76 LEACH ST - BPA 4-73 2ND LEVEL PORC H & ROOF -PL-*f0S-Mt1ST-9Ef4Lf� APPROVED BY T*IE
IAISPEGT�?A ,PF,WR TD A_PEBIAIT BEING GRANTED
CITY OF SALEM
No. 7 v, —2QQ r�( ; : Date
J'
Is Property Located In Location of the Historic District? Yes_Now/ Buiiding ? teac4
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,
pair/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 �ja� � FCm/� lL4 =-T)
Address & Phone 26 teat-1 �5i. (21) :� 40 3220
s Name t ✓
n
Address & Phone I'0 M �^cl� I (97K 7�U 97
Mechanics Name
Address & Phone ( 1
What is the purpose of building?
Material of building? If a dwelling, for how many families? �—
Will building conf nn to law? — Asbestos?
Estimated cos f7 City License n N A Stat License * < 0'77YZ4
L 116 5 as Rome Impro,v,eame�n�t:
Lic. I ,
7S�D Sig e o Applicant
SI D UNDER THE PEN LTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE j _
CA L W V , 42r1
MAIL PERMIT TO: _Ts S C A r�w^T�`r ?% 'j;>>ox (o Sc�_ VA JS �IvO
v4k oic7 q(
.t
No. -7 3-ZAC>c--
APPLICATION FOR
PERMIT TO
LOCATION
-7 G
PERMIT GRANTED
7 - .30
APPROVFD
INSPECTOR OF BUILDINGS
G - �o3
d"4 W
/�ull `tnr551� � �-
� Ilow /T' ' Sgr / o
C0mm0nf.utiabk of ///a6eacL646
nQ Iuai F
y J/ epailmanf o f 7ruirial�4 c.,nl+
boo 1,Ilmh:,"Sleaef
James J.camtoe9 &afoa, 9W.ssackusatG 021 If
Corrrrusssorser
Workers' Compensation Insurance Affidavit
Ie _ T 74� SI.v \ -Z
With-a principal place of business at: Q
Co
aJnrsw✓atn
do hereby certify under the pains and penalties of perjury, chat:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
a -
1 am a sole proprietor and have no one working for me 1n gry cU paeaty.
I am a so a propriet enenl contactor or homeowner (circle urge) and have hired the
con�ctors tsted below who have the following workers' compensation policies:
Contractor Insunnce.Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Humber
O I am a homeowner performing all the work myself.
I unoerwno wt a tarry of thu a,,trmmt unit be io,,arord to the ORKe of Imescgauons of the DIA for coverage.erWkadon and wt falure to secure
coverate as,,Duero enoer Section 2SA of MGL 15 2 can lead to the irwoution of criminal oenatdes corstsdnt of a fine of no to-S 1.500.00 and/or erne
years'i:wuomm t as aea as cki venaldes in the loan of a STOP WORK ORDER and a the of S too.00 a gay aff"t me.
Signed thi day of
Li s c/Fermitcee Building Department
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X4031 404, 405, -T 775
co " ' OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3110 FLOOR
1, SALEM,MA 01970
r �~° TEL. (978)745-9595 EXT. 380
Grnre FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge 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,S150A.
The debris will be disposed of at: (tee 1 ICJ ° T
Location of Facili
— ) �— 33
of Permit c Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
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 call,S 150A, and the building permits Or licenses are to
indicate the location of the facility.