95 JACKSON ST - BUILDING INSPECTION (2) ' CS
r '
IL9tMI MtlST-BE ffLf� APhPROVED BY T44E
.W5PFXT4R ,PF,IIiQR TD A.PERMIT B,EWG GRANTED
CITY OF SALEM
\\ � cA or�a
No. \ st? ..� q�\ Date 3 a
Ward
� 4mNE ° Zoning District
Is Properly Located In / Location of
the Historic District? Yes_No [/ Building '76 , aT Ct soy S
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
air/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 �u e, 68aCGv-i
Address & Phone �� ,�ac�ro� ESL ( )
Architect's Name
Address & Phone ( )
Mechanics Name F'e/1. 1\ , cowffi-
Address & Phone 10 ryrrak6h S7 - Sg 6,,,
What is the purpose of building? now
Material of building? lj,7j If a dwelling, for how many families?
Will building conform to law? Asbestos? ifi 0
Estimated cost 570a, OG City License>< [CIF state License 0 CC BCi;
Home Improvement
. Lic. IILC os-0
Signa Lire of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: pt-A�c, Crrr~s11
S�i�� /vlf". u1976
No ,\AA v�
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
19
AC�VPD
INSPECT011 OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WA8NIN6TON STREET, 9RD FLOOR
i
SALEM. MA O 1970
TEL (979)745-9595 EXT. 360
FAX (076) 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,Sum.
The debris will be disposed of at:
Location of Facility
C/o 0 0
i of Permit Applicant bate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
�1� fi,Ctr CoV�4
Firm Name,if any
Address,City dt State
The above statute requires that debris Sum the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defned by MGL cIII,S 150A, and the building permits or licenses are to
indicate the location of the facility.
� COmmOnulrlQ� Of /1/iW6L1LWSLLO .
600 w.1.11«.SWJ
�ofnaslGaloaM &d, //.J.A 0211/
J / Workers' Compensation Insurance AffidWh
. . wio-a principal place of business ac:
/0 k,I.
. . cus,«.Waa
do hereby'cerdfy under the pains and pesasltia of petjory, thm
() i am an employer providing workers' eompeasatioa coverage for my employees working ees
fhb job.
Insurance CompwW Poliq Numbs
1 am aisole proprietor and have no one working fdr me is any cap acky
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-be" the following workers' cosnpensat3on Pascua:
Contractor Insurance Companry/PoRq Number
Contractor Insurance Compan ylPoRgr Numbs
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I canoe Wr4 ow a Caa1 d de wwmere we!e fon•aroee oa da Ogee el Irr.edg... of Ow DIA for cavware ewikodoe OW ON Nitre r aasare
ce.ware x rewr,o enew Secdea SSA of MGL 15 2 can kid as Ow inarwiea of erW&M oenado eorjsdM of a fire of to W4 14O M awor ON
rcon•irWocawa l a va a ew seealrio in d+e loan of a STOP WORK ORDER ands frw of $100•00 s N ap:at sae.
SiErled this • C, �h day of lnQ �Gy
:;ccrseciFcrrriueeeuiloinQ Gepars ent
:.jcensinf Eoare
Seiectmens Office
rie:lsh Depar•.merc