18 OCEAN AVE - BUILDING INSPECTION 4mwlw q dw4m APPROVED BY im
V A'.MMW UNG ORAWkD
CITY OF SALEM
No. Wad
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NN NWAft DYb1oCl� Yes No f Laatioa of
is pl"aly Uomd in
CH mm one . YM ft f
BULBM PERIMT APPLICATION FOR:
i'sffnk to:
(Ckois whidwvm apply) W. Ra MsM Sifinp, Ccrar fot Dook, OWL Pool,
Otltsr:
PLNAU PE.L OUr LAMMY•COMPLETELY TO AVOW DELAYS IN PROOEBMIO
TO THE INSPECTOR OF BJILD W&-
The undsrslip hereby sposs fora mmk to buN w=ditlo ft.ln!owirp
O~s Name L z�- 1,114Z- !:2j;a11
Address 8 Phone 2 VJ �l0 / 7
Mohksot's Nww
Address A Phom q ( 1
Msalsnics Name
Address a Phone
wow is is p.pow it b~ yir,f f0 u,�ar
MotrW of Iw-SQ1 S 4 1 H l 6 L i/— � N a dwoi g for how WAM Unon4
wek a"mftmbNw9
&WAM Wd Or t,o 0 f w tJo.n a r O
am apt
U6. 0 / log..?
Of Pim�
�IEIfIm INOEII THE PENALTY'
OF Pw4RW
DEBCRIpT10N OF YMW TO N DONE
rrwc 6 tea` V(— kw LiQ G ep- /e s,.�=_-C1411,A/6 G,,1-
MAIL PERMR TO: l��oG�� O ��iL Gr �!'J S'/ �r/! CSC¢ G ld�1,/'
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l.,oenmonwash of !1 euse &
� •1J.,..i..ea(s��.fa:6fr�erlliab'
boo waeL#SLJ
�aaaealCssosal l3.d e. MeA.& 021I1
conamew
workers' Campectsed= immance AM MIS
•b Lr e N ✓ �a—� u U L C� -
. . wi*�.a prbm"place of bsislams an
ic
do hereby'csr ft undo rin pains and pmstdw d parlW. don
Q Iaan emplaM prvvWb+s workers' compsmakm cowralfe for nW sinplej a working N
bk
lawerana Canpsq P Number
�an a sok proprkw and haw tee am workbag fair an In aq opadW-
() I an a ask propriesor, general coneraexor or homeowner (cirds one) sed hwe Brad do
cencruaon lbsed below who•hsve the fopowieg workers' conpsnasslon poldm
Comusesor Insurance Compaq/► unbo
Comacsw Insurance Compaq/PokyN
Conualesor insurance Company/fo Nennber
() I am a homeowner performing all she work myself.
I veow Yae ow a can d 06 allow.a be Iwwwood a Ow Can A Yweiraw of ON M k eerwase vaakaOes aM Ow U&M a nets
cowsp a twee wa Iscira IIA d 1'IGL t I I rr 4N r e+s irnaeiee d oiawa naaOa eenseOwl d a Ise d n M 1,1Oa0011O1er w
naa':.wa«.ww a ors a . Ilia w O d STOP WORK ORDER see a hn d I IOOAO s q grin ns.
r
Signed ch day of ,
:iceraceiFcrtniucee Bmldun1 Geparsn.enc
:Jccnsin, feare,,
Selectmem Office
�ealtfi Geparmer.:
_—.45CC "eC : 90e e0c spe 77!
r
rvmuc rw0rlWTY DIWANTM@Xr
UEU PW V&SHINUM a MKW 3a0 P6Ao0
eALtM.MA O1 e30
7'a1.4978)749-MOO DxT.3s0
FAR (Y78) 740.04"
sTANLRYMATL%DV CZ. .I.' - -- -- ---
ON
DISPOSAL CW DEBRIS AFFIDAVIT
Ia eooadaoos with the poviaioms of MM c 44 SK I aalmo+rb*&aa as a oaodboa
of Bml ft P®it/ .as deb&s okios am&D ccmomcdon acd ft
pvaanW by&b Bm'ld'mS Famtit sbaS be d wooed of in a pop*&am "ao "aft
disposal Sdit,as defined by UM IM SIX&
1Ls debris wE be diapered of at:
14cadom ofFam-ft
Q G
S oshm OfPiggh Applieaot
MEASB PRDIr CLBARL
Nhm ofFunit AppHoW
/ ,rr �C III L � �_ ii� �u C✓�i' C�G�/
Plain Namsr if asp►
Addlaal.City A State
The above statute mgmm that debris fmm the demolidoe,mwvxdM rehab or odw
altenad m ofbW ft or Ouctum be disposed in a properly-hoom d solid-wMe di�oW)
Lca7ity adoused by Mt3L cIQ SiSOA,and the bw7dmS Permid or hcroses are to
iadieabe the locadom of the fic ft.