104 TREMONT - BUILDING INSPECTION 4PLAMBIAWSEfILf04ND APPROVED BY THE
JMPJ:J:MFJ PROR TT1 A MWT BEING GRANTkD
CITY OF_SALEM
Non Date ri & l w
WWd
Zonkq DWW
IM Hl m omftt?„ YM No�i Location of
b Prapwty t.ocated to
i rte Cansmalon Ante? Ye No_
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Instal S Construct Deck. Shed. Pool,
Rspair/Replace,
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCEti O
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accortLig.to the follomwirtp
specifications:
Owner's Name
Address Q Phone /o`( TAz-w�, ( 1
Architect's Name
Address d Phone ( 1
Mechanics Name
Address A Phan �� `� �fh G d�esm. ar� ( `IJ v1 7 ys'
what Is ttr Pupa.it birld W
m"m ot bdtaop? .Avv-r� for taw mmy luau?
wa b Adrp carronn to law? Aster �o
Estimated coat kOoo, fi
r�_CRYu erw am uommeo Ga oe6s
20 Impro�t
Lie. A Signature of Applicant
810NED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
APPLICATION FOR
PERItT TO
LOCATION
PERMIT GRANTED
19
`1
APPROV7D
INSPECTOR OF BUILDINGS
PUSUC PROPERTY DEPARTMENT
e 120 WASHINGTON VMM, aRDFLOOR .
SAUMI.MA 01 S70
TEL (270)745-9595 Eff.380
FAX (V79)740.90"
STAN iryJ. L SOVWZ. JR.,
MAYOR
DISPOSAL OF DEM AFFIDAVIT
In Accmdfmce wit tie psoviskms Of UM a 40,SK I aclmawlWp dW a a cao"=
OfBmlft Permit S .all debris resal"g from ms cImOrucdaon wdft
1overned by tiffs B1ail ft Permit Ad be disposed of in a p mpady Hcwmd soH&wasle
disposal f baUdy,as de$Dod by M(13..c EL S130A.
Tie debris w M be disposed of st �urp .Ndeat e r( t�
Location ofFacift
Rra� � rvn l3rA� PRF
a t�
Sipe air Appffead Dam.
FULLY complete dw foliowi s inh maim
(PLEASE PRM CLEARLY)
Name Of Pamrt AppBeaot
Fina Name,if any
Aadraa,(sty at state
The above stsaft mgmra that debris fmm die-demolition.. rawatim rehab or odwr
altandon of bail ft or sbucom be disposed m A properly-licensed solWwsate disposal
hd ty a defined by MCI clM S 130A,and tie hn' ft pamitR or>i am to
indicate tie locodea of tie&may.
A � �t,mnsp/attlaa6Lilt ofn--�a``���� .
• •.1J.paala.d a�-!al/ralei��aria�iab•
• boowaaa�ie'fet,�(asel •
aww.lca...+ Muse)-A 0211
Workers' Compenssdm Insurance ANidayic
le
wisba prim pba of bosinas ass F ti Cf ve apt.», , �Yf G�
%
do hereby'cer* under tlee palm and pens4-1 of p W. ye thm
I an an anpk*w pnwUbW workers' compeoss" covga/e for my tn*h vu workbW on
slik
LwiL4a. �, �P�, , 6 0 �i, �o a 7 706
Insurance Campay Policy Number
I am a sob proprietor and have so one werkbg fir an Is any cspec y.
() 1 am a sok proprieser, general contractor or homeowner (drde one) and hove hired the
comracos listed below who-have chi following workers' esimaPesaaeslee Po9dm
Conaacmr Inwranie Comvwq/Po Nundber
Cofttracser Insurance ComPasry/Po Number
Contractor Insurance Company/Policy-Number
() 1 ant a homeowner performing all the work myself.
• .nsoauw ON a CM/J W6 a MMM.e N Isewmese a doe Ogee if ImodNeew et on OK ter te.eraee wwtaaadae and an tin a wean
aa.ware Y tt&wfe Meer 1'ee6en 11A st WL 152 call kid MOM hassles d obows stand"gwmdalt of a tee et ee w41.no owe/eft
recta'ieereennm a vs add sends it the keel.l a STOP WORK ORDER awn iM of 1 IooAo s act/ass aaa saw.
Signed this , l��I D u day of ,
:icerseei'Fcrmiuee juidlnf Departfieent
:JCensittf Ecare
Seleamens Office
riealth Dcpsrmer±
- - _-.ccC.r Yr : _ e(ta 40e 405 775