27 INTERVALE RD - BUILDING INSPECTION -ft-*146-MOS4'-9E fiL{-B-1fJD APPROVED BY T4IE
.1NSPFCT0R PIER TD.A PERMIT BFJNG GRANTED
CITY OF SALEM
`aN
No. 23S` w
ZOOY ``� .. �i,\ Date Y O
Is Property Located in / Location of
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.,_Construct Dk, Shed, Pool,
Repair/Replace, Other: f iNt5fV ? aLE✓EL
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 �7riamzt adeffEL
Address & Phone Z7 1AIrKeslAtE (r rb ) 7yS'y y
Architect's Name
Address & Phone ( �'1
Mechanics Name 4"Iet l04,tr rr'A,6 E
Address & Phone ?7 /1L1rj6eV iF oet 36 -rdJ
What is the purpose of building? 'z
Material of building? L'4/0C) If a dwelling, for how many families?
Will building conform to law? 7ES Asbestos? "a
Estimated cost '�City License n N k State License 6 19114rl 3 V
CALSI SZ Lime Improvement X `
� rne. e I ' Sign[at� ure of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
&Vi51 2"%° 1EdE1 j
nVst#tc >3�9r �a(oa�r
MAIL PERMIT TO: ( �N II4a MA- d�g7r7
•No. Z 3 s
APPLICATION FOR
PERMIT TO
LOCATION.
f '
PERMIT GRANTED
APR OVFD
iNSPECTOF00F BUILDINGS `-
COrnrrwnwaaAk 01 0-6.iachtveft6
5 :
J.Pnrlmsnl a f.J aduslriaf�iccit/ .b
600 w-111m
James J.Camoo" &6, 7&." 02llf
Commtssrow
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
-77 dlt6 irA1 4/ -!;AnQ + ,0;,4 41i9 70
(Ggataa✓tap
do hereby'certify under the pains and penalties of perjurY, that:
O I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Dumber
Vra I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unetrwne we a cm of chit scateetnt wa bt for aroeo to the OffKe of Itnestitavons of the DIA for cottrate v Akadon ana emt Mute to Have
co. atr y reovreo unaer Section 25A of MCL 15 2 on lead to the invoWoa of crvr:nm ottattks corusunt of a fee of we tot I.So"D WNor one
yesn'inorwnmtnt n.ua u d Ido M tie Iona of a STOP WORK ORD ER ano a fee of S I OOAO a nary st"t me.
Signed this 7I day of 2L
�icensce/Fcrmittee building Geparzra+ent
Licensing board
Seiectmens Office
Health Department
': C :'EiFY COVERAGE iNrC�4;': iON CALL: c I 4400 X4C' , 40<„ 405, 409, 375
goy _..'7Y OF 5ALEM. trtAS�a..n�+= - •
PUBLIC PROPERTY DEPARTMENT
° • 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT.360
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# ,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: Location of Facility
Signature of Permit Applicant
Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
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
indicate the location of the facility.