17 LOVETT ST - BUILDING INSPECTION (2) r �{y T .0
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ST-MfILf9>Aid0 A°fPROVED BY 'T44E
U�SP�CTQ1 PF119R TprA..P.ERfN17 BEING GRANTED
FCITY OF SALEM
No. / .` 4 i Date
(ar s Ward
} f
\"�trnsNe Zoning District
Is Property Located in Location of —7 Lover S�
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Rero Install Siding, Construct Deck, Shed, Pool,
Repair eplace, 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 ���Ut' �1 \ `1l1
Address & Phone ), -7 L-%c;,ve.� S (97X,) -7LjLj 0(p` (.O
SCE,\e,n Mci• 01970
Architect's Name
Address & Phone p p ( )
Mechanics Name I"IG&Pk./ �`
Address & Phone Qy Pln(`&Wc O�Mk))
What is the purpose of building?
Material of building? VJobC\ If a dwelling, for how manyfamilies? 1
Will building conform to law? Asbestos?
Estimated cost City License # t Li s #
Home Improvement
ignature of App a t
1679 SIGNED UNDER E PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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Coemussmow
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
. . lu<risu.✓sarl
do hcreby'cerzify under she pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverate for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capaetty.
O I 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/Polity Number
Contractor Insurance Company/Polity Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
f un0en:anC wt a coot of tho acaunrtnt pie be ior,�aroce w the Orfce of Inrotieawns of the DIA for co.eratt+e<itestioet ausa enx faaure b aeevre
co• atr as rewr<o unoer Section 25A of MGL 15 2 cm kao w the inao ,ion of crvrimat oetwues corn tint of a fm of W mi 1-500A0 Uwe(one
r<ara• ir..�<uo t chi ""iLi f n the loan of a STOP WORK ORDER ane a W of S 100.00 a 027 apirst me.
(�( 0 �3
Signed This , day of
iccnseci F erm, met Builcing Gepartn ent
hcenstng Beard
Seicamens Office
tilt Gepartrcnt
(I " . ., _
CITY OF SAL.EM,yMASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
o 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
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 IIII, SS 1550A.
The debris will be disposed of at: y 1 '�-p ���(�75(1\ V e0 w� M
Location of Facility T—
ignature of Rennifl4licant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
2N Q� G��� oc�'nVzj�5 hc.\ v c�z%
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.