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460 LORING AVE - BUILDING INSPECTION MU T-BE f L-E8—AidD APPROVED BY T44E IfSP,E.CT.D-J3 PIER TD.A.PERMIT B,EWG GRANTED CITY OF SALEM 1 ^ 261 No. I17�—?-00�-t ��\ Date -UL{ nrlo���fi Is Property Located in / Location of the Historic District? Yes_No !! Building 116 D fo „� 1 � Is Property Located in / the Conservation Area? Yes No 1/ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding,=ConstructShed, 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 tee©� A-G a, IA- COM0 Address & Phone Gl (7�� Lam. Cnr d� r9�8) 94o -SW 2 Architect's Name Address & Phone Mechanics Name �iS2tp! l r ( C Cce-L—�Li 4 Address & Phone 3G What is the purpose of building? Material of building? If a dwelling, for how many families? Will building conform to law? Asbestos? Estimated cost City License # N P' State License # CS 063149 Home Improvement Lie. / �a 0 S nature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE 'MAIL PERMIT TO: ] �O O No. 0%-Zooy APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED 2 - 9 - 2-o03 APPROVFD INSPECTOR OF BUILDINGS �o T OF SALEM. MASSACHUSETTS 3 PUBLIC PROPERTY DEPARTMENT ' ° ® 120�WASHINGTON STREET, 3RD FLOOR a y; gP SALEM,MA 01970 TEL. (978)745-9595 EXT. 380 �Grnr� 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: C''2� Location of Facility R - 03 kIgnat&e of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CL E ARLY) u Name of Permit Applicant Firm Name,if any 34 2, �os �� ue ��veA 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 cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. COrrmOnu/sia& of V&a 6acktc6¢ffi „a s J,Pa,lr„snl o/.Jn ,Giaf�+«iae nn 600 ,WU.1ie t.S1-.1 Jam ,Ues J.Camccell A., ///asaachma.ffs 02111 Cormrssaew Workers' Compensation Insurance Affidavit Kc with.a principal place of business at: tutisw.,wl do hereby certify under the pains and penalties of perjury, that: () 1 am an employer providing workers' compensation coverage for my employers working on this job. Insurance Company Policy Number X1 am a sole proprietor and have no one working for me in any capacity. () 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 Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O 1 am a homeowner performing all the work myself. I undentand that a cony of this statement will be ion+aroed to the Me of Js dtaoont of the DIA for cordrate WeAC31don and Mat faiore to ware coaeratr as rewwro under Section 25A of MGL 1 S2 can lead to the i noomdon of crmrsiml oessanies corsutint of a fine of w to-S 1.5O000 and/or one reap'in Wnrn nt v+ea as&A ""Ides In th loan o(a STOP WORK ORDER and a fine of S 100.00 a car agairos me. Signed this day of Licensee/Fermittee Building Department Licensing Board Selectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375