10 NIGHTINGALE LN - BUILDING INSPECTION (2) ti
fhhNS1AUST9EfKA94ND APPROVED BY TW
JUS,PEECM!PRIOR TD A.PERMIT RMG GRANTED
CITY OF SALEM
No
0�3
Wad
Zoning DIShM
na Mlstolt District? Yes_No Location of j (?
Is Prop"Located in �n
nre Caroemtlon Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remd. Install Siding, Construct Deck, Shed, Pool,
Repal epla ,, 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 accordNig.to the following
specifications:
Owner's Name Sa�
Address & Phone l0 K)ia7 to(A 0 ' AA 07A "M (1R .l
Architect's Name
Address & Phone (� r ( 1
Mechanics Name q-)Uv\- l .fn�o u c 4 17L rr e on --
Address & Phone Jul� l�r, Q ,,,,� (q-7j1 5G c - S tj71
LvorUS r
wtm Ian,.purpose a q? D\J �, e �,
6Adwkd of buNdng? \Atn�r ( OA. MWIA&Aa*MOM,for how nmy famaas?
wa b Afty�confoorrm to law?? Aebegos?
E.. \✓, L(q's 1 CRY ucerw# aqM Ugrw e
CP l bU Li`" G Sighature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OFF WORK TO BE DONE
61 - 0 U 5 -�,,re (), vnrW
MAUL PERMIT TO: ' I f 0 6j fln
+ I
No. -
5 �
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
19
APP OVFDQ
�Z �I
i OR OF BUILDINGS
PUBLIC PROPI Rnr DaPAmmas(T
.f 120 MAaflINgTOa1 l 91 aRO FLOOR
" a;aLaar,w►o)slso
TIM- (970)745-OSM an. ago
r FAX (9`70)7
STANL9V J. USOVIM JQ.
MAYOR
DLSPOM OF DF.=AFFIDAVIT
1'a w0miaoce with the*&idona of MM 0 40 SX I wko wlWp dW d a ceoodWm
ofBnilftg Pendt t_ .OR ddxw malbvg&a to ononodm wd ft
Vvamdbyd&DuDft Pem t eba8 be d4and Of ill a PMPGdy liomand a d sft
heft,a,defined by MM a HX 8130A.
7U ddds wM be dieyaeed of at S 4.S C?e2F&/V6,,!G ,6 i
Locadon OfFadhty
Io ( L of
S*Mtm of Pew* Dab
M ASB PPRRM CLEARLY) o..
Name of PermR AppH*mt
Fiaa Name,ifaaw
Szl,s Cr�����uc�� ST �,��c STEM , /77,4 01,1,17
Addrmr.City R sate
Mw above statue regwm that"a from titre damohdoq mwvaboo.nbob or o6ar
akmad n of boO ft a aknctme be disposed in a Poparly-boa med solid-wdte
8cift as defined by MM cJA S130A. and the baildm" g I nFirs or iiccam m to
• indicate 16e>r)caden of the fatality.
� - l.,.oaaaaonwa�4Wt.af !1/as,4at�cssJ� ;3 _`:
boo Ul..tl.�ae.Se�a.� •
Joan Coma 8—slow. maa..J.A 021 l 1
Co mallow
workers' CoecpeeaslmI, Immswee AlfWwk
ira
. . wldl.s ptbm W vLa of bmbm as
�. . I KE�NGyOOJ1 ST i s 0/66,
do hereby-C?tfq under qw Paw and d pw$iiW, them
O Idils 1�. wevtdl/ns ►voekgs' esaa�owdw eovsre/s tot np►e+plofeer walebls w .
ire /Z/CAN An, ffSSuR,,4wr ,pmwC29�! 992��
nruwaass R .
1 am a Sob aropskwr and'how aw owe works/fir ww b sq opwfts
0 1 am s wk ProVrkew. senerW eem"cow or homwwnw (drek "n) ad,hew lid the
m ow aoes Umd bdow wbo•baw tin fopow*worksW aonlosaoalew PON"
Comnow Inweana Corgi/
Comars-ow lawnnce Comp wlr/
Cooaaaer lawraaes Company Nuseber
0 1 am a homeowner perforpainv all dw woe* mysef.
•I v+aoraw tar a sM d/i nawrw rn be lwwanaa w o.CMke A Mm*aM of os alA a• emwagi Mogw"arr aM MM•man
awvaar a nwirN ww faqir!IA d WA 1 f i as lase r ae a a.d M 041JOINA l artier a
+ean'wr.u.ww a.ye a dd e.aie in he leer of a STOP WORK ORD ER &a a bw of f 10CA0 a or+laws oa
Signed this. 1 �� dsl►'of h¢✓ ad
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:'ucr,�cee - ;ou ; f Depsrsr>,e
uc nsin� Eosrl
Selee=mew Office
:;alth Geprrmer,
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