69 WHETLEY DR - BUILDING INSPECTION r�
f4AMIMST-BE f W--G fl APPROVED BY T+IE
MPECTTOA ,PFDR TD.'A.PERMT BFMG GRANTED
CITY OF SALEM
No 27— 'ZOO�( � '� /`�s�. Date J
V S
�7
Is Property Located In Location of
the Historic District? Yes_No� Build
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, qonstruct Deck, Shed, Po
Repair/Replace, Othe Ctm� 1- 2 tl
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name i� S UIs � f l� Na
Address & Phone (CPI�h Sq3 -00
Architect's Name
Address & Phone
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? t/0 DG1 If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost 0 c7 City License # N A State uc #
Ey� t� � sl^d �e Improvement X
1 Signature of p licant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE O r ] /
14
MAIL PERMIT TO:
9
•t
No. 22A15-zoc5 4
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
c0
APP O FD
r"` INSPECTOR OF BUILDINGS
fornnwnwaaanQo/r/ Ma6:5achwetb
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�Jepa,l,n.at1 e f J.dusfriaf�eeia.nis
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lames�.Cataanoel �.t4., /!/.». L.1b 02111
Carmtsstoaaa
orkers' Compensation I rance Affidavit
I, r\
with.a principal place of business at:
trhan f
do hereby certify under the pains and penalties of periury, that;
() I am an employer providing workers' compensation coverage for my employees working on
this 'ob.
Ufa ve oli tuber
Insurance Company
C 1 ae.+ a solo proprietor-and have no one working for me in any capacity-
1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contra ors listed bel who have the following workers' compensation policies:
�f�lelo 2
ntraccor knsurande ComPaTlYIPCISCY.Mumber
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
I am a homeowner p g erformin all the work myself.
()
I underuand out a e ooy of the atat wo be fon.aroed to the Ofrxt 7 hnesdPvom of the DIA for CO.c+are Welrnadon and am Wwg to feoae
Comm at «o•+rea uncle ec 2 A of MOL IS 2 lead to the inPQvdon of cr"Pul oenatnes corsvdnt of a fog of W tb-s 1.500. and/aar au
yean'i uomm t a Mal' in t e 1 f a STOP WORK ORDER and a fax of S 100.00 a dal arinatwe'
Signed this day of
Liccrsce/Fermiute
building Gepartn+ent U
Ucensing board
Seieecmens Office
Health Department
-,TION CALL: c i /- <pq, apc -09, 775