20 KOSCIUSKO ST - BUILDING INSPECTION (2) iM.ltffSIOUST19E f&*04 G AmPPROVED BY T44E
.LWFXTOA.PFWR T9 A.PERMIT EMNG GRANTED
�� CITY OF SALEM r/ Q
No. +� `�� Data
ward--�—
Zoning District
Is Property Located in Location of
the Historic District? Yes No_ Bui]ding
Is Property Located In
the Conservadon Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Sidin , 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 NameO t(1
Address & Phone
Architect's Name " mL (ZCXYc�(�c �� Pr',G (w
Address & Phone M6)
Mechanics Name
Address & Phone
What is the purpose of building?
C
Material of building? i L%CLO;�Q C If a dwelling, for how many familles?
Will building conform to law? �!� _> Asbestos? k-)0
r �
Estimated cost �_31 s U• City license N State License K
Rome Imprroove>m�^e�nt�
Lic. 01
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �0(I\
No.`V1 `-6�
APPLICATION FOR
PERMIT TO
LOCATI N ll
PERMIT GRANTED
�x
APPRO D
rw �`
INSP CTOR O UILDINGS
Commonfar CtWL Of f iliWaGh�td
M C I
�, JJ.pa.lae.at�.11t;.�.f�Yaea�•
600 ryUla1a11m J1wl
�ararea a ue+o..a And, 02111
Ca+eemaaonar
Workers' Compensation luarranee AfridWk
/
. . with.a principal place of business ac
do herebr•certify under the pains and penihies of per*y, doe
1 am an employer providing workers' compensation coverage for rrry empioy4m working an
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working far me in any capacity. E
() 1 am a sole proprietor, general contractor or homeowner (circle one) and haw hired the
contractors listed below who-have the following workers' compensation polldea
Contractor insurance Company/Poliq Number
%�/
Contractor Insurance Comparry/Polity Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I vneenund ens i caq of ofs wft r ffl ve be fc+coed ea Ow Once M hreadraeera of dw DLa.for ca.erare+tVxadw aces Max U&M w MCre
co.erare as reource ower Seeden 25A of MGL 15 2 can kad as ow ivaeoudan of crwkm aenada eorasdne of a am of as wi 1.500M aaaler ace
roan'inaroownee{a A as ew eeucpiooiin the tom eta STOP WORK ORDER and a Am of S 100.00 a an OV60 ML
Sirned this ..- A,,� day of r
:icenseeiFcrrnhEtt Euiiainf Departure
uctruinq Eoare
Seiectmens Office
=eaish Deparrrlen:
f
' PUBUC PROPERTY DEPARTMENT
• 120 WASNIN@TON STREET, 9RD FLOOR
SALEM,MA O 1970
TEL. (978)745-9595 EXT. 860
FAX (978) 740-9846
STANLEY J. USOv1CZ, Jot.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MIL c 40,S34,I acknowledge that as a condition
Of Building Permit 0_ all debris resulting from the construction activity
governed by this Building Permit sbsli be disposed of in a properly licensed solid-weals
disposal facility, as defined by MQ,c Ill,S 150A.
The debris will be disposed of at 10
Location ofAcility
Si'gnaturee of Permit Applicant Date
FULLY complete the following iubmatim
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City dt State
�q( t)
The above statute requires that debris from the demolition,renovation,rebab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL clII,S 150A, and the building permits or licenses are to
indicate the location of the facility.
ACORQ CERTIFICATE OF LIABILITY INSURANCE
05 12 2004
�mmm Tkls �W,OMM At A KUMR Oi R�FORMAT10N
County insurance Agency, inc. oNLT AND CONVE�s NO RMWTS UPON THE CERIOWATE
Y NOLDER.TM CERINWATE DOES NOT AM,MMW OR
123 Sylvan St., ALTAR THE COYERAM AFMMND BY THE P09JCM NELOW.
Danvers, MA 01923
918-774-2463 D�RERSAFFORD1H0covERwoe
MrAb Steven Lamonde ium ,t AIM Mutual ins. Co.
dba SML Roofing saurese
6 Felton Street eauana
Peabody, MA 01960 osf�waia
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IERTW=TEKOIWRj 1mwwwLwM0M MUMm CANCELLATION
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City of Peabody aosrse°"•*aawwuw"we"u 20
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Peabody, Ma 02960
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