92+94 LINDEN ST - BUILDING INSPECTION �4ND' "vPROVED BY 'T44E
y .U !?ECJ. ,?FR 7P�A pEIWT.SEiNG GRANTED
i P 'PITY OF s LEM
1 N �
No. ) -7—Z0 o C-� oats a 3
as'
Ward
Zoning District
Is Property Located In Location of
the Historic District? Yes_No_ Building
Is Property Located In
the Conservation Area? Yea No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Retool, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: ��100ye
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:
Owner's Name /p/l,%<e
Address & Phone 9 �9y L;r✓� � — ( )
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone L )
,
What is the purpose of building?
Material of building? /100 b If a Lelling, for how many families?15 /
Will building conform to law? 5 Asbestos?
Estimated cost /4 66,v,D City License # State License #
� Improvement
Signature of Applicant
GK f Zg SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE "'
MAIL PERMIT TO: el is r5' llq 4y�r9�!1/� ;4x0 e6 u7,,,f
tat B s9 7
�,N�t?M,Slb i"Olq OkAAO�Af 1 9F, OANOE
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OF SALEM. MASSAcr11Jar- '
3 PUBLIC;t�'RoP'yEERTY DEPARTMENT
• • 120 WASHINGTON STREET, 3RD FLOOR
< „ SALEM,MA O 1970
a
TEL. (978)745-9595 EX7.380
' gyl,a FAX (978) 740-9846
iTANLEY 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
Signature o Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
L// e-7 IruTn
Firm Name,if any O `/
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 cHl,S 150A, and the building permits Or licenses are to
indicate the location of the facility.
C0rnm0111us!a& 01 I► 0.66acLwaffs
• �uepat,lanaaal e/9aala�l.i�f.:«�.,�
s 1 n 600 was 16 SW41
Jame:I Cal.Coe l Wsten, 02111
cazmrssgnar
Workers' Compensation Insurance Affidavit
1,
- trio....,....;..)
with.a principal place of business at:
lGerlaw✓ala)
do hemby'certify under the pains and penalties of perjury. that:
() I am an employer providing workers' compensation coverage for my employees working oa
this job.
Insurance recimpany Policy Number
1 am a sole proprietor and have no one working for me in arty capacity.
O 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 lnsuranf:e Company/Policy Number
Contractor Insurance Company/Poligq Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unorrsuhC wt a cony of thif x tmnnt wa be ionraroed w the Once e1 immaotaoens of the DIA IV corers"r�ano am laaswe to"owe
<orerare v reoueo unoer Secoon 25A of MGL 152 can lead to the inoosnion of ersaYnat oenaties corn Ent of a foe of tv o-i I.500A0"Wor one
reap' i^.oruonmtnt v w_6 v eiri oenaltie in the Ivan of a $TOP WORK ORDER anc a fne of S100.003 am nbimat ene.
Signed this , day of
�iccnsccircrriitctt
Euilcing Deparcn+ent
Ucensinf Foam
Seiectmens Office
�,rsith Degarmcnt