7 TURNER - BUILDING INSPECTION 1
IIANSI WAIDEA1194ND APPROVED f3Y WE
JMBPZC=P WR TD A V W!AMC GRANTED
1\ CITY OF_SALEM No _ V� DO@ 161116 V
Walt
ZK"omm
k ft0P"tooaWdln ioeatioa of
ft► WAft 0W t? YMs No amumns 'I TLt r n er
b INWEIV Looftd In
ft CwMrM a Aar? Ys No
Pennn to:
BUILDING PERWT APPUCAIM POR:
(Chle whiclowr apply) RqoL Retoof, Install Sici ft Ca mIrM DocK Shad. Poo(,
Other:
PLEASE ML OUT LEGBILY A COYPLETLL.Y TO AVOID DBLAYS N PROCEgNG
TO THE INSPECTOR OF BUILDING& '
The urtdereip W hereby applies for a permit to bund acoorcki-gto the.following
sped"caftne.
Sf.�K�c-j'uNe ,�eve�o/or�enT
Owner's Name Dar L /_ C 7� 4 eo6loJ^e
Address a Phone / r19
Amhk@Ws Nome
Addme A Phorw
Mechanics Name
Address 6 Phorw ( 1
wht is ar pop =at UAW / R
Mf w er busEnp'r c✓v a cif N a dwslY g,for horn WM Wain? .3
WE bum ft oo " . to kw? VAS A bs7 �10
EdMaM eat 34,521g1,00civw *�wAftub • GS .2 h S'
aosr i�sww�at
tse. o1369u7
somIwe of
sloNEo uNOER THE PENALTY
OFF
DESCRIPnM OF WORK TO BE DONE� J 'C lac C s� 7 h L c f a Y/f 'gh / / S � X S I 4 G 4 / h
MML PERMIT TO•,, 9 L. go,w `r S jv/ih A /1, ig i 1 Z
f . , .
i
0
boo UyyL�.16 Sbod
1 cna.eaa Bod, /�p.wdLaa.ib 02111
Workers' Compensadm lwmnee AffWwk
•laT.i7i'°/LnW �s2�'rj �'SY� �fh L�U r-� �.Q.vcP ��/n er�T .
. . whh.a prindpti place of bmiwns aces
do hereby'cercry under tJw poles and paeibl a of pw yn don
() 1 an an employer providing workers' eoinpeawtion covera/e for my a h*loyew weilkLg N
Gran i�P 6-4h* 7.1 .' Comb- 1 2 83 2-O
Insurance Company Pei q Number
i an a fob propriewr and haw no ono working fdr me in any apadq.
O 1 am a fek proprietor, general conmraao►or homeowner (drde ono) and hew lofted the
conmracia" lifted below who-haw the foiiowhq workers' connpenaodoe peNelew
Comraaw infuanis GemDarry/P Nunrrbw
Cmmrarsor insurance Company/Policy NnerrYer
Contraaw insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
•t r.aaru.d ow a curl of di wcrnae.e N for►aad w dti Oran i1 Madraww of dw piA rar c~81T."Macadam WA adr tAw w w=re
tmnranr a neared.maw$cede 2$A of MOL 1$I tan kid w Nt irwawiam a/eYrina aemada eanaeitrt al a it e/A wi I.f0000 amalet w
ran•wr.m.eew a.ua a dd�m"wo in do ion.a!r STOP WORK ORDER aw n bw of 100Ao a an ePiw era
Signed chlf,� l�C Up r day of /O/�0 _
.icensevIcrmintit 6mlarnf Geparcn.ent
!ictriSIfl( Ecare
Selectmen Office
-�e.aith Geparmert
- .-.ecC.r ape epc 40e Tic
Puauc PROPRMY D[PMtrmcmT
t20 wASMIKG M lPMK T, *mDFLoo11
SALA34 MA Oi 970
Tsi. (279)740-9995 OLT.3e0
FAX (Y741) 740-96"
- STANL[rhJa YU9pVM�.NG,- - --- -- - - -----
an
DISPOSAL OF DEM AFFIDAVIT
Ia scomdanos wi&the psoviaim of MM c+%SK I aclmav►rladSe dW as a coodWm
of Bm'1di9S Pamit d .all ddxu making firm to cCm*ucd m adiviiy
governed by this Building Permit d M be diapered of is a Pop *licemwd so&i wants
disposal fK ty,as defined by M(8,c D;SISOA.
The debris wM be disposed of sd L
Lod don ofFacMW
S' of
� immitApplfeimt Dab
FULLY complete
,� °°'
T�-elo P/O. }-P P4-t -'I k r� S
Name of Paoovt Applicant
Fhm Name,if any
Addiask City Stab — —
The above statnb requires that debris fiom the demolition,renovation,rehab or other
alteration of building or sdudute be disposed in a properly-liomred solid-waste disposal
facility ss defined by Mt3L cIII, S150A,and the biding permits or licatses ate to
indicate the location of do hmHty.