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72 LORING AVE - BUILDING INSPECTION No. Z Z 2- APPLICATION FOR PERWT TO LOCATION PERMIT GRANTED 2.0 APPRO D �l INSPECTOR OF BUILDINGS I iM.�lI61Mll6i�E fiL+-& M APPROVED BY T44E JIySP=DB PRIOR TTI.A PEI WT LNG GRANTED CITY OF_SALEM No. .��r Date � s. Is Property Located In / Location of 7� / v v the Historic Dlslrkt? Yes No lJ tulldln8 a Is Properly Located In the Camervation Ares? Yes No BUILDING PERMIT APPLICATION FOR: Penn it to: (Circle whichever apply)4R.;��Reroof, Install Siding, Construct Deck, Shed, Pool, palr/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: , I et-�e�� L ✓�5� Owner's Name s ` •,, „ J ToLin e� Address & Phone SZe4�l :arg ���6�/mac j� ) 7 Y .moo. Architect's Name Address & Phone Mechanics Name II e-1 Address & PhoneAl What Is ttw purpose of wwt gT Material of twlldirg? It a dwell ft,for how many tamilles? ' C)�ard h�(- WE buildlrg cordorm to law? Asbestos? EalNnsted cost �? I� e46 . City License e N P State license it ``^L!✓��/l Haas Improvement Lic. a8 Signature of Applicant SIGNED UN DER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE e�IGI�� C� GtIG S / ' 'GGl /60 MAIL PERMIT TO: r !C �)-1 /��-- �,y/�jn 4 The Commonwealth of Massachusetts G T' Department of industrial Accidents owes otin rosugauons 600 Washington Street, 1`a Floor Boston,Mass. 01111 Workers' Cam ensation Insurance A idavit: Buildin lumbin lectrical Contractors A r /Y`/ � cv C i9 city i/'l fG�7 state zip: Ct ,`,)Gphone# e�i� work site location(full address)? ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction model ❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition aY Z-4� an employer providing workers' /compensate n for my employees working on this job. Corona t'p - "� add <. incnranrt rn, i�/i/ r�.5� oo11CYM b ��� /�• - / S��f �U.7�C < ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: c m m • address: city,: nhonek: ins nnceeo. nali¢vtk . com a e• add cite. ohR >W a, r Failure to secure coverage as required under Section 357of MGL 152 can lead to the Imposition of criminal penalties of a one up to st 500.00 and/or one yea"'imprisonment an well as civil penalties in the form of a STOP WORK ORDER and a flat of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Iniiistig4lious of tit DIA for coverage verification. 1 do hereby certify under the pains a d p flies of fr' chat the information provided above is true and cone 1. C Signature Date � Print name Phone k omcial use only do not write in this area to be completed by city or town official city or towlf: permit/license R ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑selectmen's Office ❑Health Department contact person: phone a; ❑Other i mr:ua Sepi :�M91 E i CITY OF SALEM� MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASH I NGTON STREET, 3RD FLOOR 1• SALEM, MA O 1970 TEL. (978)745-9595 EXT. 380 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, S 150A. J �J The debris will be disposed of at: 1Q0l-a5 %e1I✓ C.& cep&001 Location of Facility G Signature of P&mit Applicant bat 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 cIlI, S 150A, and the building permits or licenses are to indicate the location of the facility.