16 WILLOW AVE - BUILDING INSPECTION (3) gPL*W1WVST9Ef%*91 ND APPROVED BY T44E
.INSPJCIDR PRIOR TD A PERW BBWG GRANTED
11 ,
CITY OF SALEM
No.
` \ Date flUC; 5,zo09
warn
Zoning Distrlot
Is Property Located In Location
of ; I
the Hlatoric District? Yes No
ng
Is Property Located In
the Conaervatbn Area? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, nstall Siding Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accorWig,to the following
specifications:
SRL-LY F CL-J)R '
Owner's Name lni a D W CLARK
Address & Phone 14 WILIGW fiVE 'S6LI=M (978) 74a-2'757-
Architect's Name
Address & Phone
( 1
Mechanics Name c�e1"l1� � 11 f
Address & Phone LAO WC'ST' Dame �'A.. BGyri q r(g7Y 3 101Q,
What Is the purpose of buNlrrg9 rc FS I DI=NT 1 Fl r^
MOWN of WlldbV? W 0 0 b If a dwe",for how many families?
WIN(muck g oordoen to law? YE S Asbestos? Al o
Estimated coat I Oi000 / manse r\ slate u w m N
,05 50"
6N4am.
Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
RFMDW� SyIIJ6LF '51DIJG- ANO DLp CLI PFgojj
INSTILL NEW C.EW)Vt CLAPISOORI) S1bIoJ6-
MAIL PERMIT TO: ice,
No.
APPLICATION FOR
PERHT TO
LOCATION
PERMIT GRANTED
��clla�l 19
APP 6VFD
4
INSPECT OF BUILDINGS
l
PUBLIC PROPERTY DEPARTMENT
x 120 WA5HINQTON STRaaT, !RD FLooR
SAL[M.MA O1 S70
T[L (279)745-9595 E7R.360
FAX (076) 74"046
STANLEY J. UGOVKZ, J1L
MAYOR .
DISPOSAL OF DEBIW AFFIDAVIT
In accordance with the Provisions of MQ,c 4%S34,I aclmowledge that as a ce &den
of Building Permit S .all debris resulting fim the cmgmcbm aotrvity
iovaned by this Building Permit shall be disposed of in a propedr hcenaed cord-wasoe
diRmW SciHty,ar defined by MCX c IQ SIX&
The debris wfH be disposed of at �&fl LErl -I-RA N S Fr-9 STAZI a n/
Location ofFacii
(n) (, "Ili (Qn, 1 9-3o - 2-o-14
Slg NMM Of Pe=d Anheant Date
(PLEASE PRW CI,EARll )
W GDRpn,il CI-A R K
Name ofPamitA"licaat
Firm N if
t�
any
14 WILLOW Of- Sp)lrrl MR 6)97b
Addrw,City dt State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed 20lid-Wasts diRmw
5cility as defined by M(M clM S150A, and the building permits or licemes are to
indicate the location of the facility.
• � �oel��m,.nonuivaltk o� 1.//a`�ae�uaesftd ,
' b JJaParlasas��.�ifrddel�ailia(e• .
boo ,U,yyL.L.��..51...� •
�.la.a l e.enad B d o% /I/au A—& 021 f f
e.e.ee.en►
Workers' Comperwtio♦ Immmum AffUlwk
. . wwi-a principal place of badness am
eu
' k
I� do hereby"cerdfy under the pains and penil" of pw*yg clop
() Ia an employer providing workmve eompemad" covgage for my aaploreim woelclas eo
Insurance Censp W FeBW Numbw
\ I an a sell prepriewr and have me one workbo fdr me In say capsdW.
() 1 am a sole propriever, seneml comraaor or homeowner (drde oaa) and haw bleed she
common hated below who-be" thi followh* workers' couwens+stloe P*Bdoss
Conaracaw Insurance C,omoanylPeft Number
Cormaaer insurance Compaery//o Nsmlbw
v '
Conaaaer Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
•I mama,"aw s can of di wcaule.e be for waroN ■ ow offs 0 bwa#asole of dw M Iw ce.wap.wno4s sw an Gass u seers
col'Rare as Itowta.sae Srcdsa SSA of r'IGL 15 2 can row- - -ios of cdn:nu sasada corwdnr of a ice of se ni 1.7MA abler w
traf•iaersm.eral a ti10 a dd.rebel • lhr d a STOP WORK O�jRDER sus a Gr of s IOOAD a aa►,sic os.
Signed chit . day of
:icerscci'Fcrmiuee Sulldsng Deparxr enc
ucensinf Ecare
Seleesmens; Office
c.slth Deparmerc
- - - - - - _ - - _ -.eeC,r •,r 40e 40e eQe M