13 WILLOW AVE - BUILDING INSPECTION 1
fLANBUAb6TOE f RANIHW AAPROVED By im
JNBPJ=fi,PRIOR TO A PERMIT aWNG GRAN*D
CITY OF_SALEM
No. 2 y o
I' Ward4
ZW" DWW e/
Is Pf"tY heated In Lmatum of
ft Wabric Dbdrfot7 Yard No saildioa /3 C✓i//� �✓c
h PIMMY LooaMd in
dN CaroNvabon Aran? Ye No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) .IneWi Siding, Construct Deck, Shed, Pool,
IrIR Other.
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCE=W
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accordwig.to the.followkg
sped8cations: I/
Owner's Name G4
Address Q Phone /3 A� � (97g) 5-q- g ��
Architect's Name
Address A Phone P� (6�7) 3 3-6 -
Mechanics Name
Address 6 Phone
w m Is fra Prapoaa it b~
ma"d buYdlrgY M a dwralYrp.for hm mmy fanfts4
We b may aorrfonrr to hw9 Asb@"?
Eftn"coat 3 '_=C"Clam t a 1 7 f %yoww M 1 e / 3 3 06/-3
Horan Ir�ro�araast
TAC. i
Signature of Applicant
SKMIED UNDER THE PENALTY
OF PERJURY
DESCRWnON OF WORK TO/BE DONE /
/- / -(- +� J� lee-tiCs�• ���ws ��sw'`e ' jam'
MAIL PERMIT TO: - w`" J C o • /a����7` �j eF� s t
CiAOWo V
a3jNvueuvw3d
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MM NmyonddV
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boow.e�ifba.�.ei •
as l saaoar geolow, o.//1
ca�.ta...
Workers' Compentsssial Istttmuce /lf ki*
. . wkbs prfrj*w phiot of, ses
do hereby•certlFy under t)a pain* and peaAd" of pw*y, shop
() Ia an employer PtovUing wo►k=s* coaweawtka covera fe for aq amPlu reo wpkbg Gi
Insurance Cempggr Pe "ember
1 an:sole proprietor and have me one workbg fir me in jay capadiW.
() 1 am a sole proprietor, Reneral concraotor or homeowner (drde oae) sad koae bbed the
conuanon lined below whe•have the folkrwiap workers' ctiatpenandea poNclan
Cemraetnx
i�B��L - �z�J
Insurance Company/*o q Number
Corntraaer Insurance CompmyRo Number
Contractor Insurance Company/Tolley Number
0 1 am a homeowner performing all the work myself.
• VMl/a,lw OW J COST f(Odl ANWEM WE et br+ueed / ON Office A bradrneie of w M Aw Co"Waq.erOoew aM an MM•none
4e+4111 a nrn~fudw SSA of MGL 15 2 can 4M w w woup i.fi o6v&w eeado carwins of a it of fe wi I,fmm aWw am
+efq•�aMeerfrret a ws as d.s mLWo in ik bra a&STOP WORK ORDER aw a sew el s io0A0 s ow+slur m,
Sinned this . �� Gj dap of
:iccrscelIcrmiuee cut Departnrcn
ensint Eoart
Selectmen Office
=nith Depanmen-
a0c e05, 40e, �?c
r
071.
Board of Building Regutatiom and Staedaids
y ROME IMPROVEMENT CONTRACTOR ;-
R0910a�lan tM3
Expiratbn !hl2005
,. Partnership
SUNSHINEWIN � INRE' '
f SENDAI GHEN
145 EAST BERKLEY
BOSTON,MA 02113 Admluiatrutor
gtJq,p1N6.. #2217
<Aia late urtih Thy �
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