187 REAR NORTH ST - BUILDING INSPECTION PL*N6i W13EfL494MG APPROVED BY 744E
MAPICM.PWR TO A I WVW BEING GRANTED
CITY OF_SALEM
No.W _a \ Dab
ri �e WW1
Zonkt® D101d
Is PmPwty Locamd in
ft Mistaic Dkirld? Yw No iodation of � >
.� Doildins J 7
Is Property Loomed In
ft Cormsrgifon Am? Yu No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Re Install Siding, Construct Deck, Shed, Popl,
Repair Is Other:
PLEASE FILL OUT LEGIBLY a C PLETELY TO AVOID DELAYS IN PROCESSiMG
TO THE INSPECTOR OF BUILDINGS: '
The undersigned herby applies for a permit to build accordkig.to the following
specfflcations:
Owners Name n
Address & Phone 7 Y 3
Architect's Name
Address & Phone
Mechanics Name
Address & Phone (rya eh c.Lj rs o of 5f-- ('7r
What is ft ptapow of M AdkV?
Mdum of MtlYdW n a dwoft for how many famau?
WIN btrlidrg cortlomn to law? Albedos?
Emit"coot S/ 0 O U CRY Lkarnm• area Lkartmm»
ao■m i pro s t ,
Lie. I
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK E DONE
MAIL PERMIT TO:
b1V- �j 12CL
b s 66 / o f 6 ' S
/ I
NO. J ��
APPLICATION FOR
PEFWr TO
LOC/A71ON
PERMIT/GRANTED
19
7 VFD
INSPECTOR S
l.ommofaurua[[h of fYlfaddCClYa6iaf0 .
' .1JcPaifw@a�a�.�i�W�ial�ssi�ia�' .
boo 1al..�tyb,Sreeet •
Jstaes l Ceaoaal B•ddw. 111..M.LW.YI 021 f/
Conassos.
Workers' Comperindn Insurance AffWWk
. . whil.a prim4w plea of busbsess an
u� 0 CY� J� _ GC�a�C�J
do bereby'cer ily under ON polas and pesasfcfe of pwl.=ys tboe '
() Ia on employs: provibai workers' compeaasloo coverage for my siapMrree workig an
re`Ca�.
Insurance Camparq Fo Number
i am a sole proprietor and haw no one working fir sine to any oprdq.
() 1 am a sole propriemr, general wtnraaor or homeowner (drde one) and have Bred tits
watncton lbsed below who-haw the folk>wing workers' compensation polgdaas
Conaaeor Insurance Compasry/Po Nmnber
Contractor Insurance Company/Po Nsmthr
Contractor insurance Company/Tollcy Numbor
() 1 am a homeowner performing all the work myself.
•I cnawetaew ew a ear of"rtawacw.a aK forn.r@N a ON office S1 i owaftneW of Ow DLA M co"wato cwlitades aM can 10M o man
cowcarr a rvowto eaoa Seam SSA sf MGL 152 can Iced w ow irtcan. t/obdoa @condo eonmedat M a bu el es 041 NO OO Mwor w
+con'i@r@o,nete a%d a tl.a Noxwo in the Ion@ of a STOP W ORK ORRRDDER ar a bw of s 1OCAC a aar Rio me.
Signed this . day of 2�— _, , �-/
-ice rat ' ermiuet / Building Deparimint
Licensing Eosre
Sslectmens Office
=cslth Depammtn!
PUeUC PROPERTY DEPARTMENT
y 120 WASHINGTON ME CT. 3RDFLOOR .
SALEN.NA O i&70
TEL (979)745-M95 Err.360
FAX (87s) 74o-Se"
STANUtY J. US0v1C7, JR.
Mwrae
DISPOSAL OF DEBRIS AFFIDAVIT
In ao`mlmce with the ' OUS of provial MQ,c 40,S34,I acknowledge that as a condition
of Buiding Permit N all delEis r=uh ng from the congonam„drigy
governed by this Building Permit aball be diapoead of in a properly licensed solid-wasts
disposal facMW. as defined by MOL c 11;SIX&
The deb>!is will be disposed of at
Location of Facility`^ Grce r" 07
Signamm of Permit Dab
(PLEASE PRIM CLEAR miom,ahon.
CeIA-
Nam IofPeamitApplicant
/-� ry2. fD 6
Fi1;m Name,if any /
U 1 6 0
Address,City a State �
The above statute r qum that debris ftum the demolition,renovation,rehab or odw
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MM ciM S150A, and the building permits or licenser are to
indicate the location of the facility.