Loading...
1 LYNN ST - BUILDING INSPECTION ,. DATE: Citp Dfar�m, a �at�u��tt PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTEI Location of Building ZlAlf Building PermitgApplication For: 104 JCircle whichever applies) Roof eroof nstall Siding, Construct Deck, Shed, Pool Addition, Alteration., Repair/Replace, Foundation Only, Wrecking Other: t 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: Owners Name: Contractor: Street City Street City Sta Phone (91� 77 /ZD/ State Phone( ) Architect: City of Salem Lick Street City State Lic# � EV,# /S!/a?3 State Phone ( ) Homeowners Exempt Form_yes no Structure: (please circle) mgle Famil • Multi Family# TOther Estimated Cost of job S. Dom_ Will building confirm to law?—z--yes no Asbett03?_yes_ono Description of work to be done: Drawings Submitted:_yes no Mail Permit to: Signature of Application,51,GNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO 114t~OMPLETED WITHIN SIX MONTHS OF PERMIT ISSUED DATE f»is Department use only: ,Permil'u Permit fee S COl1MENTs: L4 �V t r � { r Poo • ppyy o : y y n'''! 7 rr �.�� I. `,`s>�.�' S }i 2.,$ Yt' aro. k . ' A'd(��) SSµµArm, �I 3�`Yr Hd ir'Y �. a�f•y�' .e '�l��Y,nb'7tk' :QDpNb•4'ahr � ' .!r ;'Ydntlko I +' r,5`k .i: 9t .'.:'�:d9 ft.�l ;cz i11� w."`�� 'ti,�� i�4 }a�p S:• : . � nk;�_:.' �a�w a4M1Y,i1t ,i i�:"1 s itr ,9.Njf�yG { r�dt lt•r;A .. dUe b•ii`f: 6 p. . ••.•-. `t 0.F (,"; 1 9 21u '^- .....,... " d t �:rPo 47�MI•fF�:Y4.f:lP 1 r fV{k�iuih,1{b1j{r��k't'✓`;. ,a��ffa�k 3wt";.,�,. tdlv.w., ,�, ;txkY�dcq�tlllev ;if[re ai,r.;�" YJ • 1 i t . w 4 rp t )a " p1 Jy 1 P�;';r + '^ rt �. Ply °{� t )'Ut�, p9� ✓a �VYlatildYY4w� n(F, iJ �j4$py+ "�' 71, l5 {B"&�4v}a°trtS6RslRRaa, ,dP'IItY��1vE1 r4 '*a'x�'�i ,ie"Ba� :i' ... � y.+Cv5�5'V{�a £ r �G �F" ..- :_ — - , IU{ uR•�; .�� .tt,:. � :JAB dt,i"til -,.�"h r .Il t,:. 6v x ,rt)'.;:- LL. Z I )t lr4trY 1'' _ r O : iy fl (33 W o 0 a- n . o O w a Salem Historical Commission 120 WASHINGTON STREET, SALEM, MA 01970 (978) 745-9595 EXT. 311 FAX (978) 740-0404 APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance, application is hereby made for issuance of a Certificate of Non-Applicability for: Construction Moving Reconstruction Alteration Demolition Painting Sign Other as described below. District: Original Building Construction Date, if known: Address of Property: Name of Record Owner(s): Descriotion of Work Proposed: All All applications niust include three to four 35nun photographs of existing conditions. Signature of Owner: rW-al� 4� Tel. #: 917F -7 //O Mailing address: City: _State: Lip: :24E7_45' a 0JC�i� n � �mfi�cs �LhusP . Public pinperig atparnnnIt WuilDing 13c;jartmini l0ae e.irm Sran - 50B-7J5=9595 est• 38a DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, 554, I acknowledge that as a all debris resulting from the condition of Building Prmit0—b, BuildingPermit dshall be disposed of in construction activity governeddisposal facility, a properly licensed solid waste in S 150A. The debris will be disposed of at: location of faaiiity o' �� ivtMe ISTagnature t Applicant Fully complete the following information: (PclleeaJse print clearly) Name of Permit Applicant F Name, if any ;70 Address: City 4 Sta e She above statute :e?vires that debris from the demolition.. renovation, rehab or .other alteration. of building or structure be disposed of in a properly licensed solid waste, license'slarecto1indicateas fthediocationcofithelfacility tatt building permits W (.ommonweaCtfi of i 1a»acnu.101b 2eoarin%eal o,1 jnjaal.ia1—cei ' Id, S: 600 VVaaKira9[ on �lreei James d.Camooeu ✓�oalon. i�asaacn calla 02! 1 I Commissioner Workers' Compensation insurance Affidavit I, - (ut�rwwrrrv�er with a principal place of business ac: '-WA 1-11976 cuvrsu..ramf � do hereby certify under the pains and penalties of periury, that: fjlf I am an employer providing workers' compensation coverage for my employees working on this job. _/)C t- VS-AL2 ILIZ-as?' Insurance Comp"y Policy Number () 1 am a sole proprietor and have no one working for me in any capacity. �y O 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the 1 contractors listed below who have the following workers' compensation poiider. Contractor Insurance Company/Policy Number Contractor insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I understand mat a coav of this astemene w,u be fcmw ceo to me Office of hrvetota=m of the DIA for coverage verification ana on falk"W aeca coverage as reauvea unser Secvan ZSA of MGL IS Z can uaa to me,,aaawn at mmmar oenaues consume of a fine of iso to f 1.500.00 sawor awe years' moraomnem u wen a ova cenawes in me loan of a STOP WORK ORDER and a fine of S 100.00 a aav SCAM me- Signed this �/ 51 day of r © A . N.inn 6Y . �j Licensee/Permiccee Building Department Licensing Board Selefsmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617.727-4900 X403. 404, 40S, 409, 37S