35 WINTHROP ST - BUILDING INSPECTION (4) �LlM46�Ab6Y�EfIL4111111401D APPROVED BY 774E
ASPECCIOH PIIIDR TO A PERMIT BEING GRANTED
CITY OF_SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Decit, Shed, Pool,
Repair/Replace. Other. 10 f-m o
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accord-ig.to the folbwing
specifications:
Owner's Name ,/ rt�' ¢ L IC 6 c.e 2
Address a Phone 3 5" w1111 l h R-00 Sj f I
Architect's Name
Addreas d Phone
Mechanics Name
.............
Address & Phone ( I
WIN Is the Psposs of WNW z t''�^^
mm"d buldrq? B 2 !C t: M■dwslYq,ror horn=M Ismaa? 2�
wa busting oaMam to kw? Asbestos?
J U ti y tl V
ErinNted noel my um"a via llmm a �✓� � � /
now Isrtv�t
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
D eIL2 j (N Ted I ern iz y iT�o ns �lw n (�e.v2ina
MAIL PERMIT TO:
NO.�yT��
APPLICATION FOR
PERMT TO
LOCATION
PERMIT G ANTED
APPROVED
INSPECTOR OF BUILDINGS
f
� � .�•P••ia•a�s�.7./rNrie(�se;�a•
boo we.L;.t63L-.j
Workers' Compen adm insor an Affidoyk
. . wh b4 Principal piam of berhtasz an
ue,
do hereby'cert/y under the pahte and pensMv of pu*ys d= '
O Ia amployer Providing wo►kets' compenotloe covsra11e for my WWWYen workiee an
61,'Ulkl re S'�fiT� . lJ� G 2
Insurance campas4 Po Numbenr
I am a sole Proprietor and have no one werkilg fir me Is mW capecky.
() I am a SO'III proPrktors general contractor or homeowner (drde one) and hw4e hired du
corltrastora listed below who•hm she following workers' compensation pouchn
CAROM~ Inwrance Company/Polley Number
Contractor Insurance Compawy/Po Number
Conaseto► Insurance Company/Polky Number
() 1 am a homeowner performing all the work myself.
• ae.vuu"ma a CM e(di mwoa..a be fen.aroed 0 da Ogee 61 ieadNwa of db M 10 cevwaq"Alkaden Me so toao•rave
C"W811 AN news Onto laden SIA of WU 152 can We so ow aaooi.a of virubw eenda cawiet of s 6a of se=41no amber so
+earl':ereeenwet a ws a der sealnia w or tom,e(a STOP WORK ORDER aw a inn of i IocAo s aw qio n.. !,
Signed chit a 1 /� day of
vittrseci Fcrini et Eui din= Depar-cment
�Jcensinr Ecart
Sefecsmens Office
^ealth Npammer:
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'N WM 740~
MAVM
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dyad fraWgr.r dsiod by lilt flll"
70 bb&wO In dbped a[ift
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oft*m ANN ng"dw dabeit fiom the deatolida�,fnmmdm nhi w dw
shaadm oft loft artftftgbe&PWWfaa
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Board of Bu9ding Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Reglstragon`130465
. Type:`Priii teporpmMon
COAST BUILDERS CABINETRY .;�`
RANDAL CHALIFOUR
9 ADAMS ST. �y.
SALEM,MA 01970 Administrator
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BOARD OF '� �FueaRy
Ems: CONSTRUC71ON SUPE
FMSOR
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RANDAL G C
57 GROVE ST
SA4&M., MA 01,07
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