9 OCEAN AVE - BUILDING INSPECTION (2) f
qPU% s1l1IlW4ftPIIrrWNO *AWROYED BY IM
TO A!EIl1ff SSM ORAN*D
CITY OF SALEM
MWd
Leans orma
LoostIm
rn lrolorla DloYlot?h Yos No_ a.iLil� of 7 D cew) /fi (e
b Plopnly L000 nd h
b CNAWV eon ANO Y«No
Permit to:
BU LDINI PIRW APPLICATION FOR:
(Carole whiol~apply) Roof. Raroof. IMhN CanNn+ot �1Nd. Pool.
Repowill" Moe. 0111ar: v GGr
PLEAtlE PILL OLIT LROWLY a CDYPLRTELY TO AVOD ON AYD M PIgClirNO
TO THE INSPECTOR OF BALDIN(i8 '
The u dws p od hereby applies for a pomk to bulld a000r ft to tl».foNorMrq
epeoNfoatlorie: -
Ow Ws Name H, 4
Adders a Phon.
Arohkerx's Nmw
AddFon a Pharr
Msdwd= NOW
Ad*m a Pharre c 1
No Y to prpm it hoses lt�e_� J l eX4)fi-L
ew.n.i a ev,a�gv�lhon�l �rR.�tnC e.�q,ror how mgrrp wnw'r /
Mai kd"oorrmm to NW? S Ado~,
EdmNed Wd f ZOQ U aN Lao...r awe r
am rye
. # W
LN1oN1 TILE PENALTY'
OP PNUW
DESCRIpt1011 OF WORK TO u DIM
e P Ce� F-0- Pimcc
MAIL PERMIT To:
-�7so •ego ,nf
e
n' y
�' • �CmmO/iYIYSZL[A Df�iWCClIaWYd .
�ap..l.a.at a��a/rabial./reri�iala•
600 w.a .6 s1...f
Coaansa.er
Workers' Comperwtia lawman AMn*
. . wkb.e principal pba of badness an
CAP
do hereby'centy undo she pains and psas7dea of pwj.wya than
— 1�asempkyvr providing workers' compensation coverafs for mY emPlareo werkbg an
VWG C000(oMVM 0
Insuranp canpimy Po "Umber
1 am a sole propriessr and haw no ona werkiag fdr ma In say ooadq.
() I am a sok proprksor, general consractor or homeowner (circle one) and haw hired the
consractors listed below who-how she following workers' compenslatloa 004111411113
Commerer Inwranee Company/Po .Number
Convaaor Insurance Company/Pe Nmaber
Ca tractor Insurance Company/Polley Nrmnhar
() I am a homeowner performing all the work myself.
i vwaauawe am a wun at ai ruauaan wo as terware.e as ew Onto i14.airawn of a1w DIA for <owwaN.aAsuien aM me basis a nave
ra.wsp at rroawn.saw SRiri 25A ar MGL 152 can kan r ow nwgpdw d wiairr aaadu cerwaiai M a AN Of as ni IJMM abler ear
ynn•wwwo "M a ya a dN&"side in siw Iona e!a ST910 WORK ORD ER ,iw of S 1 OCAC a an wbut aw.
Signed s . +{ day of C� C _ZOO
ar.467 tmet oullatn( Gep n.ent
uctnsinf f oarc
Selectmen Office
�nittl Gepsm"ienr
epe 17r
L_ - - -.ctCC �e � . eQs zpe
PUa1JC PROrurr DEPARTMENT
qr 120 V"SHINOTON Al"NAM,aRD FLOOR
SMAM.MA Ot a70
TSL (278)740-MOO EXT.a!O
FAIL (074)740-944S
STANLa V`J.11aOVICZ,JII:; --
MAYOR
DISPOSAL,OF DE M AFFIDAVIT
Ln scomdaoce wi&the Psovlsions of MM c 44 SK I aclmoa WP dW as a cool don
OfBml ft Permit S .ali debris from the coewactim wdvVy
pvwned by this Bm'id>ap Pe®it sbafl be disposed of in a properly licensed soHd waste
disposal LciHty.as deHoed by MC,c DL.SISCA.
The debris wM be disposed of at
Locarma of Pecr'Hty
pe—;41 �� ) D 0
Si" P AppHoW Dws
FULLY complete the f>'HowigS mhmut m
OU ASE PRINT CLEARLY)
G20� I,l
Name of emit AppBoaot
Fam Nam%if any
A &Gw city dt stwa V —
The above amuse requires that debris from the demohdoo6 rawvsbM rehab or other
alteration of bmlft or shucoue be disposed m a Properly-hemmed sobd-waste disposal
hd ty as defined by MM c1II.S1S0A.and the building permits or lice are to
indicate the locadw of the fscaky.