15 MAPLE AVE - BUILDING INSPECTION 1 �
fl�ll6iMW-6EfW040113 APPROVED 9Y THE
JdSPJECM PWR TD A PERMIT BEWG GRANTED
CITY OF_SALEM
No. — D�
Oda
Wald
� Zarwg DlsMct
Is PmPwty Lowed
in
>IItioa of
tfrAWINk Dktft? Yas No
Duildia6 �/j7
Is P Maly Looayd In
f►r Conorvatlon Anu4 Yss No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Romot. Install Siding, Construct Deck, Shed, Pool,
R eplace. Other: /, j c..a,- ., > C
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '.
The undersigned hereby applies for a Permit to build accordGig.to the following
specifications:
Owner's Name Su S
Address & Phone /,C_ �"t _ (711t
Architect's Name
Address & Phone /�� ( )
Mechanics Name L(.� 0/ , U-Z—�
Address & Phone
Wirt is Or p mpaaa of hulldkg7 �o ice 5-F_r yVI G t
md"of MYdrtp4 n a dw.wg,for how nwiny ratnaes?
WM Mrkatp conform to law? AaEaaos9
Edmaad cost 2� �'V C y Ucom• sfata t.kwra N
Ht Isproseaat
Lie.
Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORT DONE
/� /7
LZ
MAIL PERMIT TO:
.t
l 11
No.
APPLICATION FOR
PERMT TO
lc« ry/q
LOCATION
PERMIT GRANTED
is
AP D
OVf
u/ Lfh0
INSPECTOR OF BUILDINGS
* G, l.onvnoruoualtlt ofr �assachues�d .
• .1JaPeriweafa��i/r�i��ai�a�e
600 yW.A;.#.Shed
Jaa�.s i Cteeeal lades ///act sAm b 021//
Cee.aeaa. .
workers' o r sdon l AtfWavk
. . wb*a Prbm*W Plans of bosun o sic O 6 a 7
f %
do here"'cerdj• under tjae Pohts and peusldos of pujctra thm
() Ia an employer Providing workers' compamadoe coverage for my aaploreu working ow
Insuranp Cempangr Faft Number
I an a sole proprietor and how so one working fd►use In tray eai;i q.
() 1 am a role proprietor, general comracwr or homeowner (drde one) a helve hired toe
coaacnMIS listed below who baw the fo g IhmA workers' peildees
U� r/`C v )7� h�we2,TS-19 gz 46S
Insuranu Co year/Polio Number
Contractor Insurance Company/Po Number
Contractor Insurance Company/Pocky Number
0 1 am a homeowner performing all the work myself.
• .aeaaaee ew caer of di wwwM WE be forWWNd r OW Olica A Ywwdtaa,aa of dw MA It ce.ware Mikadw aft M I*eo w iwere
,eatery a#reeked~SWdM SSA of WU 152 can 4ae w bee wivaedee of- ' iaa etaede se«uedet of a raw of w 04 I J00 pp a Wer w
tad iaerkmwwa a.u.a dd mmwo in &ha lone as a STOP WORK ORD ER see a bw of S sO0A0 a an Mika ML
signed this . day of ,
�cerseei'Ftrmiatee 6ml6ang Depa ant
�jccnsinf Ecare
Seiectmens Office
=eslth Deparmer,-
eeC.C. . � ` _ 904 e0e 405 77c
PUBLIC PROPERTY DEPARTMENT
120 wAsmjmaTON STRaaT, aRD FLOOR
EALaM.MA 01970
TLL. (979)743-"95 EXT.360
FAX (970) 740.994E
STANLEY J. USOVICZ, JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MCC c 40,S34,I acknowledge that as a condition
ofBoildin Permit 0 .all debris resulting from the construction activity
governed by dais Building Permit SW be disposed of in a properly licemed solid-weate
disposal facility,as defined byMOL a IQ Sl-%&
7be debris will be disposed of at: 'i -P�A LAJ Oc5 S 4-
Loc '=ofFacility O/(�cs T
/'7
rgoatum ofPermit App ' DUN
FULLY complete the following M&M atm
(PLEASE PRIM CLEARLY)
&w) ' C44 c'.
Name OfPennit Applicant
Fw—mm Name,if any
Address,City&state
Tic above statute requim that debris from the demolition, reap• vatum,rehab or other
alteration of building or structure be disposed in a prDpaly-licensed solid-waste disposal
facility ae def ued by MM ca S 150A, and tie building permits or lieeoaes sm to
indicate the location of the facility.