6 NICHOLS ST - BUILDING INSPECTION (4) gPbfM1AWVKfNd94N9 MVROYED BY 1W
JNSPECMCkS POW TD A`.ffAWT BE1NO ORANTkD
CITY OF SALEM
No. `, 1c� u s Daft q7 YO
w�
In
TamatIm ci
Mn Hmft ow"? Yaa No 1, boudim 1? iAdS Vlee7�
la AWNly LoaMd In
: In Canaarraloo Am? Yam No V
I'ennit to. BUILDING PEW A "4"TION FM
Ade whM wr apptyj Roof. Ramof, Inafd SWft Consjm Ds* Shed, Pool,
RWaWReplece. Olfter:
PLEASE RLL OL1r LJEIXIBL.Y i COYPL.EMY TO AVOW DELAYS IN PRDCES M
TO THE INSPECTOR OF BUILDINGS: '
The urldersOned hereby applies for a permit to build aocor&ip,to the,f Nw&"
spedRoadons:
Owners Name ftr uG �Sf//hSY a�`r�
Address A PI niohdtS sF>'.ca4- (47C 1 7"- 600
Amhltect'a Nwne F1• FF. nl&rahfi aa✓( Ld krehi Ire&6
Addroas a Phone 221 w aal,a 0N Srrcar (gV ) 114d_ 41 S35Y
Mechanics Nerve '► kH�t r b'e y p c.
Address A Phone 1 (ear (611 1 gt7- 7za3
What Is as pupoaa it WWW n t v gycSS
MatNlal of ta~ lad — for how awr lamaaa?
wN kdd%awkw n to law? ,)a AM~
Exam W coat 7,cod ClV LWmaa• auto umm@ lr
A2 i ckwkf— e,n G 8K
same rgrw. a t �,e e:
>�� ,
s+ vWe of AppYoant
INfAiD INl1�l1 THE PENALTY'
OF PWL WY
DESCRIPTION OF WORK TO BE DONE
R -Fc.✓ i n t�,'dY Pq rl'�S�ary . c,�ra� l�
fy�rcSS
MAIL PERMIT TO: / (-L lJD
r
C31NVVD IWABd
a NOLLV=
�SdUS� d"i0'�5 ' �'II'y ail
QL 1N!!3d
F &M NOLLVMI& r
PNeu' PROFfRIY DKPARTMIM
120 V"HINeTON MOM, aRD FLOOR
SALtw,MA O1 e70
TaL (978)749-MOO Ur.300
FAX (P7e)7404ND"
MAYOR
DWOSAL OF DEBRIS AFFIDAVIT
b acom moe with the p mvno x* =of Mf$,c 4%SK I aolmowlalp that as a Cana=
of Bml ft Permit N .all debris re ubmg fmm the cn*mct m udw7►
pvuwd by this Bmldmf Permit abaH be disposed of in a popaly ucm"aolid-wmte
diROW faoldy.=ddbW by M(X c DL S15ft
The debris wM be disposed of st ncl f4h S4ct r c L Gr�r'h
LocationofFedi ty
- Cl/aCl/4
Sr�pae of Permit Applieam Dab
(PLEASE PRDIT CLEAR mfosmadao..
Name OfPe®it A',ppH=m
Yew � r)at,h� c� er✓i
Fnm Name,if my
S`X vl +civic -1�Haet SalerN w 'K5 iqj9T0
-m&elN6 aty astab
The above statute requires that debris fi m the d=olitia %renovation,mhab or other
alteration of buLkf g or structure be disposed in a p mpaly-licensed soN&aaste disposal
facility as defiaed by M(X cA S130A,and the WddioS pamitr or l;,—=to
iadieate the locadara of the facility.
� l.,ommoruuu�LUl o f� l�1�/a/�ac�l�d ,
_ � � .1JaPasiare�c��a/re4ia{��
600 UylsAu1631-eI
aanra t c.aaa.i &.(w 021 U
Cown"War
Workers' Compen adosl Inn ante ABidspk
.Ice •
. . wkh a prindpl pbtos of badneas as
6 i1 I Cha lS Sf>e zi Swlc�j. N !c f Ol q*70
do hcreby'cerft under tins palm and pestildes of pal.in don
() I an as employer ptevwbw workers' congewtdoa ca"po for mq etinplevev waking on
di jsM.
ti
Insurance Compaq P Nummber
✓ 1 an a sole propriecer and haw no one werking fdr man is MW opadw.
() 1 am sale proprfeter general contractor or homeowner (drds ocean) and have bitsd ales
cosuracsors s etw who•haw the following workers' compensation PoSchin
4,114At"/ B&n'e- I wen�0. inS beygntll-o--
Contraaer Insurande Company/Po Number
Conuactor Insurance Company/Po Numisr
Contractor insurance Company/Poft Number
() I am a homeowner performing all the work myself.
•�vwosrawa ow,aal of Oi sewweae..a k ter.+arew ■ ow Olin it Iaw+dtaasu.f Or DIA Irt <a.araR.wlirdae ar urn Ieaw�ran
co.watr ao rosewes.ricer Sadao 21A d MC L 152 can taw row ireerwa of obrror same n^+sint N a hw e/n 041,NO aww oee
rurY:rrrennnn a gas a d.t asrriu w Ow b.ra o!a STOP WORK ORDER mace s iae d f t00.00 a an atatroe na.
Signed this • 't'` x#h-z,^ ^^ &Y of ILt _
.icerseeiFcrtttittee omIBInE Gepartn.ent
�censinf Eoart
Seiectmens Office
=ealth Gepommer:
- -• _' ecGr Yew _ e04 e0e 40e 175