14 SCENIC - BUILDING INSPECTION fLWllS1ftW4SEflLtW4A9 APPROVED By T4IE
JMPJ:CSJrIFL POOR TD A PIER W IlWNG GRANTkD
CITY OF_SALEM
No. k WIC Z 9 0
l -�-&
Ward
Zor*q MOM
ft►N" obbW� Yes No Location of
smuding
Is PIWWIV Lneal.d In
ft Con maUon Ana? YM No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof. Install Siding, Constrict Deck, Shed, Pool,
RepaidReplea. Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build aocorcLig.to the following
speomostions:
Owners Name R A R&ZA A UL AL_V i� A A L.-t-
Address A Phone 14 Sft�i!)G a (2291 q 4q — 01 5-H
Architect's Name
Address Q Phone ( 1
Mechanics Name 1QOW— py—R¢.AL&"
Address A Phone I N &-Wiz '.1a2 , VIA . (` 1 1 .ESN —G 0 03
wfrt a an q,�poaa a quwar�r faF �� at�a �� �
I�1 of tarldlg? M a dwaNnp,for how mmy hm@n?
WN alft Coda"to law? MOagoa? --_
EwmMad Coat _qty uom a 9Wa UoNr>•M
Naga rmpr aaaat
IQ �IIIED O ut
SfONED UNDER TI1E PENALTY
V OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0: CLARRAe A K u n a ail: N a L ,Cr A��. SPLCM
No.���
APPLICATION FOR
PERIMT TO
LOCATION
PERMIT&ANTED
19
ROVFD
ECTOR
PFFINJILDINGS
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aM�ado�a[6�0�at a3�opw bt d6poaaa la a
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-
as 2 w.asa SmArve. X..relt.& 0.l 11
e.a.tenee. .
Workers' Comperwdn larj aaa Affidsvk
1, k L- ru i�
-• wkb+ prbudpai pleas of boAmiis au
lts(�JS� G�iR2P2iC 5 I� BKtgll< h2 . �_Ynlnll I� J1 , MA . ong)
do herebr'cerzFy under the psias and pomilsla of pwf.wy* don1 am an '
employer provwIfts workass compensation covsPde for nqr dnploree wmkb@ M
ASSQICjA-QED A&AF- r7s 1105 kANCb aGVXX ItJC-. AWC901 b7 q.3n I
insmanos Camp w P "Umber
I am a sole prepriesor and have no am working fir me in mW capetdq.
0 1 am a sok proprksor, general contract or homeowner (drde one) and hew bleed *4
conmaors listed below who•haw she foliowbq workers' contpenasdon pander
Contractor instrarste Company/po Number
Conasaw Insurance Corrspmry//e Number
Cosuraaor Insurance Company/Polity Number
0 1 am a homeowner performing all she work myself.
•1 vftft%W4 ow can to M wts.tw.e M 10 .srab w aw ORst al wMegsws of ON MA(r cv. aft.wliuew aM M taw r wen
ta.walt al 1~94 taar Rabat?IA a(MQL 152 can kae se ow i+- iat a(- I i etaaaae cer"d t of a saa d an ni l.It70;00 mower am
rtara'ianwmww a yr a dN Jerrie in rht jars a(a STOP WORK ORD ER atr a 1w of I IOOAO a an spbat as.
Sirned this .
day of
:leers eiFe t ii d f Departrw t
Jctnsinf Ecarf
selectmew Office
-ialth Geprrmer,:
epe• 779