17 JAPONICA ST - BUILDING INSPECTION (2) IdlttST-BE fH.fQ--AN0 APPROVED BY T44E
.=P CTD13 ,PMDR TVA_PERIT B,EW G GRANTED
CITY OF SALEM
No. Z `7 I —ZOOS C �v � � Date ` — 3 U 3
\!
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 Deck, Shed, Pool,
Repair ep ace, 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 (� ���°tir �� L -7 //��-� �l l
Architect's Name
Address & Phone
Mechanics Name1C1
Address & Phone
What is the purpose of building? 0 �t7o
Material of building? �JO&z/( If a dwelling, for how many. families?�J
Will building conform to law?_ —Asbestos? c'
Estimated costs --') 0 0' Cy City License # N TState Licens #
Home I
i�a�� X CS' 073
Zp ooS T �� Signature of Applicant
�ur»ps SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No. Zy ( -2aot
APPLICATION FOR
PERMIT TO
LOCATION.
PERMIT GRANTED
9I�0%-?,
APPRQVED
INSPECTOR OF BUILDING
(fOfnr)'LOnwt:6a '� oP Maiaac�affa
I
�:Jeparlmsnl a/..7,tduif.iat.:«;4.,�.�
b00 "k-11 ~S1..e1
James J.camm" Ueslon, ayac�uu.W 021 11
e«r+rysabaer
Workers'
Compensation Insurance Affidavit
1aa�,ee,twnrrw)
with.a principal place of business at:
teaersw.✓s4) J
do hereby certify under the pains and penalties of perjtny, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 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
() I am a homeowner performing all the work myself.
1 vndeniand we a c and out faaurt'd Secure
ooy of the wustxnt w.'B D: iorv+ar0ed to [Pt OffKe of tmasitaoons of the D1A I« co+erare reriRcatian
co. arr w tewvee under Section 25A of MGL 152 can lead w we onoeaesion of erkninas oetuwues eorxstini of a h"of go t04I.S0000 Mwor one
yean'iraruonmrnt v Rta as dri oeulsies in the loan of a STOP WORK ORDER and a tine of S 100.00 a am against we'
Si ed this day of
i.icensce/Fernittee 6uilcing Geparcr.+ent
Licensing board
Seiectmens Office
Icalth Department
- -'G?+ C L` - -_4cOG X= 0�- 40�, tOt, 40°, :7r
_F_I7 tom.`, f v r.r,
��oxnr ' OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RD FLOOR
a
p SALEM,MA 01970
TEL. (978)745-9595 EXT.380 _
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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 D
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.