3B HART WAY - BUILDING INSPECTION fL*NSINIS�Efi ABAND*AWWVGD BY TW
A ll'is,7AmPUM MDAP. JkUff AgM GRANTED
CITY OF_SALEM
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YIALDNI PERWT APPNCA M FOR:
Pamul im
ocis w wiwm apply) R ro ko ww% CaWno0�Slwd. Pool,
apsirlilsplaos. +«'�..
PLEASE PILL OW LAWNBLY i CCNPLSTELY TO AVOID OELAYS W PROCESS"
TO THE 4&QECTOR OF 6UIL )M&-
Therrdsrsiprwd hw* appbs br a pom* Io bulld a000rdirp to tlw Ioko"
Owes Narrw Lot 11 M I l a o
Addrew& Phom 3- Z d4 a r
ArdM ods Name N/�I
Address i Phorw
Ysoharww NYlla
Address E Phwo l-B 14a- 4 CO�-� 7?91 S7$- ql& z
wwr wsr PAPM d kWp l�s, e,6,
ki"m d v a dNaft for how stiwy Iamliaa4,�=
vm burore aoatsaa a I 1�j
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EiOMEO UNM THE PENALTY
DESCRI FM OF W=To bE DONE of PauuRY
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Worker'Compenaadon Ineannee AfIIdaft Bader>AContndwMecbfdnw?Ianben
AppNewd bt stfon Prose hiet i Rothe.
Name 11
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Addr : J4 a4 b Cud
chy& ftop Sd� - ? NA- at g 7'16 Pkoae
c7eet trf ti�praprlw coax' 'Iyp.dpaeJ«t O"dredx
1.(] I sm a empbm wilt I am a Bmad con"' mr asd I
employee+(m and/or pul th a}a i,aveliroi Aa ai�aeb�e d ❑New cow"dias
X 10f I ants nob proprietor or parma. Had on td ads"areal l 7. ❑ R®oddbg
grip and bus so®per 7bensubastracimbM & ❑Detudkin
worry a ftmefo xw0apaft wod<W ON* . ,,ism nce. y
(No wodres'0omp,maorsocs 3. ❑We ate i corpOt�ti3a earl its. Q addition
repleed.}-1 ofsoi liiyo "� "• 1�Eleeaial npsos or additions
3.01 am a homeosma doing ap.wonh &K ' 11.(3 phnMeg repars or additiass
myaaK(NO wodxsi'comp o 132.t1( im s+jeliav�im 12 Q
ioaa:anoasegairud jt. empbYKa
msnasoq' ' " y 13 Omer 12cro( 4 ee.. 8"L
•Map&mat Own cb&baa1 unman 9eat4tnowi j. Adr,
tH4sow.aw�a.lush.mavvrht�aQrrwddq�.a�tray. ar+l.mid.�+4.°dMbs.ae�
rCawrcdasMdeasbbaa'wtrrri�/ tl�lortsrtdbrvlysra�arOta►wrpo�rtmbwink" oOWDel
l ear aei?arpby�rAet bpraidag avr#ws•eeayaatarfaa bn'rO1�1�a4�X�* DaM►btMpflS►aa�foj sAla
by...nrlwa
Imeaoce CompmyNamx
tuft•or Self im Li0:tt Expkadon Dace
Job site Addn:ew Chh
Attach a copy of the worterV eon fawk!on po ft dedar les pap Ojowing tre palc7 auo*w gad cq* dos date}
raBme b secure oovera a>r reglmed ender Seettoo 2SA of M(Z o. 152 ca lead b me maposidw ofQio®ai pmaw"of a
Bose up b f 1,J0000 and/or 0ne ycw iWrbmowK s well a.dva p=Wa in me ibrm of a STOP WORK ORDER and a Hoe
of op b$250.00 a dry+pint ma vblmc Be adviaa l mat a copy ofmi staoemM may be Axwutded b me Ot1Yce of
Invadpoons of ma DIA far bsw=co coverage vaiHcobL
f Ap Awrby eaa&aalpA#psA a sodpwam"oJperl"AN toe lvfwnrwkx PrM*d abow to a wr a/ewrem
l7 C>e�
n�
phone A 9 -y S> g- yv e, Z Z Z o G
O,ffeld nu oabt Do so*Y&In Ah any to by eaar k*d by cAp si0 w aolefd
CHy or Town: rermbveraae p
Inning Audortty(drde one):
1.Board of Health L Building Departmeal 3.CRY/Ibws Clerk&Otter 1.Eieetrt0al lnnpedor ! Plumbing Impactor
Costal remont phone#
Information and Instructs i av%yca
caQal L ae chapter 152 regoaa A 'Mjp��=od1ff woe aw Cad of kkai
West of inv a wrMce. doer aosPassdaaof othakpl es"at say two a
rM
>s dedsed ss"a;mividsaL pa of a deeovb o@L HO .
