120 NORTH ST - BUILDING INSPECTION fLtrl18�A1l6T�EfIL404ND APPIi0YE0 BY TW
,JdS EC3=PIER W A.PEBW BEING GRAANTkD
CITY OF_SALEM
No. \ oa. �' O
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BUILDM PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Retool, Instal Slc tp, Conat Deck, Shed, Pool,
RepaidReplace. Other: Q ?-#
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AYOID DELAYS IN PROCESSMq
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accor&,g to the following
specifics ns:
Owner's Name 7T4VPwSIl-ta�
Address 6 Phone sl-
Architect's Name 210n•0-.
Address A gone ( )
Medtartics Name ,so w Moazla4
Address & Phan 96 7kgY, 7� >sf z2 -vt -
wha Is sn p,mm it bwow 'k' rr
mdmw of W~ M a dwalkq,for how many Wngm' 3
Wa&Adln cmfty. to law? yes A"Mm4
EMnwNd cos ely CRY Ua • 91Nc Uowm• C'_S O•?WA 3 4
1awa hwrawmmt
rc. f ems,6 ���
gnature.of Applicenr
SIONED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO
• .t
APPLICATION FOR
PERUT TO
3
i
LOCATION
PERMIT G ANTED
APPROVf D
INSPECTOR OF BU S
PUauC PROPERTY D PARTMENT
I ZO WA{NINOTON lTI19" aRD FLOOR
lM.aM.MAOto o
TaL.(970)745-MOO aR.a!O
FAX W78) 740400"
STANLEYJ. UaOVTCZ. JaL
MAYOR
DISPOSAL OF DEBMS AFFIDAVIT
Ia wco*mc with the prOvisioaa ofMM c 40.9"K 1 aclmowlwp that as a con"ca
of BmldinS Peewit/ .all debris resaldnS from the what ucdm mayty
lovemad by this BWMivS P=k abaft be disposed of in a p vperly licensed solid wmb
disposal Sw3tp.=defined by MGL c nL SIX&
The debris wM be disposed of at; k9 C
Locanan of Fsa ty
3ineaeofPaeeeeitArwHead �—
FULLY complete the folbwigS iafo�oD;
(PLEASE PRW CLEARLY)
Name Of
Firm Namq deny - -
CP4 %rL sf
Address.(sty dt State
The above sma mgwu that debris Am the demolition.renovation,r"or other
Wtaadw of bm3 to j or sJ umn be dispaed m a properly-liceared solid-wnte&*Og l
5cruity n de6aed by WEL CUL S150A.and the bWUigg pssmits or licence are to
induate the location of the fatdlityy.
`` � �Gornanoau/ua(i/t Of, !.//a`Wata��d •
' .1Japaaiwa,rfa���dr�i��a�
600 U�l�M sired
�1 canna Sadao. //l m-J—b 021 I l
e.eaata.a. .
Workers' Comlperu dow Imurnum /lffU*w*
• • whb•a prbu*W pbw of b=Wm au
� k
do hertby'certry under%)n paint and peeiUm of perfm duet
0 8 anempbyer➢�+i wo*os' compenndoo covepie for my enplorea workbg go
ddoti
Insurance Company raft Number
I an a sole proprietor and haw ao one working fir me In mW cap cky.
I am a sole proprietor, general can raesor or homeowner (cb one) and how hind do
contractors lined bebw who have tin faillowing workeW compensation pepdan
Con ructet Intursnee Company/Policy Number
Contractor insurance Company/policy Numgr
Contractor Inswanee Company/pocky Number
0 1 am a homeowner performing all the work myself.
• waasfuad ma a"M J 06 r MMM we be fa+sraea a dw Olen A M.edtaaara of dw M far eowwaaa nAka"a"taw hone a man
eo.erRI a reowraa.taw Sedse SfA sf WM 152 ear We NOW Womadsa of erMrna nand•nrwdm N a aw el oe ni 1.NO muter err
+Tarr'isar.owrar a Sys a dd sauiew in the rant et a STOP WORK ORDER sw a fee of s iC IA0 a M Riot as.
Signed this . MO�LG , a'dsrof se�tH.82/G aeeq
.iccrscei'Fcrmiuet eull6,ng Deparsra.ent
licensing Eaarc
Seiecsmens Office
=ctith Geprmcr-
904 ape ape 17c