8 OSBORNE ST - BUILDING INSPECTION (2) e
11:4 1 $WST�W 4RW WWD APPROVED BV TW
IUPE=B PWR TD A.PIe WIT JIWNG GRANTED
CITY OF_SALEM
No. \ �� Dab I )
ward
Zaip asMct
Is Propwty L.ocatad In Loeatioa of
Rn NsWc DktdW Yas No
Is PI*Wty Loceled in
ft Casuvalon Anx7 Yo No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, stall Siding, Construct Deck, Shed, Pool,
Repel . Other
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS MI PROCESSMKi
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accorMig,to the folbwkV
specificaOwner's Name tkxra: 60
Address 3 Phone
An hkecrs Name
Address A Phone
Mechanics Name 7 �n/I
Address A Phone � d U► zi o S-6 l�U( b
w m is on purpm cr gy
momm of tarlr•Ig4 n a ri W g,for Now many%mom?
Wa bus*g Cal"" to hw9 Asboom?
t.alYnLsNd coat �O� ' qq U arra a atw # 00//
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Signature of Applicant
THE TV'
OF PERJURY
DESCRIPTION OF WORK BE DONE
S�r a� l at l 6 00fe
as 611664
L 666 De
MAIL PERMIT TO:
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Workers' Compensadow Inntrance Midavk
1, /�✓� J HGc/(—,E
. . widl.a prbm*W pLoe of business a:: '
do hertby'cersly under the pains and pasiftin of pw*y, don
iv 1a ago employer previding wo►keta' compensation coverage for ahwilrrees wakisR m
Insuran" Company Pe Number
1 am a aelt preprieter and haw ne one working fdr an in a W capadq.
0 1 am a secs proprieter, general contractor or homeowner (drde one) and be" hired tam
contractors listed below who-have the following workers' compensation polices;
Contractor Insurande Company/P Number
Cenusaer Insurance Compswylfe Number
Contnaler Insurance Company/Policy Runtbor
0 1 am a homeowner performing all the work myseN.
• reooaueo Me a COST of AL ANINO a.a be fen+uaN so cake sr M.wit din V"for ce.erare.eaftueee ar a fAWe a soot
COMMIT al norrso sow Swim 1SA of MGL 1 S 7 c k ew irweniea of oiviaw etwad m w ceei 6 ft of a a of A 041 tI0,fA0 aiWw*aTeam'%aereeaeew a dolla OP WORK ORDER awe a frw of S 1 na.
'=a an+ti e
signed this . ` car of ` G — —07 Z ,
:iccnactiFcrmittce 6taiding Depa nrent
�Jctnsing Ecarc
Seicamens Office
ricsith Deparmcr-
_ = ::: . - - .-.ccC.r Ye ` _ See epc eye 775