22 ENGLISH STREET - EXTERIOR PAINT REMOVAL U �
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• CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
r 120 WASHINGTON STREET,4";FLOOR
TF.L. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR 1r ndin salem.com
LARRY RAMDIN,RS/REHS,CHO,CP-FS
ACTING HEALTH AGENT
APPLICATION FOR PERMIT TO ENGAGE IN EXTERIOR PAINT REMOVAL
FEE: $35.00
Date: Property locate a
Owners Name /I r R I ml��` l � Telephone number: �5luk _t
3 ij2
Address of owner(if different from above): l �/� r7 t 1�'v� On 70
Contractor/name of personr'agent that wyf rformjpaint removal: /p
Wlarzi Chillik-11A' �. _Telephone Number: C
Address of Contractor / r' 5f 5 W)i AIA
Dates and hours when paint removal will occur:
Type of Exterior Removal to be performed-Please describe:
Clean-7c,
ocedure —Please Describe: llm
; >1 G
1 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.
Pursuant to MGL, C62c, S49A,I certify under the penalties of perjury that I,to my best knowledge and belief,have
filed all state tax re d state taxes required under law.
Signature:
SS#or Federal ID
For Board of Health Use.Only
Approved by: _ EN ''�� C,(y
Date permit issued:
Permit#: Check#/Date: Ai
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Updated 5123/11
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