195 JEFFERSON AVE - BUILDING INSPECTION (2) i
"IUMIAtIST9E fKA944NO APPROVED BY 771E
J 9P=XlR PRW TD A PERMIT WWG GRANTED
CITY OF_SALEM
Des 0
No
s •
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Zoning often
Is ProPsrty LocMd in �. Location of r/Uro Nlatab obtAct? Yw No _ ��s /N V ¢ice Ae—
Is ProPwty loceted in L/
IM Corownlon Ana? Ya No_
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof Install Sing, Construct Deck Shed, Pool,
epatdReplace Other: erd-s'n
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accord„ig•to the following
specifications:
Owner's Name RAHV Lf/kiln,
Address & Phone l9s p ro„ ,� u�, (47A 7f�'= 72i 7
Architect's Name
Address & Phone Ifj�
/
dots Name ?4- L V/:, �r.a.�lr l .
Address & Phone �O Lfnj.Co 44-
rj
Whet Is to purpose of brdidgrg7 Pesj'CJ-ta (.
M WW of Iarll W to ZI kC/ .Pi j jW' Had- 11 for taw moony lvNes?
WillMdk twrg oordorm to law? 4•Pj Asbestos? /V6
Eetltnabd cog7�fli cay Ucww M��State M 6 y 6�
acift
x
Lie. i
Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORKTO BE DONE
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r
1 B -e or � Ins Ig- r n Z/¢/
MAIL PERMIT TO: 19 S— �,Te-Z �
.t
APPLICATION FOR
PERW T'TO
LOCATION
PERMIT GRANTED
IeA7 19
APPR 7D
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT '
120 WASHINOTON STRWIT, 3Ro FLAOR
SAL Km.MA OI 970
r TEL.(978)749-MOS EXT.360
FAX (976) 740-96"
STANL.EY J. USOVICZ, JR.,
MAYOR
DISPOSAL OF DEBRL4 AFFIDAVIT
In accordance with the pmvisiow ofMQ,c 4%SA I aelmowledge that as a caodition
ofBm'ldinj Pamit g_ .d debris reaWbgg from the consbucbm gftvy
govaned by this Building Permit shall be disposed of in a Popaly ficumd soH&waw
disposal facility.as defied by M(R,c nX S1Sa&
The deb is wrll be disposed of at
/ Location of Fsality
S*Ntmv of Pamit Appliaot Date
(PLEASE PRINT C LEAAM )
L -, /c �.
Ncam�e ofPco*Applicant
Am Name if any
oz
Address,City a Sate
7be above statute requu=that debris 5om the danolition, rmovation,rrbab or other
alteration of buUdmg or stmcaae be disposed in s properly-licensed Soh waste d qmW
5cility as defined by MGI,cnZ S130A, and the building pmft or lie==m to
indicate the location of the facility.
a � �L/fP.���YWtf��• . .
600 U!/.116 S1aea1
JOW40 t caasad Qwlwti X..rei;rrlb 02111
c.fafea.ar .
Workers' Comperwsin Isaarance Affidavh
. . wkb.a orincheal place d bosbaeas as
do her47'cerslp under z)w pains and pesnsialoa of pw yf don
() 1a an employs► pro Wbw workers' composeatko coverage for my einpley4m working on
Insurance Can*any Policy number
i an a sole proprietor and have ass one werkhe fir me lei amp capiocky.
I am a ask proprietor, general contractor or homeowner (drde osse) and hove bred da
ce czors listed below who•hsve thi folkvwhq workers' eomnpaanties po0deas
ter insurance Company/Popgr Number
Connraanr Insurance Compamp/Po Number
I
Conuaetor Insurance Company/Poky Number
() I am a homeowner performing all the work myself.
•1 w swul"am s CM of 06 Amon we be ferwwose a aw Office A Wrn*aeafe of dw V"10 co.eraR.elakwas me on 6aes is mean
ca.earr a ref Wed owe ftcdae 2sA ff MGL 152 can leas s ow Wwardea d ainwa steads carmdas of a tar of ae w4 Lr00A0 saver eas
ren'isersewnne a.ya add fmdda in dw bm a!s STOP WORK ORDER sus a few of s 100AC a asr stdea dr.
Sinned this . day of _
:icenseeiFermittee Bwidtng Department
ucensinf Ecare
Selectmen Office
�esith Geprmer:
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