97 LEACH ST - BUILDING INSPECTION (3) Fit ILZfQS* ST- E-RL*WAN iAPPROVED BY T44E
WS,P XTQR PFWR'TD,XPERIAIT BEING GRANTED
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CITY OF SA�LEM
No. , Date /y,-63
t:.
Ward
\hymNr Zoning District
Is Property Located in Location of
the Hist6ric District? Yes_No Building P,7 Z!5W&/
Is Property Located in the Conservation Area? Yes_No X
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R�eace,
all Siding Construct Dec Shed, Pool,
Rthey:
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 �: �A)U
Address & Phone 60f0l� 577-4F9% i7 ) 7 V C{ -5aa7
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone /mod, �'oiCaSrSf/L�iyi �i� �7cFJ ) 7y�-U/o/
What is the purpose of
Material of building? zgp00 If a dwelling, for how many families?
WIII building conform to law? Y'icS Asbestos? ND
06
Estimated cost/yr S , ' City License# state License # /261a5:2
/V\) Home Improvement ��
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Lie. /1Zc�o25.3
Signaturb of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: ✓?o� vd
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JamesJ`Caaraooel f)oalon, //laswetw+.lL 02111
cw-.mrss�ona
Workers' Compensation insurance Affidavit
tiva.o..r.:�•e)
with.a principal place of business at:
zl,4 G/9 '7e
. Caerlst+Way) _
do hereby'certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
I 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 she following workers' compensation policies:
Contractor Insurance Compatry/Polity Number
Contractor Insurance Company/Policy Number
Contractor lmurance Company/Policy Number
() I am a homeowner performing all the work myself.
I whom ano wt a coon of the wtt t rie be for aroee to thr offace el 1m &gavon of the DIA 1w cor arfc eerikadon ana ahat Oaurr u aewre
co.efarr a rtoirro uncef Section 25A of MGL 15 2 an k)o to or inpofnbn of cr6rJ l oenrdn corxadnt of a for of w w-S I.5M.00 NW*r otx
rtan'iraruommmt n .rsu a rice oenalues in he form of a $TOP WORK ORDER an a 0 a frx of S Ig0.00 Oar srantsIOH.
Signed this ,
()0r102CA,- day of
�iccn eiFtmiutt
Euilcing Deparirmcn[
�il ttT[51[1F �G7TG
Seiectmens Office
*;culth Depar[mtn[
7 — - - --_tcpp Y
�o CITY OF SALEN19 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT -
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
S� 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, S150A.
The debris will be disposed of at: 1z/D/277l8//, C:¢ -1i ;2 u/4417L r''AGai7y fir/iy9
Location of Facility
Si
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
L'. Cvyam✓ s�•vs c�orr�e`7id �'a
Firm Name, if any
Address, City & State
976^ 77lD ' D/o('
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
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