414 LORING AVE - BUILDING INSPECTION IL dIHST-BE fiL-E8-AN{3 APPROVED BY T+IE
WSPEXTD-R .PWR T-O.A.PERMT BEING GRANTED
CITY OF SALEM
a;
No. 5� Zl'�o q y�." '� �\ Date
Is Property Located In Location of //
the Historic District? Yes_No_ Building L /p !
Is Property Located in
the Conservation Area? Yes No
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:
Owner's Name MAVkrAA1WP y71tY3�b S
Address & Phone X o{2 i'N,� A u�Z 7 y5 - ?I Rl
Architect's Name ln2 1W 67-A o X/
Address & Phone 2 -00107D A/E IM 4 Z 5 T el
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost /o 8a6 OU City License# W/o' JSINED
cense # a%3 `� �'9 7
6 6 Home Improvement v L
I3c. i '/
Z� tur o pplicant
qs - `I CAC Lj l y3 UNDER THE PENALTY
ERJURY
DESCRIPTION OF WORK TO BE DONE
Srn / 14 /?d0 /L Ti+ c-L 3,01,'eliK Ce-/-L/-2--�
Xo F
MAIL PERMIT TO:
No. 6 '2d o `4
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
�ls)tS�o 2.0
APPROVED
INSPECTOR OF BUILDINGS
�om-monLVsJh 0 m66acku6clL
-.7c i"
n/ 600 �ywyymla:.y"31 ..I
f>o
James J.Camooes alon, ///daaa L.ib 02111
Canmrsssona
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
cGrYrsxreraaa)
do hereby certify under the pans and penalties of perjury, that:
O 1 am an employer providing workers' compensation coverage for my employtts working on
this job.
C/Z4,kJTi— 0'7A% five T 9-
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
Q 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 Insurame Company/Policy Number
Contractor insurance Company/Policy Number
L
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
1 understand tot a f lhit tcaeemen["a be ion+aroed to the Office of Inwdtauow of the D1A for coeerate Yerikadon and 03t Mute to secure
co.•erate as r<ourr un er Section 2 SA of HGL 1 52 tan lead to the inoowon of cr6ninas ornastks corsadnt of a fine of eo etrd I.SOOCO mWor one
rears'in. " t as as dui oenaid corm of a STOP WORK ORDER,anon,Me of S 100.00 a d' Against me.
Signed this day of �G0 . '1
Licensee itcte Building Departraeent
licensing Board
Seietzmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X4031 404, 405, 409, 375
o OF SALEM. MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
Sgp SALEM,MA 01970
'L TEL. (978)745-9595 EXT. 380
�G FAX (978) 740-9B46
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA 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,S11�50A.
e d is will be disposed of at: rI r
Location of f acility
o
igna of Permit Applicant D
Y complete the following information:
LEASE PRINT CLEARLY)
/T) �^ t- gAm)g sh Ir- S
Name of Permit Applicant
,4Vn TIV 57-A-U- A' A/
inn Name,if any
� J ui, / � C19 I� /n
/L�
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
b MGL c]II, S 150A, and the building permits or licenses are to
indicate the location of the facility.