332 LAFAYETTE - BUILDING INSPECTION 0- ,
qPt* 1SiMWT19E fKA94MID APPROVED BY TW
JMSPZCMB PWR TD A PERMIT BEWG GRANTED
V\` \ CITY OF_SALEM /
a6 c)FI
rl\ � Ward
Zoninp o1shtt
Is Proprrty Located in its of
nta Hlatodc oWdot9 vrs No
18 PMPWtY LWOW In
Ba Cattsavadan Ama? Yss No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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 accort6ag,to the following
specifications:
Owner's Name �� �✓�
Address & Phone r2 3
Architect's Name
Address & Phone e f
Mechanics Name ��,
Address & Phone /O Le, - CL 3
What is tta prpm cf bWWpq?
At"m of&~ B a dwaatq,for how mony fatness?
wo bulidUq oonfomt to im? Asbestos?
Edmated cost 1A-6C 6 f Cfly Liomm r sdq Umm r
Home t
Lic.
�"— Signature of Applicant
SONED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: /D b:. t .ke a Q L
a
No.
APPLICATION FOR
PERM TO
LOCATION
u C�
PERMIT GRANTED
19
APP GVFD
14 ,
INSPECTOR OF BUILDINGS
• � .-lJapa.Lw.wl a��i/r�ia(�sc�iaafa'
boo w.a�iw,6..Naw1
..win 1 cuieaaa Swiso, /I/.aa.J. b Os/It
. nn Workers' Compeswdm Inmate Af Uln*
. . whil.a prbu3pa) place of badness as
do hereby'cerWy under t)n paten and peaikb of poilm , thm
() Ia anploy" peovidtai worksis' compemadon cwmrats for myeingp/lryew workt�M
•�-l/7/� .rr"✓���2 � - �C�� / /b it �' � .
Insurance Conwww FolIV Number
a ,
i an a sole proprietor and haw no one working fdr an `say npadq.
() 1 am a sek proprietor, general contractor or homeowner (deck am) and hews tetrad the
contracton listed below who-bsve the following workws' eompenmdon poSchn
Contreeter Insurange Company/PolbW Wonder
Contractor Insurance Company/Po Numbw
Contractor Insurance Company/Policy Numbw
() 1 am a homeowner performing all the work ntysslf.
awairaaiy ar a Waf of si a MMM wa be far.aroal as to Oface i1 M.vdti w of w 0"la ca.arata•vikaaw w ea Mm ap more
tamale a rearm awe SRa SSA of MGL 15 I ran I.ae r w irgaafew of ob,"aewade tuusiet of a aac 41 M 041•500,00 alwar am
Teo"'wwwommm a vA a 44.a Ms in the bn..f a STOP WORK ORDIRR swn,6r of S 100.00 a an spine s.
Signed this . 6 day of b _
l
:iccnscei crmiicee Buildin{ Deparzn.enc
uctnArif Eoard
seiectmens Office
=cslth Deparmer,-
e0a e(+c 40e, 77c
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET,3RD FLOOR
SAUA,MA O1 D70
TEL(D78)749-MDS M. 360
FAX (D76) 740-9/4O
STANLEY J. USOvIcZ, JIL
MAYOR
DISPOSAL,OF DEBRE AFFIDAVIT
In accordance with the provisioca of M(B,c 4%M I aclmowledge that as a oonMon
ofBu&%g Permit M .all debris resulting fiom the mom&ckyW
govaned by this Building Pemrit shall be diapered of in a properly licensed a.r&w m
disposal f cmw,as defined by M(3L,c 11;S13M.
The debris will be disposed of at C XD,,c,
Location of Fad*
D-6
S' of ' Applicant Date
(PLEASE PRMT CLEAR meson.
Name ofPennit Applicant
Film Name,it-My
Addresk City&State
The above atatihte requim that debris fivm the demolition,rmovabm rehab or other
attention of building or atiucdne be disposed in a properly-licahaed soH&waste digmW
fihcik as defined by MGM.cID. S1 BOA, and the building pemuts or licenses are to
indicate the location of the Scility.