20 OSBORNE ST - BUILDING INSPECTION (2) 4Pk*W4AWT13E YrD APPROVED 8Y TW
=PJ=PWR W A PERMIT BEING GRANTkD
CITY OF_SALEM
IN Oft
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Is PropsnY LWOW to Location of
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Is Propmy Located in
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Instal SidlnE, Contract Deck, Shed, Pool,
RepaidReplace. Other. 11
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSMq
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build aocor&q.to the.folktwing
specifications:
Ownses Name
Address APhone a C)AU sr (9-)F )")Yy -3ZoS
Architect's Name
Address & Phons ( )
Mechanics Name —i S,\v g
Address 1M Phone 61 Pvr-�V^3� it
Wirt Is ar p xpm it u l*W RC_s .
MsMrw a tturdrg9 w c,<jd n a dwsanp,for now nrti NOW i
We buftq coift.. to low? Yes Amber=?
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3-a5 Signature of Applicant
SgNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Floa.-
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MAIL PERMIT TO: 610 T— 5:.io, rm o is) o
APPLICATION FOR
PERRY TO
All
LOCATION r'
00 USJol�✓n�i
PERMIT GRANTED
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INSPECTOR OF BUILDINGS
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workers' Compensation Insim ce AffWavic
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wkb+ a pla m of bmilneo as
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do herebr'cersity under the paters and Powiftla of perjamp, dm
0 a ananPlorer ptovMW workers' coatpemadeo covepfs for MW siaploY*u twook i; m
Insurance CempmW PAW Nueabw
I ant a sole proprietor and haw no ons working fdr viva b airy 000 ft.
I am a so'k proprksor, general comrscwr or homeowner (drds one) and hnve bind the
contractors listed below who-haw the following workers' conwemade•polidest
Contractor Insurance Company/►eft Numier
Contractor Insurance Compnry/Po Noutber
Contractor Insurance C mwarry/PoiiFdumber
() I am a homeowner performing all the work myself.
• w1/.rY)wa eNl a dq d of surassw WE be forvrsre r d" Olen A Mne$aw7 of fx M k Corsage..raeuew err an saM r soon
rowrsry a rrwsrM nut Srr�a SfA d MGL I s 2 ran lad v YM a noewies d efmwa Bemis rarwint M a im d w na•s I.fOD.oO elder ON
+raq'imve.nnne a ws a,d.I wuMae w r 1 of a STOP WORK ORDER sM s em el s IOOAo a M spMsa on.
Signed this der of
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:icerseei'Feranittee eualaang Depart ent
�censint Eoar[
Selectmen Office
=mlth Deparmer:
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