21 PROCTOR ST - BUILDING INSPECTION 1aLWWfAtW13EfILfi5#N9 APPROVED BY Z414E
,WBPFCMM PR"TO A PERWT BEING GRANTh
CITY OF_SALEM `A
N1. ° Dam
ww
zariq DWW
Is pmpwty loatad in T.omtum of
ft A Wftic Dhbia? Yak__No szt]diaa a/ P t o cFo r SF .
bt Ropwly t octlad in
tM Canwwaon Am7 Yak__No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install idY�p, Construct Deck, Shed, Pool,
Repawmeplace. Other
PLEASE FILL OIIT LEGIBLY i COMPLETELY TO AVOID DELAYS N PROCEBOING
TO THE INSPECTOR OF BUILDINGS: '
The urtdersiprted hereby applies for a permit to build accorcLig.to the.followkrp
apedRcatlons:
Owner's Name AstY
Address & Phone P 1 P u ci„I- t (q-791 -7 NS 9 qkS-'
AmhitWs Name
Address a Phone
Mechanics Name con i AO IT/oin
q
Address & Phone S3 1--tdme,S St .,L1w;nuT ( 6t7l 667— 777 /
Who is the pu m at buYd4q?
tr"m or b~ s■ rl , I g,for how many lamaas? S,4 /e m�41
wM bLddrq contour►to inw? Agnew? /
Ealmo ad sat P!� 0 my ucww 0 rift N /3 as l 2
9
Ito Is�tvsswast � C,die. I i 3gs l y is
/ VV Slipulure of ApOlicant
SIONEO UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE/DONE
MAIL PERMIT TO: 6_3__Nv Ineu If eccf o P 17 /
NO.
APPLICATION FOR
PERWr TO
LOCATION
PERMIT GRANTED
APP,RCkoIs
ff) I p'
INSPECTOR OF BUILDINGS
' Camnw�ur/wa�A 0�!/NwesJuw�i .
k v WAAL.#34 ad
i C.eaer Q.Aow M j.A 021)1
GaweaaeR ,' -
Workefs' Cofnlpeeasna lwafsum AffWwk
. . whks prledpl pha s1 bwbW
Ha f sf �' Gy daho/
de?rrey'cen!)r u"w rfie pohir and.pumAda of prlwya % ea '
O I as ae a *aM pravfdhas werke Tfe my ChOlVYees watkba=es
di Nk rs-<� Ins G/ . 3Cg 30(L/
wevaena °a~
J( I aoa a sole pmvrkw and have me am werMa fir ane IN aq eapeaYy.
(� 1 am a>tok preprkuw, sonsral conusaw or hemeewnas (drels een) and hmq lime da
coamcimra IYad bdow who•hwe the (olkwAN warkers' uw4suaden pefkIM
.0 TiGrands campulylp
wvooN nrennta Compaq e
CeabrasaM � nawanea Cenepey o
() 1 am a homeowner porfervning all dw work "MoV.
I.pMrYMp/1°I pal of aY a"M M as ON Qrwrwe r On oft*of tr°Mgsene N MA M C&"rge wAaldm W&M M°■een
ee.wap a rnMN per feteu°PIA N FICL I f!tag 1°M M s YremAee rl vin+�M$OWN""N@ft e/a an el w M{.aoapl aWM er,
"in,rrw■MM■yta dd aMida w da IorM a i STOP WORK OROE R er l he of s IDGA0 a on atiot R
sisned rhb.•. 10,4 der or
&mcj)
.ie°ntt rrmiteao ut ml Deparsn.on►
:icrntin/ Eoa►d
iaiaexmenf Office
Rtalth Deporsmcry
.. . . 'cam- _. ... . - . -
Td WdZP-:SO 5'OOF OT •day 9r,%ONOL6. 'ON Ydd 1N3wiaHd3:I9NIa-ling: WOJd
• PUaUC PROFERTIf t�ARTMOiT
1 TOtiMaIaMiNCrON aRRaaT,iR0 FLOOR
aALaM.au Oi aY10
TaL.(970)740- DOS IMTT.i!O
FAX MG) 740.E
STANLICY J.TL%kW=& JR,.
MA
DISPOSAL OF DEBRIS AFFIDAVIT
m aceordma with the paovis M cf MM a 40.M I aclmowlo*tint as a condition
of Bml ft Permit/ .A debam muldag ii am the cmdmcticm aebv W
itovumd by Obis BUMPS Peamit slid!be disposed of m a prWutr licensed aoH&vtn e
dposd facility,=deffmW by MM c UL SIX&
MW ddWs will be diapered of at
Laced=ofFacalt'y
G �,Q qboloq
SiSoaom of • AppBcmt Dab
(PLEASE PPRRINr CLRAR Y) .
Name of Pe:mit Applicant
LanG�. ✓� GdnSf Cfid <-U
I=Nam%ifmy
53 Hu/ten-es Sr.-e t,
Address,City&Stato
The above statute requires tint debdo 5om the demolition,renovation,reW or other
alteration of bug ft or str wren be disposed m a properly-hcomW solid-agate apoeal
hd tf a defined by MIR ca SISOA,and the be Mag Permits or licema sre to
indicate the location of the hmHly.
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