26 LEE ST - BUILDING INSPECTION fL1tNSIMT13EfILA94AD APPROVED BY 744E
MSPJEL=PRIDA TD A PEWIT BEWG GRANTED
CITY OF_SALEM
No. Dab
1 �..
Ward
Is Propahy Loeabd Y1 Location of/�
ft Historic Dbhld? Yas_No� Building `�11�kee
Is PMPWW Locabd In
tln Caroanatlon Ana? Y«M No
Permit to:
BUILDING PERMtr APPLICATION FOR:
(Circle whichever apply) Roof, eroo Install Siding, Construct Deck, Shed, Pool,
Repair eplace, 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 accorc6ig.to the.following
specifications: n
Owner's Name c.4 4a
Address & Phone 2 6 L r e
Architect's Name
Address & Phone f
Mechanics Name rGIz! '0n.4 cv
Address & Phone N 2// /12
What is tha purpoaa it tadldYtp? ��r3 I
mdWW of tarMlrq? w D 0 A It a dwa ft.for how marry fsmtlo?
Wa bukkV Cordon.to law? AW*dos?
Eatllnabd coat 91rGy, - Ctly um"« �yTiOFPERJURY
Lie. Ia4roAZA:Lic. / Aliof Applicant
NDER THE PENALTY'
DESS�C//RIPTION OF WORK TO BE DONE/ / /
MAIL PERMIT TO. a C
.t.
No.�1 — Q�
APPLICATION FOR
PEFWr TO
LOCATION
�� tC A
PERMIT GRANTED
gAP7V,D
INSPECTOR OF BUILDINGS
l.ommonsar►a�h o� !/Jea�ac��e
� •.1JaPadwaal s��i4�ehiK�ati;i�ials
Csse.e.
boowyy..�,.Saa.l
2.aoiw IN 1� /I/esaeJ..6 o.1� It
,
Workers'
/ Compen acio, Insurance ARidasrk
.1, a�J v � • h �n r t l�„✓ . r/� rv�%l/p,r.,i �ar.�� � C;
. . while principal place of boainees/a'�c �y
t
do bereby*cercry under i)w pales and penihi a of paf.m elan
(,yr, Ia n*empIam p wknns workers' compensationcavetate for my etA��O�eta worklnt N
Z� ✓��h d/77r164
Insurance Compesbr policy Nunsber
r ,
i aces a sok proprkzw and have no am working fdr mie fw a W cspedq.
() 1 am a sek proprksw, general cesaracter or homeowner (circie ease) and hove hired sloe
contracson kneed below who-he" she folknvleg workers' conwensstk►u pe9deat
CantraQw Insurance Company/Pe Nueaiber
Contractor Insurance Compasty/po Numror
Contractor Insurance Company/PvVWy Nsm►bW
() 1 am a homeowner performing all the work myself.
• r.arrrrawa airr raq of NY sorsarw w7 k ku..araa a aM Alka A M.edpasie of ar[r1A kr rn.rap vw kaie am an blow a aasa
rewrap a rrawa ore Saar SSA al MGL 152 can kaa a ace incept a(afnwar aaaads sarysairrr a1 a ear el m rare 1.lDDAO aiwer ma
rrsrr':.ara.,.n,nr a!rA a dri aaraie ie rM knra of s STOP WORK ORDER aaa s br of S►DDAD s an spier nrs.
Signed this .
day of Af err/ C'f /'� _ 7 G° y
racei'Fcnnircee 6u►b ►ni Department
kenning, Eoarc
Seiectmens Office
ricslth Depammer-
- - --AcCC "e : : aea s:pc ape 775
PUSUC�PROaERTY DEPARTMENT
120 VYAlNINSTON STaEaS, 3mD FLOOR '
SALEN,MA 01 Y7o
TtL(979)740-90E5 MW. 360
FAR (976) 740.94"
STANLEY J. USOVN:Z, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the Provisions ofMGL c 40,S34 I sclmowledge flat as a condition
of Bm'1 ft Permit M .all debris result mg hom the conmucbm activity
governed by this BuildmS Permit shaft be disposed of in a propwly hcenaed aH&w"M
disposal foci&,,as AdbW by M($,c 1%S150A. /
Mm debris will be disposed of at
Location of FacBity
Srgnattne ofPea nk Applicant Dab
(PLEASE PRINT CLEARLY) mto on.
Name of ennit Applicant
UU1" Ui / 4
Fam None,if any
Addtas.City k State
The above statute requires that debris fi m the demolition,reaovation,rehab or other
alteration of boikHog of sbuchne be disposed in a properly-Hceaeed solid-wane disposal
facility as defined by MM cIq S130A,and the building paWta or He m ate to
indicate the location of the faciHty.