4 LOVETT ST - BUILDING INSPECTION J/
-KA4iSlAiST-BEflll--E �4dfl APPROVED BY T44E
.=P,ECT.DR PF,t,IDA T-O A.PEAMIT BEING GRANTED
1��p\v `,,\\\_ CITY OF SALEM
,yI` 1A, �� Date
�'�C/PIING C�y�
Is Property Located in Location of
the Historic District? Yes_No_ Building L- p v per, St`
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 a lac Other: W i, n�� c
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 -7 Q V, cz
Address & Phone LA L QV
Architect's Name
Address & Phone )
Mechanics Name L p_: C b. LV Cn 21 4
Address & Phone 14 9 iM1J r,� S7--:FP.4 b,, y 63Y) S3 1 R �
What is the purpose of building?
Material of building? If a dwelling, for how many families? l
Will building conform to law? Asbestos?
Estimated cost S, 8 (� °ice City License # N A State License # n S 4 'V R
Home Improvement Ll� k� :4
71 (� Lic. i O 11 X
Signature of Applicant'
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: `_ o . i h , L y '�10 A -
No) A
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
AP OV�D
INSPECTOR06F BUILDINGS
i
_ . '" ��+:. �< ll-II� DI �AlYII1. 2�F1tit�dL1111bY111a
� ��• , �ubiit i�rnpuip �t{�artmtiti
S �1311�111L� �L�I'III1LA1
(Oat tislem 6tstn
v 5DO-745.9595 txt, 300
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance, vith the provisions of MGL.c 40, S54, I acknowledge that as a
condition of Building Permit 0 , all debris resulting from the
construction activity governed by this Building Permit sbali be disposed of '_n
a properly licensed solid Waste disposal facility, as defined by MGL c I11 ,
S 150A.
The debri's,i+ill be disposed of at: !Voet 1 k S l r)-o CQ�c ( t
location 01 ireility
Signature of Permit plicanz Date
Fully complete the folloving information: '
(Please print plearlY) L l
L b � >
Name,.of Permit Applicant
F+rm Na4z, it any
PC ,�
address; City i State
The above statute requires that debris from the demolition., renovation , retuC
or other alteration, of buildi-ng or struczure ' be.disposed, of .in .a proptrly
licensed,.,solid Waste- disp,os'dl facili-ty as defined •by, MGL•clll,• S150A and that
building`perud is""or license's are to indicate the location of the faUlity at
R OF t
Commonwealth of Massachusetts of GEpR
Department of Industrial Accidents 32 atp. NEW eyFro
Office of Investigations
600 Washington Street p tggg ' 6
Boston, MA 02111
�cy4 o*a` � 9'fr9000SF'�
Workers Compensation Insurance Affidavit
Applicant Information Please PRINT Legibly
Name:
Location:
City: Phone:
I am a homeowner pertorr:ng all work myself.
I am a sole proprietor and : .Jo no one working in any capacity.
I am an employer providinn ;vorker's compensation for my employees working on this job.
Company Name: L -e G�
Address: j Y 9 M A 'Av T
City: Re a 6, v' tj R O 1 9 G c7 Phone:
Insurance Cc: A T. u-Fv A C17, Policy#: d C7 --
_I am a sole proprietor, gent ,ontractor, or homeowner(circle one) and have hired the contractors listed below
who have the following worker's _ ,,.lansation policies:
Company Name:
Address:
City: Phone:
Insurance Co: Policy#:
Attach Certificate(s) of Insurance _.. . additional sheet if necessary.
Failure to secure coverage as required i. section 25A of Massachusetts General Laws 152, can lead to the imposition of criminal penalties
of a fine up to $1,500.00 and/or one ye n'sonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00
a day against me. I understand that b L.: y of this statement may be forwarded to the Office of Investigations of the DIA for coverage
verification.
I do hereby certify under the pa;i s and penalties of perjury that the information provided above is true and
correct.
Signature: L-0--n a,._.p_., A:�
Date:
Print Name: C 6 p j"_r Phone:EmmmmmmmmmmL—
Official Use Only Do Not Write in This Area—To be completed by City or Town Official
City or Town: Permit/License#: _Building Dept.
Check if immediate response rc d _Licensing Bd.
Selectmen's
_Health Dept.
Contact Person: Phone: Other