5 WOODLANDS RD_ CANCELLATION REQUEST City of Salem •� Massachusetts
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INSPECTIONAL SERVICES
City Hall Annex 98 Washington Street, Zed Floor Salem,MA o197o 978-6i9-5642
PERMIT CANCELLATION/ TRANSFER REQUEST FORM
Permit No.: )_3 _qe U
Property Address: IN Co C-,r\
Original Applicant's Name: c
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I am requesting the following action to the permit listed above:
Cancel Permit(if permit has been Issued the permit fee is non-refundable)
Reason for Cancellation =�cz ,�V/,C- -w C �r C✓1 -Ct<_S �,
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OTransfer Permit to different contractor(Viewpoint Cloud Account Required)
Transfer Permit to(provide name):
Contractor License No.:
Address on CS License:
Contractor Phone No.:
Contractor Email:
Additional Documents Required to Transfer:
• Copy of Contractors Construction Supervisor License(from&back of license)
• Copy of Contractor's Certificate of Insurance&Workman's Comp(If applicable)
• Completed Debris Affidavit
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Date: -7 �
Homeowner Signature:
Contractor Signature:
Required for Transfer of Permit-New Contractors signature Indicates the contractor accepts the scope of work listed on the permit.
Doc.3/20/23