11 PLEASANT ST - BUILDING INSPECTION Pe
fL�liNl3iMh8T 9E OVED BY T44E
It>!SJ'�ECI�F.t IQR D P AMS GRANTED
CITY OF SALEM
NOCI\a Dab
1�
is Property Loomm
in
Location of
NwHdodcDiddet? Yw_No_ Building f� �vi5u�f Sip
a Property Located In
Nu Cauwrvatlgn Ma? Yet__No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R Reroof, I I Siding, Construct.Deck, Shed, Pool,
R iNR , Other.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROOKSM 1
TO THE INSPECTOR OF BUILDINGS: ~
The undersigned hereby applies for a permit to build according to the following
specifications: /
Owner's Name 6 /)
Address & Phone
Architect's Name
Address & Phone ( 1
Mechanics Name p r
Address & Phone
I
What Is ara papow cf arWrq?
• faatarl.l of talldrq? N a drraNkq,for how marry famNlas?
WE hull "conform to law? Admdos? .� I
n A, ' 1
Eatiaalad coat. (/ Cay Uoarra s �A Skits Llow" M
Loma L'OSYpYIIC yT' i.
Lie. I
" Signature of Applicant
SIGNED UNDER THE PI1111114"` .4
OF PERJURY ; III
DESCRIPTION OF WORK TO BE DONE
114
i
� I
�. ;+. MAIL PERMIT TO; Vol
711
No. 611A
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2C! ;
AOVFD
INSPECTOR OF BUILDINGS
s
//,,�� II
�_ Cammonwt a[ih o1a�athwafl`3
� �tPa,ie>,.� al,9adeislria(�itdio.aLs
boo wa111lon 3lrasl
�atnesJ Cafnood (below, /!/aunckoatW 021 f f
cotfatssstoaar
Worke om�pw ettion Insurance �dapjt
1, G�; N ✓� /w y/ C//
ts= l
. . witilla grin 'pal plea of business
P4,4'al-�..
do hereby'certffy under she paints and penoitim of perjory, thatt
() I am an employer providing workers' compensation coverafe for my employees wo"S an
this job.
��'✓✓ J 97� 7��6 Gj� <
Insurance Company Policy . umber
I am a sole proprietor and have no one working for me in any capaekye
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired tht
contractors listed below who have the following workers' compensation policies:
Contractor lnsuranie Company/Polity Number
Contractor Insurance Compatry/Policy Number
Contractor insurance Cotnpatry/Policy Number
() I am a homeowner performing all the work myself.
I vnorntano tnat a can of the writ t WE be ioM1aroed m the Orkt 0-1 Mreseeawns of the DIA for eo.erate eerirKadvn WA Wert last b woore
co.eeate at rto-+rro unaer Section 2SA of MGL 1 52 can kad to trx inootMion of erjn�al ognufin eoraatint of a twe of w tai I.SMCO area/or ON
roan, inorwnment x 'e as ei.i exnaliio in the !extra of; STOP WORK ORDER and a itx of S 1 .00 a ON aniwt tne.
Sirned this . day of o
Liccnscer'Fcr-nittet Building Deparcn+ rat
ucc-isinf Ecare
Seieamens Office
"c<Ith Dcp;r-:mrn*
t� 4 Commonuft:a.(lh o� 111a.�aC�a�
6 a 1Jepa�feauai e1 Jaduliriaf./att&AMA&
600 ryw�U-11m.31,od
Janmi.cain ad > ae //la.aaelue.flr 01111
corwas ow
Work=ctionInsurance lnsnce Affidavit�
cis
. . wicha principal place of business ax
Z2
do hereby certify under the pains and penolties of perjmya 111M
() 1 am an employer provid'uag workers' compensation coverage for my cinployees working an
this job.
Insar`snce Company Policy Number
I am a sole proprietor and have no one working for me in any capaeky.
() I am a sole proprietor, general contractor or homeowner (drde one) and have hired the
contractors listed below who-have the following workers' com sa
pention poBdes:
Contractor insurance Compatry/Policy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I uneerwnc me a coot of the casement aal be f�aroed m the Once 1 Inworaoont of the D1A for eoeerare .etlata" 000 am faaeae to aewre
co.eeart as teoo►ea ones Section 2SA of MGL 15 2 can lead to the iraoetcten of oaeanat ocneota eorswtint of a Red of w 041.50=WWW end
rear'ir..aenol►nmt>, .01 at om r.G oertL;0 i+ he lo of a STOP W ORK ORDER ano a br of S 1 :00 a an Krbet ase.
Signed this . day of -
iccn5eti'Fcrmittet Building Depamrti cnt
,.jcen:ing Ewrc
Seiectmens Office
^,ulth Dep:rmcn'