1 LAURENT RD - BUILDING INSPECTION (2) fL 11S YBtI$Y T44E
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CITY OF SALEM
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Permit PERMIT APPLICATION FOR:
' to:
(Chb whlohewr apply) Roof Retool, InM Skft Conaut:ot.DocK Shad Pool,
RepaldReplaoa, Other.
PLEASE PILL OUT L=KY a COMPLETELY TO AVOID DELAYS W PAOONSO N
TO THE INSPECTOR OF BUILDING&
The umWeVW hereby apples. for a permit to WW accom ft to ft foNawirq
Owtm'e Name
A*Wu a Phone
Amhkwft Name
Ad*m a Phone ( )
Mechanics Name
llddnaa a Phone
%%d M ow pupme at r'avI a
pari: .
MOWN of'bulphol led for how WAN hmaoo4
vtr twadtq oodona b Irw/ C� Moo? � / � . 1r
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te.. L�evsss�t `'
Lla.
S re of Appftnt
SONR�D UNSER THE 0*
DESCRIPTION
DESCRIPTION OF WORK TD BE DANE OF PERJURY
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��"' : MNL PERMIT
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COmmohWc 6 o� 111a�eaca
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Man
6 1J.Pn,4n.� ./�.�af Jfcciirafs•
600 w.1-11m 31 al
Barnes l curca" l�alo.a /au.ela.a.w 02111
Cvwwsaw
Workers' Compensation Insurance AffidalAt
1,
too
. . witha principal place of business at:
. . Itaansaar.n41
do hercby•catify under the pairs and penalties of palmy# that:
() I am an employer providing workers' compensation coverage for my cinployea working on
this job.
Insurance Company Polley Numbs
1 am a sole proprietor and have no one working for me in any eapacky.
h
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contn=1dw who-have the following workers' compensation policks:
rats r insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
1 vneenune wt a coo/o!rhu wa.ment ri Ds ior..arwa m taw Once of M.cseeawrn of dw DlA Ix ce+erate.eefrcaden ask ants lain m a.evre
conranr n tewere unoa Secoon ISA of MGL 15 2 can kae to raw inoercien of c^m^m oeeaeon cor"riM d a gnat d w tet I.SOD GO ndl.r Drat
reap•maroon t v.01 as eiri "Apwm in tow loran cf a STOP WORK ORDER ane s fax of S 100A0 a .at J98'""OL
Signed this , day of
:iccnscci'Ftrmmtt Euilcing Gepartn+cnt
'�ctnsin€ Ecard
Stieetmens Offict
PUBLIC PROPERTY DEPARTMENT
• V 20 WAfNINQTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL (979)743-9393 EXT.360
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
a
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit M 'all debris resulting from the contraction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-wa to
disposal facility,as defined by M(3L c III,SIMA.
The debris will be disposed of at
Location of Facility
SipofilreofPemutApplicaot Dab
FULLYlets the fo
comp lloa'mg nrfomiation:
(PLEASE PRINT CLEARLY)
✓ye �cLce✓la�i� c � '797�
Name ofPennit Applicant —'
Firm Name,if any
Addtess,City dt 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.