63-65 LEACH ST - BUILDING INSPECTION jd fW Ica o
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WPROVED BY T44E
PF.CT P;FWR J.Dlr p t T.B,EING GRANTED
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CITY OF S`$ EM
No. �.�Q JAID
,!, • Date V
A
Ward S
Zoning District
Is Property Located In Location of
the Historic District? Yes_No Building 6 3 - 6 S ✓ ¢ aeti SI f ec�
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 Sou 4h ��ar bar �,-�� ^ jS 11 A C
Address & Phone PO 4 oX
Architect's Name
Address & Phone ( )
Mechanics Name ;)
Address & Phone 5
What is the purpose of building? otcn
Material of building? Wood S 4occ o If a dwelling, for how many families?
Will building conform to law? I/c S Asbestos? N O
Estimated cost 1 000— City License # state License # '�>2✓
Hose Improvement
Lic. i 4/O „
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Dcr c�cS
MAIL PERMIT TO: �� / /z r' lr� Oy l�C l�Jl�i60
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Si Jeparlmanf o/.Jadaslriaf�iccia .b
rl 600 -1-1 rt.51.81
dames J.Canaooel Uesloa, /!/aasocL" 02111
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
. . lraenseat✓7M)
do htreby'certify under the pains and penalties of perjury, that:
1 am an employer providing workers' compensation coveratc for my employees working on
this job.
L V1 i,-�EQ CCU N3 — I
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/Policy Number
Contractor Insurance Company/Policy Numbec
Contractor Insurance Company/Policy Number
{) I am a homeowner ptriorraling all the work myself.
I unoemuno wt a coot of the su,e t WW be iorv+arece M the Offre c7 Inocta,o of the DIA for co*cratc reepkation MW Mat hire to ucure
co. air a reoireo under Section 2SA or MGL 152 can Ieae to the mooytion of cri"nai ct"Oes ccruuint of a fine of w teri I.SO0A0 a wor one
roan• i:.xuonnmrnt n mc6 at ci+i o "Ido in time loan or a STOP WORK ORDER ane a kne of S 100.00 am atairot m-
of /� 2 O C)da
Signed this 2 U Y /4
.iccnscciPcrmritttt Sul701ng DeparYn,c t
licensing board
Seleetmens Office
t<1th Department
- - -__cCC - 0- cpa �Oc, =0° 77
OF `aALEM. MASSACHUSE775
i 3 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
g'p SALEM,MA 01970
_ TEL. (978)745-9595 EXT. 380
ar„rB FAX (976) 740-9845
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
ions of MGL c 40,S34,I acknowledge that as a condition
In accordance with the Provis
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,S150A.
The debris will be disposed of at: e 'x�Q
y'A LA \mil -McJ
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
C'b��,� CFt�k�J Cr�I�S\ : �IJ� j��OLoPNt��YC
Firm Name,if any
2
Address, City &State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of buildingor structure disposed
be di osed in a properly-licensed solid-waste disposal
facility as defined by MGL cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
• Number: CS 06=9
Birthdate: 09/23/1966
Expires:09/23/2004 Tr.no: 5693
1 ! Reehioted: 00
KURT f PO
NEED
' PO BOX 241
TOPSFIELD, MA 019M Administrator
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ACOM CERTIFICATE OF LIABILITY INSURANCE oo° o e Y""INWO61"03
[ PROOVO6R TNI9 PICATY IRRUED AS A NIA ROFINFO ON
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