25 LIBERTY HILL AVE - BUILDING INSPECTION i` BE f�Lf ;" ;?PROVER BY T+IE
If�,Si rWCT hWR • Did P 7 BEWG GRANTED
CITY OF SALEM
�--, � 2 �y1�3
No4 'L4" ,5e`r �. �
Date
Is Property Located In `x/ Location of
the Historic District? Yak_No�\ Building A✓E
Is Property Located In
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo Reroof, Install Siding, Construct Deck, Shed, Pool,
epalr/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: '1
Owner's Name 1 40L -J c/
Address & Phone 35 7o�WASiGvUG SD- �yl� oy, -;,Lvz s-
Architect's Name
Address & Phone / L 1
Mechanics Name �i f / r e " .?�i Lfb
Address & Phone
What is the purpose of building? L y
Matedal of building? F�'L Y12E If a dwelling, for how many families?
Will building conform tolaw? Asbestos?
}�
Estimated cost i�t-6`b'd Gty License d N A state Li a AIA ) /L b3S�Sy
r6- I(p r b-b� Home Inpzovesent
4 5 3 f Signature of Applican4
�1 O 16p . 1 -$/ 5-6 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
d Nam✓ �?�r�
F/ Fevvtoye cxrsf. C�A/,,3 � �ylu�t2l_ w1-nti S'kc-/,
MAIL PERMIT TO:
`D f?CU�
No.' -Ze
APPLICATION FOR
PERMIT TO ,
x1Pcc) ''
LOCAT
PERMIT;GRANTED
APPROVED `
INSPECT-GR OF BUILDINGS
5
b� /Y'�I�arnmonwt.a o 0-eeackcrs¢i`f6
.� j �.Jepartmant d/.J.w...triaf�eeitunla
600 ,woaki'llen sw*t
James J.Camtoe6 6,01 n, JJ/asm k .ib 02111
CarmrsstwaN
Workers' Compensation Insurance Affidavit
I• _ ��- J ��iu2ce�
(ata,eeryrer,:me)
wich.a principal place of business at:
d
ItJn,+wa/tMI
doh certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
�oNWefrev7' vw,-IeA414 k)6 7OD � 2 d
Insurance Company Policy Number
a sole proprietor and have no one working for me in any capacity.
O am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
T� CKAd LLD. �10/V" 2/ - ova
Contr
actor n Insurance fCompanyp/Ppo'l`icy Number
5Jn13�ln/L (yf/40 C' l41/�.
Contractor Insurance Company/Policy Number
tL
�r &w GLL o
Contractor Insurance Company/Policy Nur6ber
() I am a homeowner performing all the work myself.
I undenta a tour of the ttatement wM be for armd to the Once of 1m dptaoa of the DIA Ior coeerate veri6cado+and Mx(more to teCnre
w.erare — eo Mer Section 25A of MGL 152 can lead to the inoos,tion of er'ie iw,oenattiet corsatint of a fine of teo to-S 1.50000 wWw one
a a a6at rot.
filace /
" t n.rsa as eie2 oenaltiet' the loan of a STOP WORK ORDER no a Fru of S 10000 aar t
l day of
mlltee Building Departrent
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517.777-4900 X403, 404, 405, 409, 375
OF SALEM,- MASSACHUSETT5
PUBLIC PROPERTY DEPARTMENT
120 WASMINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT.380
�WAIryg 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:
Location of FacilitY
Si gna of Permit Applicant D
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
90
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.