12 FAIRMOUNT ST - APP B-05-310 gPLAM1 111WIDEf4lM4MD MPROVED BY 744E
JMPJ:Cm1 PWW,IRR TO A`PEA W JlUEWG GRANTkD
CITY OF SALEM
oaf.
Wed
zarno oaaa
ft FhbMc ow�Cx?„ Y.. No 1 se9oas o!12 iV�yGau��
Is APMIY Loomm in
No CorwrNMon MM? YaM No
Pennn ro: POW
BUILOW PO APPLICATION POI:
•
(Clyde whWever apply) Roof. Refoof, 1 18ldin�,� nan,al Oflok. Shed, POOL
RspakfFleplaoe.
PLEASE WLL OUR L OMLY i COM LATELY TO AVOID DELAYS M PROCEfgl4
TO THE INSPECTOR OF BUILDINGS: '
The unc' ipnad hereby applin for a panne to buAd accordinp.ro dw.t ilwaft
speomoafts:
Owner's Name D" r" Z '/' c-c- l
Address A Phone
Amhnods Name �—
Addross A Phone /(/
Mechanics Name S
Addrm Q Phone,3
Whd in Vs pupae of WN*W P'l /
UArMIr a W~ 6614 crz,l N a dwdYip,for law mar W~
ww kd"aodonn to law'► Llle 's mbs"4 /r-/ U
E�smtlad cod/ O CRY Lbanaa• shM oaflaa R /G 3 52
sgrwtwe of
SION�D UNr1DERFIE PENALTY'
of PWAW
DESt tlPflON OF WOW TO W DONE
zo
MAIL PERMIT TO'ti /o� X/ e-
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{I ��-J nY V�L'
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.,` �G,ngi0/l1OiViWBof IJ/iW4Gifo .
�awalCasoesi l�..l.r. /7/.0 A.& 02111
Caeeasase.
Workers' Compensacia locirutce Af Wn*
- perce.�
- • Whi1.a principal place of basmns at:
o
i
. . . 1.
do hereby'ctrdfy undo she pains and peaauildes of per*y, daso
Qy 1 m[ an employer proving Wwkos@ COSTIMIKIIIIIIIIIIIIIII coverage for ng aiholey*0 wmkbg an
dib jaM.
6v `
Insuran" Conapmy Po Namaber
i am a sole proprkow and have no one working fdr rae in mw ooadp.
() 1 am a sole proprietor, general corns eaw or homeowner (ClI one) aosl IMAM tise
contractors lined below who-he" the fcillowis[g workers' conupnrsatiwr 1001119511118
Contractor Insurance Company/Po Nua[iw
Contractor Insurance Company/Felley Natanber
a
Coswscto► Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I reaoaoea ens a cael a/Oi sacrsas we ae (Grand o ON Olin it fars4aana of ON M lar cererate.a[ioiae aM on Oar.M Man
cenrap it rrosn~Swim 25A of MGL 152 can We r ow ira,ewian a(oriiwar..ends cBc++aiso a aaB el A aai I.f00rOs eWw aaa
rca7•jvas eni a.ur as dd m w o in Ole fans ei a STOP WORK ORDER w a Snr of S 100AC a an Bobo Me.
Signs-Id this , day of
:i cc rj c c iF c rm =7 6uilcing Department
JCtr[Slrlt EOare
Selectmen Office
:;eslth Depinmer,:
90e e05 ape• 77r
PUDUC PROPEIe1Y DEPARTMENT
P3it111A%1 HINOTON STHWff,3RD FLOOR
SALEN,KA 01970
TEL.(270)745-=95 EXT.s!O
FAX (srn) 740-96 0
STANLEYJ..YUaov1CZ, J16.
MA
DLSPOSAL OF D>BS AFFIDAVIT
In sceasdlmee with the proviaiM O f UM c 40,W I aelmowle*tit at a COMM=
of Bmlft Permit/ .an debris rea bbs from thD com oudiom acdvily
®ovau d by tbit Buildinf Pesmit dmH be diapered of in a p mpaiy licmaed soH&wub
disposal Sct' *W,as deffmW by)AM a IIL SSISak
The debeia will be disposed of at:
Laudon of Fm-*
S*N me ofP Ap HcW
(RfoinS ASE CLEARH L1) imfimatao.
/L ✓ r
Name ofPu=it AHWcm t
irma Nam"gory
Ad Koss,City A State C/
The above atatuta requires that debris from the demolition, mwvg ion,rehab of other
altaation of bm&%g or smwu a be disposed in a properly-h muw so"Wome&wow
5cilit m defi8W by MM cA SIXA,and the blft pamita or licenses see to
indicate the location of the hmHly.