13 1-2 MARCH ST - BUILDING INSPECTION � Su
T44E
AM D P. MINA GRANTED
.CITY OF SALEM
No` V Dab 12 ►Z o`I
4_.T
is Pmp"Low"
Localtlam
hr' abDbl f'l� YM No of
ft ConmrA qn An.9 Y.IR_No
suium PERMIT APPLICATION FOR:
Pwmk to:
(Carole whichever apply) Roof. Ramof, Install Siding, Da c, Shad. PopL
RepaldReplaoe. Other.
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROD
TO THE INSPECTOR OF BUILDING&
The ndenipned hereby applies for a pwmk to build acowdinp to the follow q
Owners Name
Address 3 Phone ��Sc� — 7° t o q O O
Arohkeds Name
���
Address & Phone ( )
Medwim Name
Address & Phone
Mdwm a twldrg9 �J�r�� .k.dwratq,for now mmy tanaer4
5
wee oalfam i+.Ouldrq b I�w7 �N
E.finMw cod. 4�0 n 0 air uo edb uoau. O i 13
i
so..
L .S
S)gfiatfire of Appfi&n `
SKiNM UNDER THE
OF PERJURY ERJU Y
DE
SCRIPTION OF WORK TO BE DQNE
i
I; q1
MAIL PERMIT �2\g �.i
dl':. �yl1
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Vl�
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APPLICATION FOR
PEROT TO
'12 -
LOCATION
/ 3 � re�f—
MMIT GRANTED
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APP
INSPECTOR O BUILDINGS
PUBLIC PROPERTY DEPARTMENT
• 120 WASHINGTON STREET, 3RD FLOOR '
SALEM,MA O 1970
TEL (97B)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge that as a condition
of Building Permit# .all debris resulting from the construction activity
governed by this Building Permit sball be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL,c IM S150A.
r
The debris will be disposed of at: _ L-rsc_ Z Aa a oc cl �!4AIn 1 ( 4
Location of Facility
_
Si of Per Appli D e
Y complmit ete the following information:
(PLEASE PRINT CLEARLY)
C.
Name of Permit Applicant
Firm Name, if any
Old AL�P4!27j Aq-. d'gys
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
COmmOriWe:4kk 0/Mal.1a[LCiL'f .
l
�. aarlaaa.aal . 9ad�,wf AbJ9 •
boo w 1mal
��.�
James J.CamM &4 , I/I. " 021 It
comnssaaw
Workers' Compensation Insurance Affidayit
(aereegwee�te) l
. . wit.h.a principal place of business at:
. . ttatra..a✓taq
do hereby'certify under the pairs and penalties of perjury, thac
I am an employer providing workers' compensation coverage for my employees working on
this job.
�.•Ira�(-f �1,�J� _ c 5 315 - 3zlo�rb - dl � .
Insurance Ccknpany
Policy Number
1 am a sole proprietor and have no one working for me in any oPaekye
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation pofieks: .
Contractor lnsuran4c Comparry/Policy Number
Contractor Insurance Comparry/Poficy Number
Z.
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoersund wt a coon of No woman wiN bt iory arced m dte Once el Imcsc AVM of die DIA k` cot zse "Micadon and ex lancers m Mare
co.erate x reviree under Section 2SA of MGL 1 52 can kid to arse invowion of cri final oenvem eorsadnt of a hm of w$04 I.500,00 anol.c owe
rcan• ;.droonmcnc at ad at cni oauicw h the form of a STOP WORK ORDER and a bee of S 100.Oo a 4m ata:de me. `e
L day of �� ZOO 7
Signed this , /
tense cr ,iuccL,71 cuilaing Geparcn ant
accruing bcarr
Seieeimens Office