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0006 KOSCIUSKO STREET- BPA-97-2004 DATE: ( CS 3 �itp of 'orbal, M2 atfju EttS r u � PLANS MUST BE BLED AND AFPROVEWBY THE INSPECTOwPRIOR TO A PERMIT°BUYING GRANTED Location of Building _©SC l I� 0 Building.RermlWApplicatio or: -(Circle whichevorappl es) oof roof, Install Siding, Construct Deck, Shed, Pool dition, Alteration, Repair/Replace, Foundation Only, Wrecking Other: PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Bui dipgs: The undersigned herebyApplies(f�or a permit to build according to the following speeifcali—s: / OwoeriName: 9�,\. KVOW� Contractor: 42C4t4 c `f(L Street 6 KtSCrl O SILO City ♦�ti94 Street P06>s� 4C4 ' City �� State Phone (M:/y% _ 2 ram_ Stated. Phone f' ) q;�-rl Architect: City of Salem Lick Street Ci1v State -1 3 HIP N 16<•E 3 S 2—, State Phone ( ) Homeowners Exempt Form yes no Structure: (please ci LSingle]Farnily, Multi Family N Other Estimated Cost of job S WiD,*4ill((ug coon rm,to11 ' c/yes no �AAW#0a? ;yes ao n ,,DeseriptioWof wor^Ittt be done: . 21t r Draw'ngs-Submitted:_yes no M'ailTennit to: X --- t ature.of Appli . one I ED ' :DER THE PENALTY OF PERJURY CANSTRUQTIO LETFED WI77iIN'SIX (6jrMQNT$S OF PERMITatSSIJED RATE Department r,only. Per "il :4pq � �'100"aoipg_T Map/Lct Permit fee $Fyr/I j J L ct�t $ COHHENTS: _ N c'� :, � t 5�� '�i✓. {L,b�l�c�. C-, t vie /2.�-�,�,t�y��l-, No. -7 - LA APPLICATION FOR PERMIT TO LOCATION. PERMIT GRANTED v Za 7 19 AP .ROVFD Ul L() INSPECTOR OF BUILDINGS + tt O Z _D g D B, DISmzI Ci- (fornmonw;Ak of Ml ae.iacL646 � �5 6 J.Jepa,lm.ttlo/.1ndu+lriaf4eei1.nLs _ 600 Ul.Lyldn-31 ..I .fames J.Cameoes &,i , ///osaaehus.ib 021 If C Wntnrssonee Workers' Compensation Insurance Affidavit cola (aeatev,ettitrt) with-3 principal place of business at: 15 tunrs.a✓s4f do hereby certify under the pains and penalties of perjury, that: () I am an employer providing workers' compensation coverage for my employees working on this job. ✓ham���� �.`�c�?�7 �i/l 31 S z15�rG Insurance Company ` Policy Number 1 am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor enera contractor r homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Polity Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. I understand wt a cony of this stattenent will be iorwaroed to the Office o1 Investigates of the DIA for coverage.eri&drien and wt hire to socalt ceveragt as «Mired under Section 2SA of MGL 15 2 can lead to the irnodution of criminal oenaues corststing of a (n,oft td-S 1.500.00 muter one ytari imortnmm d u cid oocnalua in the form or a STOP WORK ORDER and s fire of S I00-00 a wr stafnst me. Signed this /, day of 2, _ Licensee/Fermitcee Buildin Deparcrrt nt ' Licensing Board Selectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 40S, 409, 375 -� _ _ 10 FROFERI " UEFARIM EXT �R 120 WASH INGTON STREET, 3RD FLOOR SALEM, MA O 1970 �G TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 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 M, S 150A. The debris will be disposed of at: 6�"// C.) Location of Facility Signature of Pe`mut Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any Ta 90";' qc(,6 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, L