71 LEACH ST - BUILDING INSPECTION (2) � 3os
'PL*NS1M W`BEfNAB-AND APPROVED BY 774E
JUSPECTM PRJDR TTI A PERMIT BANG GRANTED
CITY OF SALEM 44 NCO
Z0nkV District
Is Properly Located In Location of
#0 HWAft Diddd? Yes No Building eA CL S
Is Propoty Looded in
IN Cansarvadon Arm? Y91 No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: nu Cow. 4 un.� Cn4
CLri,q.stwAlk C4wA6
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accord,ig.to the.folWwing
specifications:
Owner's Name a w—i S L QjrSAA S C u nues /�(t✓
Address A Phone 14 ►AoOLL I A-F 61716/3 a7o --
Archkect's Name _r�.e r-<L
Address rg Phone uJ gas �� 1 a'0� WA-)
Mechanics Name 64r
Address & Phone 5- \ I a�e� A (�ft�1 7ySa�
WW Is nu purpose of bWldi W ZSi oe--tR
Mdow of b~ n a dwebig,for how mmy famaas?
wa blr*v cw toms to law? tS AsbIIstos? 96
Erimdad oodT,, aN u ma r N"Llcwna N C- S 6-71 e 9 G
Rona isrprasaaan
�Si�rlattfto
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
tLeub �t \\ +� L� 1 S C-zAk>e.1
MAA \\u�� C — eC o. �v w� S L45 9 a Er 17 —
a-- C'e..SiCewtl'1� COWDbw�LN�u+w1
MAIL PERMIT T0:
No.
APPLICATION FOR
PERIf'1'IITO
• � FJ t, T J12 ✓ GtN�'� -
Pr
LOCATION .
PERMIT GRANTED
19
AP
,PROVFv� D
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
I20 wASNINar0K $Tour, aRD Fwoe
SALEM.MA 0 T 97O
TEL.(976)74S-9595 MIT.360
FAX (974) 740.96"
STANLEY J. U9Owcz, -4L
MAYOR .
DISPOSAL OF DEBRIS AFFIDAVIT
In eccoidaoce with the pmviaioas of MQ,c 40,S34,I aclmowledge that as a condition
of Bm'ldiag Permit N .ap debris resulting RDm the conxftucb=Whyte,
governed by thin Building Permit abaft be disposed of in a
Prope1Y liceoaed wlid-watts
disposal facility,as defined by MCB,c IIL S130A.
The debris will be disposed of at: 30c7 FO 2f S 7 redo ��.
- Location F "--
gnatme of Permit Applicant
FULLY compl
ete the followiqg fi&rmsd
OWASB VTCLEARLY) �
Name ofPemTit fiamt
Ffrm Name,if
my
Add<eas,city tit state
The above statute require that debris from the demolition,Tenovshm rehab or other
alteration of bufld*or sM=tme be drVOW is a properly-licensed soH&waste diW"
faTti*as defined by MCM ca SIS0A, and the building permits or litmus as to
indicate the location of the facility.
M ofa�ac�ivasttd
600 WaSLU16SL-ed
1caa.eea &olew,, Muss -A 0.21/1
Workers' Compensadm lautrana ARldavk
. . with.a principal pbce of bminew ac
do hereby certify undo the polus and pemiftlo of perl.ow, sloe
0 1a an amploysr pnwfdkw workers' coaapetwtbn coverage Ew my eintplerpoea working on
Insurance Cempeeg► p "Umbew
1 awn a sole propriets►r and have no one working id►see in any aPacky.
M N 1 am a sole proprfeter, general contractor or homeowner (drde oven) and hew kind else
Vj' contractors lined below who•hawe the following workers' compensation polldrr
Concncsor Insurances Company/Po Nundw
Convector Insurance Company/Po Nossabelr
Contractor Insurance Company/Policy Alumbsr
0 1 am a homeowner performing all the work myself.
• vasenuae wr,caw of di aaee M"a be fwwarees it on Ofles A Mredtaow of dr MA 10 corwara.vaka4a sae an&N we w roc
cowrgr a reread user Swdsn SSA M MGL 152 can lead row iretriss cf aln:ne stare CoMAWM at a aer et so ni I.IM a Ww oov
rend w*rwoawr a vs add w w a in the Imm sa a STOP WORK ORDER xw a inn ca S Itr0AC a am Spixia ar.
Signed this . day of
.icenseti Fermi t r MIdan{ Department
G�''' �'�'��"`i �ceruinf Eosre
Seiectmens Office
riealth Depsrcmerc