53 TREMONT ST - BUILDING INSPECTION �� ��Irrwo ArP�ov+�o aY �
.UOA PIM Tn A'VMW 221101 ORAN*D
CITY OF SALEM
No. l - Ogle
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BUl a�lli PlIMrT APPMATION FOR:
Permit t0:
(Chole whidraYar apply) Roof. Reroof, Instal 8idlrlp, ugnowusp OsoK Shed, Pool.
RWaWPAplaos, 011ler: i� i I G
PLEASE PLL OUr LiWAB1.Y a COMPIEf>IELY TO AV=DELAYS M PROfN111111111111q
TO THE INSPECTOR OF BUILDING& '
The urdwWgned hereby apples for a psnnl to bold a000rdErrp.to to lolowhg
owner's Name 124P1 N
Ad*m a Pharo < ?"re r�oNt 5t ( 1
A d*oo's Nhrns —�
Address a Phone
LbOdmice None
Addnef a Phone
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1NIDN111fE PENALTY'
OP ponam
OESCR I NXI OP WORK TO W OONE
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Workers' Compemdm lassrsllcs Alfidsvk
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do lleraby'cerdry under qNs paw and pew 4 of part. r, don '
() 1 am an empleyar providing workers' eompeaodos eovapds for NW dnpleyoes werkim in .
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isuwanos CempeW P "Umber
1 an a sole prop lem and have no am working fir main eW opadq.
1 am a sole proprle er, general contraesor or homeowner (drds om) and have brad do
comranon Ibted below who•haw she following workers' eenipsnsasioea pe9den
Centrepur insunnis Compsivy/roft Number
Cosmaeter Inursnes Comp"W/pe N
Coapsaer Insurance Cornpanylpolla Naaaber
() 1 am a homeowner performing all the work myself.
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vwtarna/aSTO/ WORK ORDER moshmef 110040saospia1er.
Signed this , 9 t dsr of
.accrscc� Fcfmil a euflamg Geparsn.ent
censinr EcarE
seieetmem Office
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( + BOARB1"o CATIONS
Cliense: ,CCoNSTRUCTION SUPERVISOR
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JEFFREY L LEGEF��$�, �
I 13A'MANORDi.�l .�+ -administrator
J. GROVELAND, * ,
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