23 GROVE ST - BUILDING INSPECTION (2) QPI MMWI E 44LI94 D APPROVED By im
AmVa W MW To A'Vef W SII M GRAWIM
CITY OF SALEM
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BLfE�Mlfi PEfIMAMT APPL=TLON PM
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(Ckola WhWWYar apply) Roof. Ramof, In@W SMft Co Who of Dank, Shad, Pook
Ra Wd%P*A& Othar:
PLEASE mL our L.Lf Ly&COINtEf y TO AVDw DN.AYi w PROO�
TO TM INSPECTOR OF MALDIN(LS: '
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ANN=A Phona 5t3 SV. (M) 7Vf-- 77a G
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DESCRIPTION OR VJW TD W DONE
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Workers' Compensatia Istsur an Alli&*
. . why prindpal place of boslssss+a ae
do hereby'certlfy under tjn pahss and pewiMaa of pM%7S dome
() 1 am an employer providing workws' compensaden cove;ads for sq dapleresa woskbe on
skis jsb.
Insurance Compaq raft Numbm
1 an :sale proprietor and have no one working fair me In aq almdb-
() I am a sole propsfemr, general comseesor or homeowner (drdt ons) an/ have hhrd shs
cannaetoss lined below who-ha" thi following works"' «impeosasloe pe0deas
Cemraeter Insurance Compa /Po q Number
Contractor Insurance Company/Folicy N
Concraeter insurance CompanyMoft Number
() I am a homeowner performing all the work myself.
I vaprtaaea ew a ceei e/Oda aneerw urn ar fen.re" a er OHee if brakn ow e(On DIA ter Ce.eraR ewioesa ale urn 6iea a Mve
ce.eraar M sawn.esa SWdM ifs a(MGL 152 can kid w ew wwwde a(ub ow eaadn cueeint el a it el m sa•s 13011AD abler eee
teUa':seresn�ew a or y t1.t eraw a b dw ions of a STOP WORK ORDER am a iw e( t I00A0 a an atdec ML
Signed this day of Id - I2'°-� ,
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:icenseeiFcrmittee eiuJ6tng Gepsrtn.ent
Lictnainf Eaare
Selectmen Office
wealth Depsrtnenf
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