450 HIGHLAND AVE - BUILDING INSPECTION (6) - V�N 66u
MHsT-BE f UES-4 JD A?PROVED By T*IE
LU5 FXT0R ,PfWR TO A.PERMIT BEING GRANTED
CITY OF SALEM
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No. ,F., L %� Date � O
i_ y
Ward
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NEI Zoning District
Is Property Located in Location o
the Historic District? Yes_No-)( Building
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, onstruct eck, 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
Address & Phone
Architect's Namerr7�
Address & Phone lJ T- Wei-) 3.G9- 5;,AG�
Mechanics Name
Address & Phone ( )
What is the purpose of building? Mill i pt 7bno7-5
Material of building? 6�/-'5%P-i If a dwelling, for how many families?
WIII building conform to law? �! 2S • Asbestos? "y b
Estimated cost City License# State Lic se #
Home Improvement
Lic. i
ignature of App lca
�J J� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
71�UCi>Y'_ ci�77,a0 � �i �`�itfcJ�•y� Gr�ss� �111 ��
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✓l�+ll;t;.t� l�Li�l��/6 �//E �o��T�'S �d �u� r'��s� [��
MAIL PERMIT TO: / j�Ss
ij/r' �i�vl ��✓s�d
r� -
�T
No�� ���
APPLICATION FOR
PERMIT) TO
LOCATION
PERMIT GRANTED
19
AP 606V�D
INSPECT R OF BUILDINGS
1
G COmmonJ�rsfs[Ut of /IJcWathwsld
loin
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//� d 600 w�� w.A., Simst
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�aJaeq 1 Caaeoaa , daaeLolb o2 i 11
Consumer
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f� Workers' Compensation insurance Ada k
. . whh.a principal ph= of business ac
do hereby'centify under the pains and penalties of po*ys than '
1 am an employer providing workers' compensation coverage for my employees working ees
this Sob.
Insurance'Company Poky Number
1 am a sole propriesor and have no one working for me in airy cap4la3q.
() 1 am a sole proprietor, general comrae:cor or homeowner (drde one) and leave hired the
contractors listed below who-have the following workers' compensation policies:
Contractor insurance Company/Poky Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• uwaenuna atac a won d tlti weernen.r.e. itN+.arMe m tM Ogee of M•atiaaapr of cite DU.Jar caearate.w6kadw and war lam r woare
co.erair ar ifWred enact Secden 2SA of WU 15 2 can kad ro a" of eriI osaade eenaadrat Of a 6r ed w w4I.1100M anal r one
Lean'inananewat a•ue a aanie it the Jove of a OP WORK ORDER am s tee of S 100.00 a a" araww cot
Sitmed thi day of
:icerseeiFcrmiitee "tuildinf Depai-Er ent
ictn-sirif Eosre
Seieamens Office
rie:ith Gepar-merc
PUBLIC PROPERTY DEPARTMENT
• 120 WASHINGTON STREET, 3RD FLOOR '
SALEM,MA 01970
TEL (976)745-9595 ExT. 360
FAX (978) 740-9846
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# 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 a III,S 150A
The debris will be disposed of at _ j T
Location ofFacility
Signature of Permit Allplicant to
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
elver �i� / �t-✓ 1�r�
Firm Name,if any
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 150A, and the building permits or licenses are to
i indicate the location of the facility.
i
"ali
fi � � # ��e Vi on✓uernuuaall� a /��4vlr�uavlr'd '� �
I BOARD OF BUILDING REGULATIONS 5
License: CONSTRUCTION SUPERVISOR 11
Numberi'CS 074148
m�
p` Birthdate. 01/14/1973
I}{ Expires: 01/14/2005 Tr.no: 7253 J
Restricted_:III 00 }((}i G RE
13A 13 DAMS CIR !!
REHOBOTH, MA 02769 Administrator 1
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