R-170 LYNN ST - BUILDING INSPECTION OVEO BY T*IE
T R,EING GRANTED
x a' IT1 OF S EM
No. r i� � Date /D
i f..
Ward
\ Zoning District
yl�1Rropgrty Located In Location of
Ire;Hlatg14C District? Yes_No_ Building 12(2,e
Mt' ? y Located In
conedhraflon Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, 6nstruct Deck Shed, 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 �i c yi9rh hrl Ca.�,00 Ai�iJ.aM. LJ//B/fe3 �•�
Address & Phone r�O�IiJJsJ 5H'£I,O./�7�or f` 81 5-32—
Architect's Name �/09/jXi•� �SJoci�TT
Address & Phone /Da 7ir,oH.7"X• A)• /V L )
Mechanics Name /11) (/• .Se0e. r•Aqs
Address & Phone /�'l�d 4l n
What Is the purpose of building? C /`��/3r l'��c7 N£n1• �tG�s
Material of building? 4J48D I /r+t9o",T If a dwelling,for how many families? 4 - S
Will building conform to law? r �S Asbestos? A) D
®stimated cost 36•eve city License k State Llcenss o
Raise ImprovoentLie ^
�W - Si lure of Appficent
SIGNPIP UNDER THE PENALTY
OF P ilk JURY
DESCRIPTION OF WORK Th BE DONE
DI-) /►l/9c/ £5/ � C
MAIL PERMIT TO:
IT Ya Wvop GOA. 0
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Ccmtmonwaahk of Ma6.iackaffs
6 1Jepn,Irnanl or.J.d+�Iria(f+rciu.�
600 w-11-ILM �b.d
Jame:I ea.19" Uoslnn, ///asw L.A 02111
cormrssoar
Workers' Compensation Insurance Affidavit
tin 7.dA/0.'
(ivr.vf.e.e••e1
with•a principal place of business at:
�'l �� i,� ,✓�,/ sf' /°«�op� mom'
trxsaw✓sar)
do hereby certify under the pains and penalties of perjury, thus:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
lnsur ce Company Policy Number
I am a sole proprietor and have no one working for me in any cspaetty.
O 1 am a sole proprietor eneral contractor r homeowner (circle one) and have hired the
//.. contractors listed below who havt the following workers' compensation policies:
W-L nia5 Q LOvTnlC Num
Contractor
ctor insurance Company/Policy bet
Contractor Insurance CompanylPolicy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoentane wt a coot of this a Itenent tie be iorv+aroea w the OrrKt of Inresritavom of the DIA for eo�ate ee"Co6on aee Nat have a s t
co.erate as reourea uneer Section 25A of MGL 15 2 Can feaa to the inoauden of crunvtm oeswisn coausdnt of a robe of ae=4 I' CO b"Wer one
rears'raruom+/nt�aass•t,0 as c*i ocnaities m the loan o!a STOP W ORK ORDER ana a rnt of S IOO.DO a vY atMA me-
Signed this/rs.ar, day of
ccnsee/Perriuea Euil '1ng Depart ent
��iceruing Eeard
Seiectmens Office
i-f- , Department
-- - - - - -_a qC[ " , - -
f -
CITY OF, SAEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
3 120 WASHINGTON STREET, 3RD FLOOR
'(R a SALEM, MA O1 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. LISOVICZ, 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, S 150A.
The debris will be disposed of at:
Location of Facility
,01gnature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Gy /A-fa I;f j A'9 r��
Name of Permit Applicant
Firm Name, if any
Address, City &Mate
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, S150A, and the building permits or licenses are to
indicate the location of the facility.