurdrq oarona b IINr1 r
ap U=W• N A sYb UNW•
SWdbM of AppYoarit ;.
SiGN90 UNBER THE R '
OF PERJURY
DESCRIPTION OF WORK TO BE D"E
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c w r duu, ` t d g !� 17 vG✓
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u MAIL PERMIT TO: I /h L g,-4 �
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A
i
y PUBLIC PROPERTY DEPARTMENT
120 WASNINQTON STRIAT, 3RD FLOOR
SALEM,MA 01870
TEL. (978)7484388 EXT.380
FAX (878) 740-9644
STANLEY J. Mower, AL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordsnoe with the provisions of MGL c 40,SA I aclmowle*that as a condition
of Bm'ldmg Permit N all debris resulting from dht cmmMwtion activity
governed by. this Building Permit sm9 be disposed of in a properly licensed solid-wate
disposal facility.as def ned by MGL c I$,SIXA.
The debris wEl be disposed of at !L -a ev�-
Location ofFacilky
SigoatlmtofP APP Date
FULLY complete the following nLimost m
(PLEASE PRINT CLEARLY)
.4
Nam ofPcamitApphem
CPa HL't 7/1 -7 U�J;,,; i4.
Firm Name,if any
74166 r-� -S OYaI ` L7 P"
Addmm,City&State
7be above statute requires that debris from the demolitiM renovatim rehab or other
alteration of bm'l&g or structure be disposed in a properly-licensed solid-watt disposal
faality a de dined by M(X ca S I50A, and the building permits or licenses are to
indicate the location of the hdhW.
.j COmmonwaah o/ 4_4.66cLett6
6
JJepnrinauaf a/9.d�.iaf�«ia r.1t
600 wow SWJ
�amesaf artfp0ea �o.1.w, //l..a.d 02111
crow
Workers' Compensation Insurance Affidavit
I, 4—( e dAcyAer ���
. . w'ut.ba principal place of business as:
• --� IOer�aare/La)
do hereby•certify under she pains and penalties of perjury, thm
- I am an employer providing workers' compensation coverage for my einplOyees working on
this job.
Ci%d TH3 , q(,, /,.� 177'� �Pt�d
Insurance CompwW Policy Number
I am a sole proprietor and have no one working for me in any capaickye
Q 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired she
contractors listed below who have the following workers comperisation Policla:
Contractor Irauranu Compatry/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Poliey Number
() I am a homeowner performing all the work myself.
i vnoeratand wt a cm,of two wcemnx wa pe imaroed ev Me Once of lnvedeaviceo of ehe 01A fa cererare rrrwKadm aab Ynt(,Ale m sedere
co.erart n reo+reo under Section 2SA of MGL 15 2 can kad w oK ireoowiee ed oinvtm oeni gin eorwdnr of a tree of R ni 1 SOOAO■d e r oa
yeah,ineroonnrnt X n o u dui Mr.9 ie in the loan of a STOP W ORK ORDER and a toe of S 100A0 a daf ars:w aat
Signed this day of
.-icensetiFerrrnirttt cuilcing Dcpamro%ent
-ictnsing Ecare
SeiteLmens Office
". .alth Dep7r-,n•ten•