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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT- g.,. - Tel:(978)741-1800
Fax:(978)740-9705
COMMONWEALTH OF MASSACHUSETTS "r
• s
CITY OF. .SALEM `
S
EXTERIOR PAINT?REMOVAL PERMIT`
Property located at : 80,. Bridge, Street
Owner' s Name: Joe Skomurski
Address of Owner: 7 Willow Avenue; Danvers,» MA
'Contractor �s>,Name. .RaymOnd Stf,.Pierre
e — Address of'Contractor: 56 `Salem Street° Salem MA =r
Date- paint`removal,w ill occur'c 5/15/2001 A6/30/2001
Hour's Paints removal'will occur.:?,8 c 00` am 4 `3Opm � �
i :` 6< `. .YG,S`., Y' • x '��P�`-t_y° - u- "' � 'k _ - • ;*q`�',,;"}r„`
This -license; is granted- conformity*with' the' Statutes and ordinances .
€.relating to,-Exterior Paint Removal: ': hP"r'. •> `';; '� ;;a" -
Pl .
ermit #:; fw•; 10-01 : , c
Application Date: 05/15/2001 ' ?° '
Permit Expires: ' 6/30/2001 , unless suspended or ,revoked.
"NO ELECTRIC SANDING" .
HEALTH AGENT
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT //1 ,(�I Tel:(978)741-1800
V Fax:(978)740-9705
APPLICATION FOR PERMIT TO ENGAGE IN EXTERIOR PAINT REMOVAL
Date: S /SJ�G�/ Property Located at:
Owners Name dA2Q_,-
Address of Owner (if different from above) 7 `ZtJi.�.e r c��n r�'-� 4
Telephone Number cl�Y—?c/ i %Sa /
Contractor/Name of per on/agency that will perform paint removal:
Address of Contractor 4-7S, C,n 0o-,.., . �f - Telephone Number 1'5F-75fs'_—_5_6Dd
Dates and hours when paint removal will occur:t
Type of Exterior Removal to be Performed-Please Describe-
Clean-Up Procedures Please IZ16kribe:
Bre � l/,m�.pi� `�„#/ �,�..�% .ea Y�if"��.✓-GL/rJ,��/U-�'.,i��-rai� �
I have read the Board of Health " Regulation 23 Rules and Regulations". I have had the
opportunity to ask questions regarding those Rules and Regulations. I understand them,
agree to abide by them and understand that failure to do so may result in fines and/or in
revocation of my Exterior Paint Removal Permit.
Persuant to MGL,C62c,S49A, I certify under the penalties of perjury that 1, to my best
knowledge and belief, have filedNall State tax Netums and paid all State taxes required under
law.
Signature\
Social Secruity or Federal ID#
For Board of Health Use Only -
Approved by `
Date Permit Issued 1 I
Permit#