25 LIBERTY HILL AVE - BUILDING INSPECTION (2) Cx 532 2
idfHST-9E fILf� APPROVED BY T44E
.IAhS.PECT.QR ,PFWR Ta .PERMIT BEING GRANTED
CITY OF SALEM
"N 7 No. (�-I o "Z.O O L( `� .� �` P Date
'4<f
NE
Is Property Located in Location of
the Historic District? Yes_No Building P2,�- f fs`r 6 !11l1Avf
Is Property Located in
the Conservation Area? Yes_No Z
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, 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: nn
Owner's Name I''4-n J E-Cj�:Y-,tcCC,
Address & Phone 3 WA x 92F) 7f�d�a�
Architect's Name
Address & Phone ( )
Mechanics Name << C 6-(�b
Address & Phone I �7 g�
What is the purpose of building?
Material of building? t.✓D b If a dwelling, for how many families?
Will building conform to law? Asbestos? ^,�d
Estimated cost OE UUa City License# N A State Licei aer e`H d 3 5 a sY
Home Improvement
Lie. i
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �3s rvli
No. 1 O - ZOO y
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2.0
AP VFD
INSPECTOA OF BUILDINGS
.- a
f
jr /fit �—ommonwi:a k 0/Ma6dackcl6atb
r, �1.Jepartmtnt a/.7.w,..trial seeia nit
l 600 rwr�aa�:npta Sirest
JamesJ.Camcoet &I. , ///auaeL ib 02111
Cor,-.mrssrona
Workers' Compensation Insurance Affidavit
ff�e..r..r•�.t1
with.a principal place of business at:
iekr/Au"MP)
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.
I am a sole proprietor„general contractor or homeowner (circle one) and have hired the
contra workers' compensation olicies:
contractors listed below who have the following P P
g
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Polity Number
Contractor Insurance Company/Policy Number
O 1 am a homeowner performing all the work myself.
I undv=no wt a coot of the mct t wo bt ion arotd w the Office of Jm dgauow of the DIA for covaarte verification and out bbm to seatre
coverall as rMirea rncer Section 25A of HGL 1 S 2 can lead to the inaoodon of n4ninas otnattfes cannaDnt of a fie of wo ttri 1.50000 Mwor one
year,,6nwuomment a•tea as Ida in the loan of a STOP WORK OR a a R firte of S 100.00 a dar asai ut ene.
Signed this day of —
Licensee/Fermate Building Gepartn+ent
Licensing Board
Seiectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL. c I- -27-4900 X403, 404 405 409, 375
co - ' OF SALEM. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
5 - SALEM, MAOI 970
'?rYy TEL. (978)745-9595 EXT. 380
�Gmu 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 di of at m6G 6� v
Location of Facility
Z La
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY) /
Name of Permit Applicant
Firm Name,if any
luxA
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 cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.