2 LEAVITT ST - BUILDING INSPECTION 44*NSIMT-BEfB£94040 APPROVED BY 774E
IWECIDR PFWR TD A_PERMIT BEING GRANTED
1 1� CITY OF SALEM
No. L — V _
Zoning District
Is Property Located in Location of
the Historic District?ct? Ye No� building �ny/� Tf-
Is Property Located In
the Conservatlon Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof Reroof Install Siding, Construct Deck, Shed, Pool,
RepaidRepla 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 accor&-ig.to the following
specifications:
Owner's Name
Address & Phone
Architect's Name
Address & Phone f
Mechanics Name
Address & Phone I
What is the purpose of building?
Material W Ong? &)O ak� It a dwelling,for how many famlies?
WIIII building conform to law? yz-m Asbestos? !UZ14
Estlmated cod 9 e ` 6 CRY License N state License It 0 0
� I"tove ant
Signatu of ApplicanrA
SIGNED UNDER THE Psi
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Hr?l�ilnl�'_ r/1'/�i�l//�r ����f''' D®f7 f'� o✓I,�/Y/>l/ /�e/c��.f
MAIL PERMIT TO: /`&4^,e A -"
. .t
B
No.�
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
ll d GI 19
f
AOVFD
CCCC1111 ,-,
INSPECTOR OF BUILDINGS
r
} I
• yr 0/�L/r��t{V�WWi 0/ I I/�Q�r/iWf.iY
boo Uled�.e.Slre.� •
jams 1 Caeeed Seei, //led .A. .♦ls os J I I
Cer..esew
Workers' Compensation insurance AffWwk
1, S f,Uti �l raw ,/ . jba. Bra uilcj—nq ti,�
. . wkb a Principal place of bosiaes at:
4� jj) is ► 0
do hereby•cerft under:he paint and pencil" of per* titres '
I am an employer providing workers' compensatksa coveraje for my emplayeet working a
dbis JOL
s , Cb - ' 07 6 q
Insuranp Cempea>Or Polley Number
1 am a sole proprieew and have no one working idr me In any capedey.
O 1 am a sok proprkter, general con=ceor or homeowner (drde am) and hew hired dN
contractors lined below who-have thi following workers' compensedon polides
Conaaaer Insurance C.ornpaay/Popq Number
Contractor Insurance Company/Po Nuaier
o
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
•I e.drnta.d nw a c.q.106 wraa+e oe be f.n.ar.ed r ow Office it b rMknew of dw MA 10 covers"•slats aM an Isi,et r non
M%warr r rrearrd sass SRren SSA of MOL 15 2 on kid re Ow isoeree.df OW&M oeredte edrusdm of a Aar Of w ni 1 SM MW r.ee
?can*i Mersmnrwµ a va a d4 mortis in the krs.e1 a STOP WORK ORDER awe s iw of S It20AC a ear atd4n ne.
Sirned This . 0 fh day of IT, I
.iccrscei'Fcrmiuce esuildinf Depart ent
�Jcensinf Ecard
Selectmen Office
-�e.alth Depommer-
-- r - - -- ;:: - - - -.ccCr 90e epc sere Tic
PUBLIC PROPERTY DEPARTMENT
120 WASNINQTON STREET, aRD FLOOR
SALEM.MA O 1970 -
TEL. (276)745-9596 EXT. 360
FAX (676) 740-9646
STANLEY J. USOViCZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MCM c 40,S34,I acknowledge that as ed8 a conditim
of Building Pamito- .all debris resulting from the consbuction activity
govemcd by this Building Permit sbali be disposed of in a ptopaly licensed soH&w.W
disposal facility. as defned by MGL c III.S150A.
The debris will be disposed of d I V d 1 A
Location ofFacilityrr� ' I
SiPE#9 of Pemi Applicant Date
FULLY complete the following M&MAtiom
(PLEASE PRINT CLEARLY)
i
Name ofPamn Applicant
Firm Name,if any
I
Address.City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or savcture be disposed in a properly-licensed solid-waste disposal
facility as defined by WX cM S I50A, and the building pamits or licenses am to
indicate the location of the facility.