2 RAYMOND AVE - BUILDING INSPECTION (2) f���rNSt�N9��10 A/MMIOUiD fiY Zaf1E
'�ff��A'lOfffl�f',RM10 aRANf�D
CITY OF SALEM
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SISI. PNNNT APPLMTM !Ot
PamtR to:
(CUob**mwr$A*) Roof. AMod. bum Sift Conrwm Doak, *UK Pool,
Rlp * of 11toa, QdMft,A/ lai �T
PULME M L OUr L@LY a OOMP.R f LY TO AMOO OM AVO M PROOilw
TO THE INSPECTOR OF KNIMMM'
The undrniprMd hereby spore for a permit to bWW a000rd%to dw.loNo''I
ownsea Nerve /-a� vl c) ,�eCG.Y
Ad*m d Phone r�i�d;4 i�co tJ ✓� f rm ; Yy B�6 y
Ard*@Ws Marne
Addreas A Phons j 1
Meohenfca Nanwt ��� c�7�o UI" ����P2.A L ��1'2,a�cTi.U6
Adbws d Phone VpL f2ib ��LEiu (5?eI 7for 1,i/-2,—
wrr w ar p.poaa or ta'
mow d wart w � r a damp.for haw WW laaanI l
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flfM�lifE TfNE Ps"TY'
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OISCRITION OF TO U am
VALPEWI
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600 W.1.16 Simi
Sdw M.aa.eLwa.h 02111
Workers' Compensadn Insaramn Af UWrvk
.. wh*4 principal place of bmtlws ac
do hereby•certffy under s)w pains and peasldoa of perjaap, tbasis
Q 1 am an employer pnwMing worksts' cempemadon covefa/e ter my employees workLg an
dsls W
IM U U)(/< 5
Insuranxe Compaq P Number
I am a sok proprietor and have as one working fir no in any apadw.
() I am a sale proprlesorr general contractor or homeowner (drds osm) and have hired do
cennacwn listed below who•have the following workers' compensasieat poBdasi
• Gentraowr Insurance Compsny/Po Number
Contractor Insurance companyipoky N., N
Conuaeior Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• •••craws ow,t•w d a1i waswa a er ten.aroH a.w Olin i1 k+.edawoo dew M ter eo.•rsq.wlksesn ant e w[oars w a aen
c•nrarr r tmwre*am Sadm SSA d MOL 1 S 2 can kae w err:rows.ei aiwlnw s•sads cMwd"d a iaa of•w4 IJM=feeler eae
rcaq•:ssro•swrsi a yr r d.1 a.•rrie w the kmw•t, STOP WORK ORDER rw s hw d 110CA0 s ew apbo aL (p
Signed chit J- day of
a/a5 epartme
rae � siennf Ecarl
Selectmen Office
ri alth Deprmert
-- - r -- ;;: -i• � . , • - .eeCr' Ye : _ 9ta 405 405 775
PUBUC PROPMM DSPARrMOff
,f 120 TASHINam &MEZT,SWD FLg)on
SALaM,MA OI Y70
Tat.(97s)740-MDS UT.380
FAa (r7@)740-98"
STANLEYMJ�.rUSOYICZv JIR,
OR
DISPOSAL OF DEM AFFIDAVIT
]n accas mm with dw psvvisic=of Mom,c I wbwwwp Wet as a 000"m
of Bmld'n1s Permit/- .all debris IesaltioS flvm thelietion aqy
pvcned by this Bm']dm8' Pe®it sha8 be disposed of in a properly lionised sox waste
deposal hclMy,as defned by Mc$,c n.S1SM
The debris wm be dispwed of me Ak—L .
Location of Fouls y
SiBoallme o armti Appliea�
FULLY complete the followhS info mstim
(PLEASE PFJW CLEARLY)
Name ofPcoo t ANHem t
BIZ c7-f2o t7f, Gn�iJ� QDlV�J ,
Fam Namq,if any
_ -
-Address,city&state --- - -
The above stag mgmm dial debris fmm the dmolitiM rmmation,rehab or other
altembm ofbm'ldmg or muctum be disposed in a properly-hcwsed sog&waate disposal
Laliry 0 defined by MG.d% SIM&aad dhe building permits or lip are to
indicate the location of 60 facility.