9 NAPLES RD - BUILDING INSPECTION �p Ir K fm*&#Ao APPROVED BY Rw
JdSPFJM?QB PUM TDA.P.MW BEJNtI< GRANTED
CITY OF_SALEM
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BUILDING PERWT APPLICATION FOR:
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PLEASE FILL OUT LOWLY&COYPLEMLY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF NN DINGS:
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SIti = UNDER THE PENALp Y
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DESCRIPTION OF W=TO BE DONE
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Job Site Addrm Lv a& QC)I& 16
Attack a copy of tie weartaeW compematioa polky declarstim pap(Wwda tin pdq as ndw and amptrdlon data).
FaMm to secam covea*w regained under Section 23A of MOL a 132 can bad b d w bspoddon ofamamd penalties of a
fine up to SI,3oaoD and/or one-yaw®prboameto s well so cdva peaabka is me&=of a STOP WCNK ORDER and a tone
of np to f23o.0D a day aSdW the v1*1sa: : Be advbad that a uW oftbb staoemat maybe Poawwded b tie Office of
laveadsadoaa of the DIA for mmrme eaovaap vaidcWon.
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Phone Ak C 1a- 63At- Lo.2-H Cll ZHI -�1a2- 12�0
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Cley or Towna FamWlJam"0
Inning Authority(circle ose)a
1.Board of HaM 2.Building Department 3.Cltyfrown Clak L Elatrieal Inspector i Fli mbiag Inspector
6.Otber
Contact[emm phone p:
Information and Instructions
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erppbyaa.a POUT a requited �sdvisad mat Atses�l4evk�a� m tM DepwUnM ad btitatt iai
.sd date tM a�vr. The affidavit sboald
be b 1Da D �,r me pait ar hams is l+fi ad ft Dgwort�t of
have any gaedoss togw i ig the law or ifyos aw tegdtetl a abtais a w aikOW
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o f do M da i me affidavit it comp
of tM affidavr tar yao tt�out is tM eveat the O®ee of Lavatipatiom 1ue to contaet you tepndioi the aPpl��
pleas be= a a®is me pie samba whit wig be used ar a wfaace mmber. is addido%as applieant
that moat wbmit>talt k pamW&ettae W& s my�C°yew,and o*sdma one affidavit iodicathtL taaremt
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dr.where a base amass b Ism this"®davit
(i.a.a do f Naase Of Pa a bum lava era)said pesos is NOT ragaitad oomp
The OWN of lavatiptiom would Blot w that ym is advsaw fag your coopaadca ad should yam have any question6
please do dot below a*a us a eaLL
The pcp test's addteae,tekphoae attd fa aumbw.
The Commonwealth of Massachusetts
Nputnea of In&*ial Acaida ft
0121ee of Iavest pdo u
600 Washington street
Bodm MA 02111
Tel. #617-7274900 eat 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
CIT1/ OR SALIC349 MASSACHUSMm!
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