11 MARCH ST - BUILDING INSPECTION -MttST-BE ffLfG-ANO APPROVED BY T44E
.=PECTD-R PFROR Tp A PERMIT.B,EWG GRANTED
CITY OF SALEM
cu�NoTT.ri
No. lO "� \ Date
Is Property Located in Location of
the Historic District? Yes—No Buildinn
Is Property Located in
the Conservation Area? Yes_Noz
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) eroof, nstall Sidin Construct Deck, Shed, Pool,
epalr eplace, 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 Nameu2�I ` �✓tJL
Address & Phone
Architect's Name
Address & Phone
Mechanics Name �(/t✓2� �����
Address & Phone 5—J- ' 13ch/ ( )
What is the purpose of building? //2
Material of building? 1n/9 1--Y�W if a dwelling, for how many families? �^
Will building conform to law? y� 9V Asbestos? o
Estimated cost o City License # N/A State License #
`z�j ome Improvement,
C.
I/�Sz'f d
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO��BE DONE
,
���1�ac,2 / Zxc J -S
MAIL PERMIT TO:
No. 1 4
APPLICATION FOR
/1 PERMIT TO
t o-xaji...
LOCATION
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
0011 MARCH STREET 142-2004
GIS#: _. ' 8642 COMMONWEALTH OF MASSACHUSETTS
Map 36 CITY OF SALEM
Block: `
Lot 0176
Permit Building
Category: REPAIR/REPEACE BUILDING PERMIT
Permit#:" ,142-2064
Project# JS-2004-0239
Est. Cost: $20,000.00
Fee:. $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Karl Kluge
Lot Size(sq. ft.): 2709 Owner: TASHA BAHAL AMERICAN TRUST
Zoning: R2 ?Applicant: TASHA BAHAL AMERICAN TRUST
Units Lost. f. AT
Units Lost: : 0011 MARCH STREET
ISSUED ON: 13-Aua 2003 AMMENDED ON. EXPIRES ON.- 12-Feb-2004
TO PERFORM THE FOLLOWING WORK:
142-2004 REPLACEMENT WINDOWS, REPAIR ROOF, MISC REPAIRS DUE TO FIRE DAMAGE. FRD
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Buildin
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Treasury:
Water: Alarm:
Sewer: Sprinklers:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF
ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2004-000253 II-Aug-03 CASH $125.00
GeoTMS®2003 Des Landers Municipal Solutions,Inc.
* Cornmtonwaabk o1 /llaeaachu6db
� �eParlmaatl df,Jaad.�b;a�radditia/tl.1
600 UldJla: 11--Sbaal
Jimea J.Campbell Uoal°^r 1�6C�" 0211 -
Commrsstorw
Workers' Compensation Insurance Affidavit
(aear..rPr.iptt)
wither principal place of business at:
te+ens..r✓s+rl
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.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any opacity
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
z�jg Z�9L
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 vnotrwna that a cony of this tutement wiN be ion+arotd to the ORtce Z In odfavom of the DIA for co+ ate veeAcaden and that baure to tearre
coverarc at (mute under Section 25A of MOL 15 2 can lead to the inVOU60n of criminal oenatties corsutint of a fee of uo 04 1.500.00 and/or one
years' ir.+orttonment v.vu at chi penalties in the loan of; STOP WORK ORDER and a fat of S 100.00 a day sgairot me.
Signed this day of
Licensee/Ferrrlittee building Department
Licensing Board
Seieamens Office
Health Department
TO VERIFY COVERAGE INFOR?�if.ilON CALL: 6i7.777-4900 X40?, 404, 405, 409, 775
co *' OF SALEM,- MASSACHLSETTS
v6 PUBLIC PROPERTY DEPARTMENT
® 120.WASHINGTON STREET, 3RD FLOOR
a �A SALEM,MA 01970
TEL. (978)145-9595 ExT.380
�G FAx (978) 740-9846 .
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SK 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 wN A)c} L
Location of Facility
�'/- �3
a Oki
Signature of Permit Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
.,V6/ /P/�-
Address, City & 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.