94 WHARF ST - BUILDING INSPECTION (5) fIAIN111~10EfNADwOND Al PROVED BY T44E
RAPF.t`M PIER TO A.PEl+lW ANNG GRANTkD
_ CITY OF_SALEM
Dob
` w.rd
zo" n-
Is Ploway Locom In iaeatt" of \ \
pn wwob oiww Yas No_ awmime v\ 1
to Pi"sty LOW"In
: h GorA wwem Naafi Yo No_
BUU DM�Ki POWAPPIXATKDN FM
Permit to:
(ChW whichawr apply) Roof, ROW Install SW tp, Cornt W Deok, Shed, Pool,
RWRWRepims. OM1er:
PLEASE FM.L OUr LNEI LY i CCYPUETELY TO AVOID DELAYS N PROCEgM011
TO THE INSPECTOR OF BUILDINGS:-
The undersipnsd hereby applies for a pw mk to build a=mditto tha.tNmv V
specifloamns. I
Owner's Name K)LrL sb fb-�t'L `� _ (�
Address d Phone �-
Architeces Name 4SCoth-
Addrsss A Phone
Mechanics Name
Address A Photo ( 1
whtl Is sr pupoaa it euMW fa}�. �wr L.\^
►mow of wmw V):35& y N a dwWq,for how nrny lan~
VAN badanp omtam to low? AdWmdoa7
Earlaalad ,T_Gty uo op ut stets umme• ")
sloFNn tNWIR THE PENALTY,
OF PNLRW
DESCRIPTION OF WORK TO BE DONE
ZC O
MAIL PERMIT To:- \A S MA 019 7(5
N
r � �OrninOruuu4Wt 0 f�iWaGMW+�o ,
f UoPsaiw.af a�.7a/sllrial JredaL.aS.
boo S"
, .a1c..aaa « rw Md ...ddarA 02111
caa.as ar
Workers' Compensadvit Iamraace Aftidwill
. . W104 pr%c%W pb= of basinsm au
t
do hereby'cerdly under the palrur and penihdes of ismf in ra dos
() 1 an an employer providlnR workers' compensation covepfe for nW eiaplareo weekteR as
di ter.
Ic � �—n ; x
Insurance Company P Nansabor
t
i an a sole propriesor and have no one warkiep fdr use in any cspadw.
() 1 am a sole proprietor, general contractor or homeowner (drde one) and have hired do
— conmaora listed below who•bave the followiaql; wor
kers' coropausathan Poncho
Conasew Insurani Company/PoIW7smvbvr
Convacsor insurance Company/Follcy Number
Convaao► insurance Company/Poiiey Ni,
O 1 am a homeowner performing all the work myself.
•I vaoeottaae ow a copy of d&aawwros wa be forwaro.d r dr Olin ii Ys.csdaaro�e d aM D{A k ce+.raed.wlitadsw tar gut faun rve
cvmap ar*mowed.toe Secd.a SSA of MGL 15 2 an Wad so dr aeon i of oitiw.oaura eo'And" cS a ids el es wi I COM"Wor get
rraq':w.em.nt a vas a tIN asMds w L%c Ion.et a STOP WORK ORDER w a fa of 5100.008 aw apiw dr.
Signed this . day of —
.iccnaetiFcrmiuee ousldinf Department
�Jctntinf Ecarc
Selectmen Office
neilth Dtpsrrier,:
_.
;- - - "eeCr �e � _ ece epe epe Tic
PUSUC PROPa.RrY D[PARrMOCr
' 110 WASHINGTON STaaaT, aaD PLOOR
SAL[w,UA 01 S70
Tst.(978)745-MOO tn.390
FAX (9`710) 7404111140
STANLZY J. Losovom JR..
MAYOR
DLSPCISAL OF DEBRIS AFFIDAVIT
In weor&=with fin pwvidm ofMC$,c 4%SK I aclmowledps that as a wodfitron
of Bm'1ding Pamit# .all debris ra ildnS fiom to cmamcd m aarviyr
pvaned by this BmU ft Pasti t abaft be disposed of in a properly licensed solidrwas0s
d qmW facli ft as ddWW by MC$,c UL S130A.
The debris will be disposed of at:
Location ofFam*
Sisomm of Paamit AppHc t
FULLY complete the fDl VIMB khIMINUM
(PLEASE PRINT CLEARLY)
Name ofPamit AmBoo t
Fam Name6 if my
11 Yi'i rL4A0 .r.T (fto r OAX4S
Addles.(Sty&Sfide
Mw above SWISS mpm that debris Rom the demolition,reoovatiost,rehab or other
altazdm of bmldim or atnwv=be hispaed m a p Merly-licum d Soh waste disposal
Sa'lity as defined by M(l cID, SIMA,ad me NdWipg pamitl or Hceave ale to
indteate the locadm of 60 sty.