7 HILLSIDE - BUILDING INSPECTION ' 1' �
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,U�S,P.�J'�1J� ,PF,i�b1R IP.A.PERMIT.B,EWG GRANTED
CITY OF SALEM I'
-I `1 UL \' �P�� �
No. Z.� n -7 Q Q c`t ..� *'Zs,� Date � � ''.
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�`�MINe�y . '
Is PropeAy Located in Location of
the Historic District? Yes_No� Building � ' �(� 5,��
Is Property Located in �
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR: '
Permit ta � ,
(Circle whichever apply) Roof, eroo �4ns���g, Construct Deck, Shed, Pool,
�
Repaid eplace;Other. �oY�!M r �'
� PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
5 �0 ,
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications -
owner's Name I�t ✓,'� � . � 1,�/_,�.�/r�YL-L
Address & Phone ������/9'� • 5 � ' ��� ���' � l� �
ArchitecYs Name !7/✓�
Address & Phone ( 1
Mechanics Name �ti, �-..-r�/I/'� 4
Address & Phone /f�l n�� rQi� .F�� �� �-s.�� `" ��J�
,
What is the purpose of building7 � �1 � ��7 r l/�'l 2` /�
Material ot building? l�/� If a dwelling,tor how many families? �
Witl building confortn to law? f Asbestos? ,�t/ ��
EsUmeted cost �� City License # N p' State License � �.� 7 O
Home Improvement
$IOl °�° r.��. � O � �
LK 3 ' ` Sign ture f pplicant
'� SIGNED UNDER THE PENALTY
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OF PERJURY
OESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: �
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No. 2� � -Z���
APPLICATION FOR
PERM(T TO
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LOCATION.
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PERMIT GRANTED
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APP�OV�D
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INSPECT OG��II�GS
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�/ �o �_. . f OF �P:LEM. lRF��fa�.nv��- . , -•
` '� PUBLIC PROPERTY DEPARTMENT
" • ° 120 WASHINGTON STREET� 3RD FLOOR
� '. SALEM,MA 01970
�Sr�� TEL. (978)745-9595 EX7. 380
.� �G,� FAX (978) 740-9846
STANLEY J. USOVICZ, JR. � � �
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
��cordance with the provisions of MGL c 40,534,I acl�owledge that as a condition
of Building Permit# ,all debris resulting from the wns��°II�►�ty
govemed by this Building Permit shali 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: .��i)__„__!Y�5//�l�—�'p �`�� �'v c,, ,5�'�jr «f f�.
I,ocat►on of Faciltty
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Si ture of Peimit Applicant � D�
FULLY complete the following information.
(PLEASE PRINT CLEARL�
���r� /M ��/`�.,/n��L L
Name of Permit Applicant
Fum Name,if�y
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Aadre—`,ss, ciry &state
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or s�ucture be disposed in a properly-licensed so�id-waste disposal
facility as defined by MGL cIII, S 150A, and tl�e building permits or licenses are to
indicate the location of the facility.
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boo w�,�,y�.��...f
�ameeJ.GmooeY Uo�oa, //lasuchuuw 0�1 /1
Ca-�ss�ona
Woricers' CompensaLion Insuranee Affidapit
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. . wich.a principal plau of business as:
iu.ris..�✓s�.�
do hereby certi(y under the p�ins nnd penaltia of PerjurY. tfia�
O I am an employer providing �vorkers' compenzation covenge io� my employea workiaf oe
chis job. /
� �';�/ G^l r � -�-A/5 , r)C-I�5 �l 7 '7' C7 � n. �
Insunnce Compam Poliq Number
1 am a sole propriaor and have no one workini for me�n-� �WarY-
() I am � sole propriecor, genenl con:n or or ho em owner (orde one) and have hired the
/ ' com tnsas�on polities: � � ��
.worksrs p �'/ 1
consnaon lisced below who have the llowinq � J 17�a��
1� 'I�u� ���n�f"rr�_ (1' r�'��� L ..�.r✓� � %-v/
Consnesor Insunn�e Company/Pohq umber
Concnaor Insurancc Compamr/Policy liumber
Conttaaor Insurance Company/Poliq t�lumber
() I am a homeowner performing all the work myself. •
I une<rwna wt�cwY o!thi+w�mimi�b�ion+aru0 m t1K Offce ol Imedt�w�u ot ttu DlA la co+erat���°O^����1O�e
co.�era�a a� rewrra unoa Seviwi 25A o!MGL 1 S 2 c�n k�E w Nr►nownion of cr6ninm oen�ues corsaont vl 7 fiae el w tei I.SOOAO�n0la oni
rears':nxuomment ai.vo m eiri oem�uef in me �orm e(� STO P W ORK ORDER ana� f+�t of S 100.00 a aaY�[+���•
Signcd this , �c,� day of �(°� ' -•--.'�=��
�iccrsce/Fcrmit[te building Gep�rcn�enc
Licensing board
$e{eamens Office
!ieafth Dep�nmenc
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TERENZONI � E
' No.38720 J. 7 Hillside Avenue
e Salem, MA
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Prepazed For:
Assessor's Map 15, Part of Lot 406 Kevin ODonnell
Existing Lot Coverage: 25%+/- Scale: 1"=20' September,2003
Deed Ref.: Book 13305 Page 571 & L.C.PIan 16595g