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2 LEE ST - BUILDING INSPECTION i -PL*t#S*MST-BE fib{-P1 APPROVED 8Y T44E IAlSP CJD13 ,PWfl Tp A_PERNUT .BEWG GRANTED CITY OF SALEM No. Date `W NE Is Property Located in Location of 2 Zee the Historic District? Yes_No_ Building Is Property Located in the Conservation Area? Yes_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) (�ffoo 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: / n / / Owner's Name L . C�s i ./(,'7 Cefc,t lam,uf- Address & Phone ZS (�11) Z30 `12,g6 Architect's Name Address & Phone ( ) Mechanics Name Address & Phone What is the purpose of building? C e, Material of building? If a dwelling, for how many families? will building conform to law? Asbestos? / Estimated cost L? 70 City License x N P' State License n e' Home Improvement v ��� O / lJ Lic. I IAi �;r� ren(GLr GGmu Z� I Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE Rf4L,g 41 e (-00 ti / Ice Lci I MAIL PERMIT TO: I� ) No. 2 39 Z©o APPLICATION FOR PERMIT TO LOCATION. PERMIT GRANTED APPR FD INSPECTOR OF BUILDINGS .,_."Y OF 5ALEM. lTI FaDDh�.nv. � . . — �{ PUBLIC PROPERTY DEPARTMENT • ^ 120 WASHINGTON STREET, 3RD FLOOR < • SALEM,MA O1970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 . 5TANLF.Y J. USOVICZ, JR. - MAYOR DISPOSAL OF DEBRIS, AFFIDAVIT In accordance with the provisions of MGL c 40,S34,1 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: x,UO2 Location of Facility �oYC� � � 8zo`a3 Signature of Permit Applicant 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 cM, S 150A, and the building permits or licenses are to indicate the location of the facility. k C0fnM0nLV0aAk 01 MwiacL¢ffi 6 =. ,�J , �UePar'lmanl a j9iadnllriaf 4 ia et �l 600 Waskiry1m �b..! James J.Camooel E>oslbn, ///asfa Laelb 02111 commrsstM , Workers' Compensation Insurance Affidavit with.a principal place of business at: �z - Dz� tutnwt.rslp do hereby certify under the pains and penalties of pesimY, that: () I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Polity Number I am a sole proprietor and have no one working for me in any opacity- 0 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 Number Contractor insurance Company/Policy Number () I am a homeowner performing all the work myself. I unoerwne wt a coot of thin suot t w J Dt for aroed to the Offce of Invutitavom of the DIA la for ate weexicadon and am bko"to more <o•erate v rec+rta uneer Section 25A of MGe 1 S 2 can lead w the irg o don of erinitun oaotties corstsdnt of a htae of w to-S I.SODAO and/or one run' i:�orwmment v.,v w ciei oem a ldo in the loan of a STOP W ORK ORDER and a fine of S 100.00 a am atairot tne. Signed this day of Liccrsee/Fcrmittee B 1lding Gep rtn,ent Ucensing Board Seieczmens Office Health Department ON CALL i — — %-' 000 X407 404, 40S, 400, 275