25 LYNDE ST - BUILDING INSPECTION (2) I MAMIM IST19E fiLf� APPROVED BY T44E
.WSPECTDR PMOR Tp A PERMIT BEMG GRANTED
�J
CITY OF SALEM
No. Date
Ward
�. Zoning District
Is Properly Located in BLocation uilding 0
the Historic Distd s ct? Ye No��
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: o,71- r
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 Z�A
Address & Phone
Architect's Name
Address & Phone fj I
Mechanics Name
Address & Phone G 6 (7jSjJ
What Is the purpose of building? </ S
Material of building? If a dwelling, for how many famiBes? Otis
WIN building conform to law? Asbestos?
Estimated costakrz 4U city Ucense ft State Licenser 'g;"'q�fz5;;
r Bowe Improvement
ignat Ire of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
=T—
MAIL PERMIT TO: n�� S
% 7
No.� 1 ^ J
APPLICATION FOR
PE TO
)CATION
PER IT.GRANTED
APP V-
INSPECTOR bF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
r t2Q1 WAsmmaTON STREET, 8Ro FLOOR
SALEM,MA O i 970
T19L (978)746-MRS EXT. 360
FAX (976) 740-6846
STANLEY J. U80vicr, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(x c 40,S34,I aclmowledge that as a condition
of Building Permit g .all debris resulting from the consaucdm activity
govaned by this Building Permit slmli be disposed of in a properly licensed soh&wasta
disposal faciliry,as defimed by MOL c Ili,SISQA-
Mw debris will be disposed of at
Location of Facility
S1960m of Permit Applicant ate
FULLY complete the following infonnadon
(PLEASE PRINT CLEARLY)
Nami am^ ofPerrmitAppfi �
Finn Name,if any '
Address,sty at 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 ca S 150A, and the building pamits or licenses are to
indicate the location of the facility.
600 W&OL.11en 3laod
�araa t Cu+mas &J , Maose" 0211/
Caenssw '
Workers' Compensation Insurance ldsyk
Ia �i' %,- ��'� lam/S•' �
pe..rw*rr�rr
. . wkb.a principal place of business at:
l/ 157
• - Icaws..rasM '•.
do bereby'certl<y under the pains and pensldes of perjerys th pin
O I am an employer providing workers' compensation coverage:for my einployees working on
d* job.
Insuan" Gompewlr ` . Policy Number-
I set a sole proprietor and have no one working for an In Our Capafdry.
() 1 am a sole proprietor, general contractor or homeowner (drde one) and have hired the
contactors listed below who-have the following workers' compensation polidest
Contractor Insurance Compstry/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
O 1 am a homeowner performing all the work myself.
I vnawetand ow s cory of Ore euewnem We be fc r woed r dw office eI M.esdeseos of ow Db(for cv. see.wlacadea see tow bbm n serape
co.waer at itowee anew Seem SSA of MGL 152 can kid so ow:rsoariew of oidne,oenade eoriodnt of a dr of n=4I.SMM abler see
798M•iaorsera+rn{a ve a d.r oeadda w du form or a 577 WORK ORDER aro s few of s 100.00 s ae1'apbo we.
SiErled this • Z.
day of `—
.ice ns iFcrmiuee Eiuiiding Departr4ent
ucensinf Eoard
Selectmen Office
rie:lth Deprrmer-