69 LAWRENCE ST - BUILDING INSPECTION I
fUST-BE IF f1PPAOVED BY T+IE
CTC?FI ,PMDR TD,A.PERIAIT.13,EWG GRANTED
CITY OF SA'LEM
No. = 5��� �w Date 16 U
Ward
Zoning District
Is Property Located in Location of
the Historic District? Yes_No Building �C1 L.e Ijr .
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(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 according to the following
specifications:
Owner's Name IVe.;\ rA. o,r
Address & Phone (,q y I Mk) -7 Ll o 54,9 o2A
Architect's Name
Address & Phone ( )
Mechanics Name 7S6l.N
Address & Phone 79 wo-L cV T-a4art4_ fq-7490
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost -ZI 0�=City License # State License # U µ ZG•tga,
Home Improvement
�1 Lic. / 11
Signature of Applicant
SIGNED UNDER THE PENALTY
J OF PERJURY
DESCRIPTION, OF WORK
,1 TO BE DONE
I� e
MAIL PERMIT TO: C ct
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�oxw CITY OF SALEK9 MASSACHUSETTS
' PUBLIC PROPERTY DEPARTMENT
R 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1 970
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 III, S 150A.
The debris will be disposed of at: ��T'
Location of Facility
Signature of Permit Applicant Dat
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any �1T
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 cIH, S150A, and the building permits or licenses are to
indicate the location of the facility.
�'--�— �omrr�nw�:aLth o� lllaeeachusaffs
s �r.Jtparfansnf ./9,�rinf�«�.�
600 W-1-11en
�a mes J.etmcoes C�tr4n, m„e�,t,,.lb 0Z f f f
Corr--Mssow
Workers' Compensation Insurance Affidavit
L 8N1 Fr
with.a principal place of business at:
't -1 i
. . loerrwwafr) U
do hereby certify under the pains and penalties of perpRy. that:
() I am an employcr providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
�[ 1 am a sole proprietor and have no one working for me in any capacity.
()/ 1 am a sole proprietor, general contractor or 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/Polip' Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoen[ane"t a CM of 0
0 tiatetnent Mir be ioMzr"g to the OrrKt ei Imasicavons of the MA for coytrate-TfWaden a 4"blurt to aeevre
co.erare as rewKea unoer Secion Z5A of MGl 152 can kao to the:eaoomion of erininai oenatks eoraotint of a foe of tao ttrb 13M.40O ana/a cant
year,, st iraruonmmnt v . n as ci.i xnaltin i1 oan the l of a STOP WORK ORDER a"i f+u of 5'00.00 a CM spot Mt-
Signed this , �fiti day of
�ictnsee/Fern-sittte building Gepartn+ent
'L3ctnsing Eoard
Seiectmens Office
ufth Gepar:ment