220 LAFAYETTE - BUILDING INSPECTION d't7
it 116iMtl6i'9EfK*9401D APPROVED BY 144E
ASPECM PR W TD A.PERW f3EWG GRANTED
CITY OF_SALEM
Nv� \ Deta —� —6
wam S
z«rrq Didrlcl AZ
Is Pmfwrty Locatao in Location of
aw Hhioft Dldrkt? Yes No U:Udiaa 2�Zp L
Is P"C113"loctla ' in
Ore COnwrvadon Area? Yw No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct per, Shed, Pool,
Repair/Replace, Other: _ �� on 3 Pot
PLEASE FILL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accordrig.to the,following
specifications:
Owner's Name
Address & Phone `l/ �Ye�r e S,'- !g t 7 yc,�- q
Architect's Name
Address & Phone f i
Mechanics Name 1611e�k
Address & Phone Lo 13(?Lea Ll � f 7SY 73 ._90Cj�
WhW Is ttr ptapoee o1 bWk*f
�r Greg_ C 4P.yva
MWWW of for how many hunew?
wn wa*q conform to law? AWwfts?
Fall noW cod S-o�' . qty Lk@M e �-O L MW tJc «C
Llc. t
Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
0A 3/- ' fin l �ii �X � Cars
f
MAIL PERMIT TO:
No.
APPLICATION FOR
PERWT TO
LOCATION
P. RMIT GRANTED
j�J
APPR t
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASMIMaTW BTRM, aaDF"MR
SAL.aM.MA O t Y70
TEL (979)749-W95 FM.a!O
FAX (076) 74046"
STANLEY J. U$cvjM JR.• .
MAYOR
DISPOSAL OF DEBIM AFFIDAVIT
In accordance with the Pzovi ons of MGL c 4%W I aclmowledge that sv a condition
of BmldinS Permit f .all dd ds resulting from the co uMwdon Activity
govemed by this Building Permit sbafl be disposed of in a pnV aly licensed solid wasss
disposal Sci}ity,as defnned by MOO c Iq S110A.
O � ✓1
The debris will be disposed of at
Location ofFacrlty
Sigoatum OfPamitApplicaot Date
FULLY complete aw fDBOWMS
(PLEASE PRW CLBARI meson.
1 vo 0 Lj o ff
Name ofPermit Applicant
Firm Name,if say
Address,City k State
Mae above statute requires that debris lion the demolition,renovation,rehab or other
alteation of building or str=Mm be disposed in a properly-licensed solid-waste disposal
facility as de dined by MM clA SISOA, and the building pamits or liceaaa no to
indicate the location of the LciNW.
�'' �Gn►>rsO/L1Yr1�iLA o�ma�a;c �d
. b .ydPa�ar.l.Ja;6if�aif..b
M.
+Nan l c.a.a.a Mm.dl.& 021/1
Workers' Compenssdion imrson ANidevit
. . witb.a prindpai place of btdanm Be j /1 [
do irrebr•cerdfy under tin palas and peniMes of pwj.myo dm
() a ansr employ providbW workers' compensation covapda fair my eiaylorita workLR M
dikInsurance Compaq Folicy I; n law
I an a sok proprietw and have ao owe workiap fir tie le aq oPodq.
0 1 am a sole proprietor, seneral contractor or homeowner (code eat) mad haw liked do
contractors listed below who-have the followbig workers' coaspentufoa po9den
Contract insuranie Compsa y/Po Nasmiet
Contractor Insurance Compaq/Po Namber
Contractor Insurance Company/Poky Number
() I am a homeowner performing all the work myself.
•1 vwwras.d am s seer df edr Arr"M WE.r !«.rood s M ORoo it Ywwfts a of dr tMA 4 ce ware.w ar an tried r MM
cvm&Fr ar r.dwcd ends SKi a SSA at MGL 152 can ksd se aM irwepd of drI i edaWa cerua6aa N a an of•041.500/00 seUw er
rrnY iaere MMM a no 4t*d ria in STOP WORK ORDER am r it N S 100Ac0)a q assirw ere
Sirned this day of /
:iccnscei F crmhttt 6u►lalnf Department
:jcensinf Eaare.
Seiectmens Office
=talth Depsrmen!
=._: : _ - -.ccCC Yet _ e04 epc• aQe 775