73 SUMMER ST - BUILDING INSPECTION (4) f1aMN6AA TIM!fILf11k ND APPROYEO BY TW
MPFCM PMOR TD A PEBWT AKINO GRANTED
Noj. \ CITY OF SALEM \�
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ward
Z4WQ Dls W
Is Plummy Loaft In Location of 7
dw 1 molb om"? YM No_ aaildiaa 7 3 S✓�h�er s�.
Is PlopM1Y LoaMd In
@N C mmalon Ma? YM No
Permit to: BUILDING PERMIT APPLICATION POR:
(CkCIe whichever apply) Roof. Remcf, Install Siding, Construct Deck, Shad. Pool,
Repair/Replace�: /`7nrr<r�
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSMq
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build a=9141g.to the following
Owner's Name _ /"(� ��P 'l/4r
Address d Phone S�mMcr 5 �. f7781 Bay/�� Ya
Architect's Name
Address & Phone If
Mechanics Name 21 22 is
Address A Phone S f 3 73- 3a2 3
What is VW p xpm it a,wano?
mdwm of huYdkq? /,r~ "all - for tow awmy famaaa? a
wo md*q la Wr? �e3 Mhaaaa?
Ewmatad oo� zU o City UmIms 1 s1Ma U=W• C5
Ems
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Signature of 400afit
SIGNED UNDER PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
13 Arl 0 9C) r— e
MAIL PERMIT TO: S �. V r��(ti Z ��/� . 01534
i
NO. IN
APPLICATION FOR
PERWt TO
LOCATION
2�7��-�•P � silr�'-
PERMIT GRANTED
1���D�iss
INSPECTOR OF BUILDINGS
�4- �T � COrltrriQrtl[/dallh o� /I/t�achWs�d •
� •.JJepaal.e.at al.lelr�ia[./sseaa�•
60OWMAU16 sip
�saaa 1 Gataaas 86dw //Mares 02111
Carraeaaer •
Workers' Compensation Insurance Affidavit
•ia /�� (2. C'� z
- • wkh-a principal pbae of badmen ac
l �. �r/i�rz..-ter - ��- r✓i'!'�uc•�.�..� �fi/J. ol�3 y
do hereby'cestify under the palms and pem il" of pelf a yo thm '
O 1 am an employer providIng workers' eomipeondon coverage for my tiaploydies worklog an
s/kis
Insurance CompAiW Poky Number
1 am a sole proprietor and have no one working fdr me In airy opadsy.
() 1 am a sok proprietor, general contractor or homeowner (drde one) sad haw liked the
comracaora lined btlaw who-have the folk ring workers' compensation poBeMR
Contractor Insurancs Company/Popsy Nomier
Contractor Insurance Company/Policy Number
Contractor insurance Company/Poky Number
() I am a homeowner performing all the work myseN.
•1 wrAwmane mat a CM of 06 wearer.e be fn wdee 0 w ORce it ip c* ow of dr DU ter ce..rare nAirarw and VA lira r racy
nr.eaer x reawee snow fedora 25A of MGL 152 can k w irt. . * e(abtinat oewade tenaedet e/a ter of w 041•f00:00 atra/er err
tsar,i"Wowt.ttee a sae a dri a e><i`i - the kmn WORK ORDER awe a it of S 100.00 a on araio=L
Signed chit • der of C 3 h` Soh �ae5�
.icenaeei'Fermhtee Euilaiing Deparcrkent
'jcensinf Eeare
Selectmen Office
^eslch Geparmerc
-• - -.__ - 7_ecCC YeC _ cpe eke eke 77E
K ` Pu/uc PRopam D<rARTM[NT
120 WASHINGTON VMS", aRD FLOOR
• SALZM.MA 01 Y70
TaL (278)749-MOD mcr.390
FAX (978)740-98"
STANLIKY JJ. IC
.rLWCVZ. JIR
DISPOSAL OF DE =AFFIDAVIT
In aaoldaooa with the plovisiaDs of MM c COL 3K I aalmawla*that as a 000ditioa �
of Bmlft Permit S .A dahlia resulting from the cmwftcdcn wd ft
pv=zW by this Bm'ld"Permit shaft be disposed of in a p 4mly hcmwd soNdAmft
dispwal fictMy,as ddbW by 11 M c 1D,S1SQA.
The dab&wM be dtgmW otst; � �f-,�,,
Location ofF&cmw
� iS_ � y
ofPaam>t AnBcom Dab
RMLyCCMPbftdWfDUUWMS
( UMBPRW CLEAR Y) m oo..
Name ofPomk Appbmd
Fnm Name.if sue►
Address.Ctty&Sbb
The above statnb requires that debris 8om the damolitico6 mwvatimk rebab or other
Wbmbm of bmlft or stlllcum be dlaposed m a properly-licensed sogd wub disposw
err de6aed Sahty by MQ.clM SISOA,and the buUdioS pe®itl or licrosas am to
iadlcate the locsdm of the&Wity.
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