21 MAPLE ST - BUILDING INSPECTION (2) - *MIdUST- E fm- APPROVED BY T44E
.WjPFXTD--R .PIRIOR Ip.A PERMIT BEING GRANTED
CITY OF SALEM
q "INDIT
No. "' J
� - Zo0 y ;F.t. '� `\ Date
\���r✓PAN6�,�� .
Is Property Located in Location of
the Historic District? Yes_No X Building / Sr.
Is Property Located in
the Conservation Area? Yes_No X
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Iie:r': �;)
Construct Deck, Shed, Pool,
Repair/Replace,
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 /0 419,VC
Address & Phone Y6-- 0 2
Architect's Name ��of C��IT /L Ile,
Address & Phone '7v 41 .1 S. fw) 9az- 6/.;z 0
Mechanics Name /L z /<�'/ 4
Address & Phone SG CLZ/ f Si ��2• ( 9��) »Y- 02I
What is the purpose of building? /71m1a
Material of building? cu If a dwelling, for how many families? /
Will building conform to law? Vp 1 Asbestos? Alld
Estimated cost 2 9 D 0. w City License # N A State License #
o Home Improvement
Signature of Appliclint
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:/o� WSJ' S��m - Z.e/4/4� G
j
No. 471 -Zoo4
APPLICATION FOR
PERMIT TO
A
LOCATION
xLple
PERMIT GRANTED
leg 19
APP TaVED
1 ,
INSPECTOR(OF BUILDINGS
i
Ak 0 II
�.orrmanwt.a /r4 ats3achiceef16
nn 600 �yW.LgLon.heal
James J.Cam000 E5oslon, ///ayacLaalla 021 /1
Commtsssoraa
`` Workers' Compensation Insurance Affidavit
(altaleel}elaaieeeef
with.a principal place of business at: yy
j`G 1.�'Ns3n7� S/ �/9Nf en jr 111yy��"4 7
. - ttsev/awa/agf
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Ca'�Biy%7<e S�is.fe IA/S y�C o _
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capactty.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation pohiehes:
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I underswnd wt a coon of tiro sulesnent will be for aroed to the Ofrce of ImesdPtrons of the DIA for coeerate•erileadon and INt Uk"to sea re
coverate v rewired under Section 15A of HGL 1 52 can lead to the inoondon of erhniwl oenanies corJutint of a fine of do toi 1.5co GD anwor one
years'imoruonmrnt v Ks0 as cw "naidej in the form of a STOP WORK ORDER and a fine of S 100.00 a oar aVirot me.
Signed this , _ day of
Licensee/Fermittee Building Department F
Licensing Board
Seleczmens Office
Health Department
TO VERIFY COVERAGE INFORMATI0N CALL: 517-727-4900 X403 , 404, 405, 409, 375
co T 'Y OF SALEM. MASSACHU5ETT5
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
y SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
a FAX (978) 740-9846
STANLEY J. USOVICZ, JR. -
MAYOR
DISPOSAL OF DEBRIS AFFMAVIT
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,S150A
The debris will be disposed of at: GU 4,/� /`Z`
Location of Facility
Signature 4P —t Applicant Date
FULLY complete the following information'
(PLEASE PRINT CLEARLY)
Name of Permit Appli
0C19
Firm Name,if any
Address, Cify&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 cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.