10-12 MAY ST - BUILDING INSPECTION M
-PL*M IAOST-BE fiL+q--AND APPROVED BY T+IE
LU5PjXTDR .PRWR TO A PERMIT BFJNG GRANTED
CITY OF SALEM
No. d� �� �\ Date
I_
It
NC �_
Is Property Located In Location of
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever appl Roof, eroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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 1)y f A/r2:rz4L
Address & Phone /2�
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone(;4?, i 22
What is the purpose of building?
Material of building? L y6 It a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cost/a G 6 U City License rt N/P' sta cane k
9,�� Home Improvement
(J Lic. ! /0 33 Signature Ap n
SIGNED U o ND THE PENALTY
OF PERJU
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: ��'
I
No
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
Arr L�
INSPECTOR OF BUILDINGS
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Workers' Compenudon Insurance Affidavk
6
. . wk." pr6cfw place d btWaaa an
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de hereby'certlfy under sloe Palos and pesaldn of pet*yo don
Q a aemploysr providtap workws' eompemdeo coverage for mW aaployaq woekil�eo
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In+uraaap Pe Number
I asp a sole proprksw and have no one werklew fir me In any espsdq.
() I am a sole propriecer, general cornrsca or homeowner (drde one) sad he" hired do
conttactets lined below who•have the fc;1lowing workers' compensation poldees
Contractor Insurance CompanylPoft Noadrer
Convsaer Insumnce Companylpoky NGXWO
Contratsor Innsranee Cornpsny/Poft Nusebw
0 1 am a homeowner performing all the work myself.
raevauae ear a CM of di aawealo.n M fer..aned a dw OQse r Wm4amm of dw M fn eo.wap•eekaew aft an b w a love
cownp as Legere awe Segue SSA N MGL 1 S! can We a ow bnaadw d a I i— eeeads cenrdoe al a fir of A lei 1 NO a00&War see
TMan'%aKeae w a ye a ebt aaww in the Iona of a STOP WORK ORDER see a iw of S IDDAD s an spier ae.
Signed this • �j der of G
:iceraeei'Ferrnistee Suil41n( Depa ment
ucensin( Ecarc
Seiectmens Office
=ealth Dtpr.rner!
_ _. :. - - - -.ecC^ 7e � _ qpe epc eQe, 775