26 FRANCIS RD - BUILDING INSPECTION Li
�LIMISAAUiY�EwIr�ND APPROVED OY we
TD A'PM r WING GRAND
\, CITY OF SALEM
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BILMA q PERISR APPNJCATNON POI:
Pamtk t0:
(Chb NhW*w apply) Roof, Reroof. Install SMft Construct Osok. Shad, Pool.
RepakiRspyoa• Oilier:
PLEASE PE.L OUr UMLY A OOWLErELY TO AVOO DELAYS IN PROOESNIti
TO THE INSPECTOR OF BUILDINGS:
The undwsOwd hneby applin for a pwmk to build a000r ft to ft.lollowkig
Ow mes Name 1,00tt�r. .ham
A4kass A Phone 2 Frra ac.^5 r� i?/Yi 7 yo"05 6
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Address A Phone Ip A ( 1
WMenics Name LJ S 1 wl o k 4
Aditu& Plone /Z( Ccn4tJ 47—�4Kderyc (Pei ?773797
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kJamm d tNmilbg4 N a dwa�g roe how m m wmw
wa eia"oonrmm b low
Es WAW=gt lb, , ,/y my lJolrw• sites • C 0 �
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of Applioant
�Iarao�nNs PNINALTY
OF P"Utw
OESCRIPTIO(wN OF WORK TO U DONE
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PUBLIC PR XWM DtPAwmaNT
120 YWSNINarON STRIM,sitD FL.00e
SAWA KA of a7o
TaL.WPM 745-MOO DR.a!o
FAX tt179)740-941sO
- - STANLEY-J.- --- ---- ---- - --
--
MAYOR -
DISPOSAL OF DEB=AFFIDAVIT
In w mdaoce witit the p:ovidoma of MM c 40,SK I aclmowkdip that as a moadm
of Bmlft Ftamit if .A debris ranitmg from the oaos&wtioat activity
pvemed by brit Bm7d'mg Pe®it abaft be disposed of in a propady lioeosad Solid waste
digwd f mldy,at doped by MClt,c Il;S13ft l
The debris wM be disposed of st /6-i K
Lace"ofFoa t,►
Sigoanae of Ptsmit AppHcM Dab
FULLY complete me followiu3 io6ao�tioo:
(PLEASE FRWP( LEARLY)
Name of Feamrt Applicant
Fom Name,dray
Address,city&sub — ----- ----
Theabove statute requires that debris tiom the demolitiM mwvmdM mbab or od w
sltaadw of buU ft or dnwnn be A; in in a propedy-liceased som&waete&wow
fid tf at ddmed by MCM cIM S1SOA,and the building permits or l e="am to
indicate 60 locoon of the f cdky.
� rl.omnlorwralaQlt of /llassac�,w.tte .
600 W.AutimSoped
a>taa l weans lbw Ma.A .111021 If
Co.aae..r
Workers' Cmnpessadon Inman=Affidavit
•la Tom, � '�f � •� �Cf. Ilp Qr
. . wh b.a "Indpai pbee of bmiaeo ac
do hereby'cenify under the pans and peasldw of pvjafyl slam
() 1 an an employer providlag workers' eompamaden covende for eq empl r " m wetkbtf as
thk
insurance c.mpanp P Humber
11�-1 an a "is proprietor and hove*me one working fair me In gar opadq.
() 1 am a solo proprietor, general contractor or homeowner (code one) and Mw lid tke
con sm aors lifted below who-be" she failbv#dn workers' cosnperasan3oa pefd;lem
• Coatrasrer Inwranae Compsrry/P Number
Contractor insurance Company/Poky Nuaier
Contraaer Insurance Connpanny/Polley dumber
() I am a homeowner performing all the work myseff.
• I vrAwm w ow a cool d di a mmae d be k+r►aad ere *a Offce a 6"a4wow of db M AV co.wap w"Callen w caw la&oe n wvs
comes a trainee eeea Seeder 25A w MGL 15 2 can kw wane:raardan of aiaiam aeaada eoewdnt el a aq ell w w4I.f00M most w
reaq':aroelnera a a e Yis w dk keen at a STOP WORK ORDER mw a file of S 100.00 a an ariw aw.
1
Signed this i(� der of /D D(/ . _
.icersetl4crmilcee eutlding Geparsr►.ent
.Jcensinf Eosre
Seiectmens Office
.�nith Deparmer,;
_ _.
1[j�_'1^y(•�y� . {.. Ae GU1
^ 9ro � " }
CONSTR�TIONSUPERVIS9R
050752
� ` Number
• a B{RhdMe 05l1161948: . .
00: 11092.
wires 0$/11d206$,
BERT MA
RO SALI
160 ST'01923�.->, -_ pdfninistratm �.
ee
Board ufYeildiaoeQulatloae,ped 3twda ,
a HOME im IEMENT CONTRACTOR
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