93 MARGIN ST - BUILDING INSPECTION iPt9tt#S k Mtf Tom£fjL-613 1fN3s ` OVED BY T44E
,WpECTDR ,PRL[)R TD,A.PERNT.B.EING GRANTED
ECITY OF SALEM
No. v �` '� �� Date I a 16/63
r ' ,r Ward
mNscA' ; Zoning District
Is Property Located in Location f
the Hist6ric District? Yes_No BuUdin&13y- Grp, Sfi
Is Property Located in
the Conservation Area? Yes Now
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
epalr ep a , 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 Name SxIfm P011c¢ �} - / Cc�� &I-e �
Address & Phone MC,rr, ,
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone 1 ( )
What Is the purpose of building? �)011 C2 APR c�.4 r ran�`Q
Material of building? VA0.se,^,r i If a dwelling, for how many families?
Will building conform to law? Asbestos? .�
Estimated cost 5 3 O o City License r State License u
I Home Improvement
aJP Lie.
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: /D ��IoV\Ir-t ed .Su40 y Sc,(Arv, YVtQ�. ( 1q7�
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.�o CITY OF SALEM� MASSACHUSETTS -
PUBLIC PROPERTY DEPARTMENT
a 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
W' 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 shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A.
The debris will be disposed of at:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
l�bcQ✓ -A— T-k v blo Lo 4yv C l avS -IY\(z .
Name of Permit Applican
•� A')-v e r b 1 a 61>4.-c,C_}- r Zvi c -
Fi Name, if any
1 O arla 1 4 S, Ij-t y
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.
I
f Ccmmanwt:aa o/ 111aeeat�.¢ti6
r
6 i !Jepar�ntaatl o/.JaL:sfat�eeiasr+L+ ,
�7 600 w�1m_31 ..I
games�.Catnded Y�elnn, asue�iu+.W 02111
Cor:�rvaslorw
Workers' Compensation Insurance Affidavit
- ,�....e,.,....e�
with.a principal place of business at:
do hcreby'ccrtify under the pains and penalties of perjury, that:
YjJ I am an employer providing workers' compensation coverage for my employees working on
V this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any c-apackY.
() I am a sole proprietor", or homeowner (circle one) and have hired the
contractors listed below who have't a following workers' compensation policies:
Contractor Imuran�.e Company/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I vnoent "wt a coot of the aatement w;a be iorv+aroed to the 0a,,t el 1n 6gavons of the D1A lox eoeaeate "Ahcacon and out lanan to Wart
coverare v rewrrd under Section 2SA of MGL 152 can lead to the invosttion of crininar oe"fM conuuint of a fine of w tei I.50000"We(ene
yean' i:.Ywnmml L ., 0 at chi "naidej in the loan of a STOP WORK ORDER1 anc a fne of 5 100.00 a dal ata:ast we'
Signed this ,
day of C) c i- - Ub
ictnseei Fcrnitttt builcing Gepann+ent
uctruing Boar[
Seicarnens Office
�;tztth Geparznent
-- - - - - - -°ec ._ 40< <eS,
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