207 LORING AVE - BUILDING INSPECTION •PLlIINGIAWT-GEfiL*B4WD APPROVED BY T44E
JNSPj=DR PFWR TD.A PERMIT AMG GRANTED
CITY OF SALEM
Date
Is Property Located in Location of
Me Historic DistrICt? Yak_No Dmilding
Is Property Located In 7 &fZ iV C?
Um CormwvatIon Ares? Yes No k
BUILDING PERMIT APPLICATION FOR:
Perm it to:
(Circle whichever apply) Roof, ReroonLYTO
on�st{uct Deck, Shed, Pool,
Repair/Replace "� f N 4W S
PLEASE FILL OUT LEGIBLY&COMP DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name MAL/ 14,gFeti
Address & Phone ao 7 L 02//v& Avg 74 S
' Architect's Name
Address & Phone )
Mechanics Name
Address & Phone
T,yiv �sn,�/zo
Whet Is Cur purpose of buUding? R9 S/�fnrT7/1 L
mdedel of bugdirrp? .(,h&!1L 49fir7mst_ It a dw"ft,for how many families?
Gv r ry j)�5
Will building cordorm to law? Asbestos?
Estimated� Gly License• N 0' State License A
Some Improveaent C.?/
Lic. / I�L�4�
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
/�_ fpl-,4ce '7 2•,!!y,4,rws
�o S1TzuC��tC ���/an�GP
MAIL PERMIT TO.—. ! BUNROFUN CHHaff
HOME DEPO:
a COBGRN Ri.
7'YNGSBORO,Mk 01879 6'-! J, 7 9
u
allo. -��_� �
APPLICATION FOR
PERMT TO
LOCATION• 9
PERMIT GRANTED
AP OVfD
U, �tiJ
INSPECT. OF BUILDINGS
" CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
]' 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, S150A..++
The debris will be disposed of at: 3 yJr (die P Pil/64.j00�6
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
14N C_ Nxyoa,c/
Name of Permit Applicant
96 ^--) e- j G i7o"—
Firm Name, if any
?� 4 6je-£ICNt�.100 G �!� 6,t'orz C l%4 j Er'L
Address, City & State
above statute requires that debris from the demolition, renovation rehab or other
The abo eq n, ,
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
77Fe capnmorl-weaNh
INA- Department of lndmstr�al Accidents
MOO - R11-reQnIfAl
-600 Washington Street
Val ------
Boston, Mass. 02111
t Workers' Com ensation insurance Affidavit:Buildi: Fliumbin Electrical Contractors
name: E)"*rj C H Ho LAyk
address: Co&_ a&J
city , *Grs�bop,& state: M A zir:_OJKI� Phone# 9 A-50 -57&
4
work site location(full address): 7 "e, 4yf
❑ I am a homeowner performing all work myself. Project Type: EJ New Construction emodel
❑ I am a sole etor and have no one worldn in an ca aci ❑Building Addition
I am an employer providing workers' compensation for my employees working on this job.
7 Ne, Al cwle�.
eons on name- i
addreW ee s Ae- ROA-6
Off
2
44 e:.c�4
1 .
cS. Co,. 1W 4,
El I am a sole proprietor,general contrnetoKfor homeowner(circle one)and have hired the contractors listed below who
4
have the following workers'compensation'PAces:
con.i.D tort I n I eme:
address:
M,
add":
city:
IN
0t;
1012it ON 0
Follure to secure coverage as required under Section 25 1 A of iid i52 me lead to the imposition of cri-1, I penalties of a fine up to$1,500.00 and/or
one yean'Imprisonment as well as civil penalties to the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this stateuteat may be forwarded to the Office ofInvestigations of the DU for coverage verification.
I do hereby certify under thepain s andpenaffies ofperiury that the information provided above is true and correct
Signature —Date
LAJ,_I Phone#.. 7k--5( 9 -7(y 62
print narm 1-4 cA AW
Q.
Official we only do not write in this area to be completed by city or town official
city or town: permit/Liceme M_❑Buadiog De r( an(
OlLicensing gourd
[I check if immediate response Is required Elsvieconews Oliice
DRUM Depo t en(
contact parson: phone a; —C]Otber
(mov!&-pt 2003)
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