10 1-2 MALL ST - BUILDING INSPECTION • . �
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JdSPFCIAF,I P91GA TD A PERMIT BEING GRANT�D
CITY OF SALEM
No.�'V� 1' \ �--�__
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� ZaNng Dlehlct
�ha NietDlic�h Yas No Lacation of
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ie P�on.r�y�oc.aa h
:� Ih�Cone�twtlon A�a4 . Yes No—
BUILDING PERM(T APPUCA710N FOR:
Pertnit to:
(Circle whichever apply) Roof,�ae�oaf,��l�ta11 Siding� Construct Deck, Shed, Pool,
Repai f�eplace, er. f�U ; �d ct-��
PLEA8E RLL 011T LEGIBLY d�COMPLETELY TO AVOID DELAYS IN PROCEgg�Np
TO THE INSPECTOR OF BUILDINtiS: '
Ths undsrsigned hereby appNes for a permit to build accord'c�ig.ro the following
specHications: .
Owner's Neme � Q!� ���' /'�� [ivL '
Addresa 6 Phone �(1 �z �'1')c, �� ,S-� �g`z� - .S9'��— �jp�
Arohkect's Name
Addroaa fl Phone ( 1
Mechanics Name _�L,C/it l �� OL�L� ,
Address & Phone 3��G%�h wc,c,� � 1' ( 1
wnn�a nw p,r�ow a ewa�r�r�c.e ��-��.� ,�yz� o�� cr7
M�MW a b�dn0? n a dw�IMg,tor how m�ny hmlles7�_
N1M aiYdrq caAortn to Isw7 A�O�etoe?
E�co�t v� � Cpy LIcMw r 3�Lloww•
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s��o uNOER n�� �u�rr�
o� �u�r
DESCRIPTION OF WORK E DONE
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MAIL PERMIT T0: U
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No.
APPLICATION FOR
PERIW TO
LOCATION
PE�9R IT GRANTED
b /31/D1'/ 19
AP?FibvFD
INSPECTOR of BUILDINGS
i
�vJ►g�n0/gu/a16{L/L Gf ��1 �
'
boo w.a�ie�fna.Sfresi •
+"race 1 c.anaasa goden, 11/umd..6 0.2111
Workers' Comperw=ia lawrava AfJidayit
. . *101.4 prbKW pbse of bmilws sa
de hereby'an* ands._!» pafas and pwlde4 ./psrjasy, th.a -
�0 1a an employer PcovIdling V'o.11WSI compowdon Ca""dee for n r sinpl0yjM weelcieR.R
.'`1"/�✓c CGc� ��� ✓'��'� L✓�t� G�--l�Ylw C2 '� •�1 �( 2
Insurance Compaq P NunnbM
1 awn a�sole proprietor and have no one working fir no b ssq npadq.
() 1 am a sok propfaalr, general comrauor or homeowner (drde one) and have hired tog
cooaaetors listed below who-have the following workers' compensa=foa poliden
Contractor Insmancs CompmW/PolbW Nuwdw
Consreaor Insurance Cosnpasry/Po Nuaber
I
Contractor insurance Company/Poiiq Hsssnier
() 1 am a homeowner performing all the work myself.
• r.aant "em a w/of di amwne WE of tor►arass a ea Olks a b"adNaaw d dor GIA N ce.wale volkedao a" Ubm 0 man
cawrary ar mowed«w Saar SIA of MOL 152 nn kN w ow wmandm of vbWw osada comedo;d a raw of n w4 I.IC "asalor w
+saq'iwaer.n.re a yn a/ai a.ww in the brw.!a STOP WORK ORDER arw+iw of S 10GAC a aw+Obw=t
signed this . l d4p of
.jcr s>�Fc ogee culldnng Department
!icensini, Ecare
Selectmen Office
riealth Geparmer,:
904 epc eDe Tic
PUBUC PROPERTY DEPARTMENT
120 WASHiNarou STRAIT, 3ND FLOOR
"L[M,MA 0 r 970
TIL (979)745-W95 FXr.a!o
FAX (076) 740.9646
STANLEY J. IJapvK7, J&
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
Ia accordance with the provisions cf MGL c 40,S34,I aclmowledge that as a condition
of BmldmS Permit# .all debris maulbug fom the conat<uctim activity
governed by this BWldmS Permit shalt be disposed of in a properly licensed solid-waste
disposal fieility,as defaed by MGL c ll;Sl-%&
The debris will be disposed of at Leo r'C e- �M t co cr7
LocationofFacrMy .
SiPaUm of Peaart Apphcaat a Dace
(PLEASE PRM EXARI
Name of Permit Applicant
YCT-� C.
Fnm Nam„of arrgr
Address,city&State G z G c
The above statute requires that debris from the demolition. renovation,rehab or otba
alteration of building or ahvctme be disposed in a p mpaly-licensed SOH&wade disposal
facility as defined by MGL cIII,S 150A, and the building permits or fioensei=to
indicate the location of the foci*.