�t awDlaya►; anect' sed me0l" 1y��rpeetedv"�_ Ham!d
� modwas of AW lepl aaA a**"�i°y°0e oEd�iF,•
{vef of uastea bum bM mt mae dM 6"apm�MA who resides dcat k�a dwditbome
)wta ots dw"Diot who cmploys PMM to do msmtensoo0.0° be damedabs to employtt•»
Ivicif L sa ��dtaeb slag enb"asse otstr>r mVbymen
mate er load at1-V 1s tube a
ilw slaw that"aM tar asp
�dW 4�p�erntt to operate a b ulom er tt ..aact�Invues enwrap nV
redaeed aeapt>aM evWes►ft n r Sri offs Pot" ON shsY
apt,ua dPo m 1WM ft"NeidW die of aomP}taeoe w&me
cam ism M eon ixdta papa of tY eo .aetAor •
��te otmtf ebapm b obew VCUC fed fm
AWSCONS a�dsvit comphdy by dteboaa d>at apply ti y°'er si aid,if
Ptwe iW die s�addrm(es)ap¢Pb w t duck ixd�s)of
odMar that der
ad
Llosbg Lisbg*Cao�(LI.C)a Limited LiabiLpf W=LtZ oe L1P don bier"
to arty wadoW ay"IPPRUN t of btdMWu W
member+err PaAea,,as not Be adviud that this s�do*maybe sobmilesd to to nepafineet Ibe stgdaviz sbaatd
a°pl0y°Es'a Posey is otimnaaa�'� Mn be Nra 1ba dP 2"dne ,0j ads 4 a of
5or the Pa®it a Nome i,beia� �tot the 1)epaameat
beretmaed M WyMbsve quad°°" thebaraifyouere'N is e
mm�betps0edbebN g�istsred'
00Owe0f1d0t
"Ifu manca
Clq of Town 01scho the DVa�bm P�cd s rvaa m den bdto m
i�be ame do dm afgdsvit it aoe,pleoa and ptmted le�blY• lion.has w contact you reguft die appNcaot
for yoo to fill out m die even do Olga of bvcsdP • in admilm an applican
of die afgdava n�winch wM be used s a re[aace mT&��one Adevit indicating"anent
pwm be sere k�in die pamNHcero° any Sives arm b°nly s write as]oeatbae
m` .(�naaM) ands" mAd.*00 2m dm sty d toa►n mey be Pmvidod to dse m
P° »A otdte soda*tfn W beet OdcWb nit m9d OLM-4 ~.dbe ffied oot eWh
;own ,bp a vau sfgdevb i a�e far��not'"W-at a wb�a commaeial venure
Wpocastasprodyear.Where a bome owner err Cilia"b obtuefot o compias this st8dsvit
(ia a dog Nave of pew 1n bum lavrt eto.)sad Palm i.IQO P tupdred
would blue m chat you is advance fa your cooD�a and shonid you tntve"try gnestiona.
The o@Iea otIavestiiav°De to SOV of s cag.
plea"do Out baitaro
The pepartmat's address.telcpbow and 6t numb"
The Commonwealth of Massachusetts
Dqmwcg of bwusuW Accidents
Oda of Investdgatdou
600 Washington street
Bos<os,MA 021 It
Tel. #617-727-4900 act 406 of 1-977-MASSAFE
Fax#617-727-7749
Rcvitcd 5-26-OS www.mm.gov/dia
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C1TV oR SALsw. MASSACHUS MS
t is%*%Smwm Mil. Sao P.O"
$"a% M..aawsens ot$"
*eti►»ewa 67►74&MN asl. Me
PAW 970-746""
eds Dfaeeaal/ees
Is mcmdaocs with the pmvidaw atMM cQ 3?4 a coodW=ctyaw
Haildtod Pa mk is that dW debris Ill a this wadt AM be dlapoaed
�
pe�oparly llceaaed Slid waaoa'
d&cft s deAaed by MC$,
Otaptet i$3130 A.
Mw debris will be dlapo"d of h6a
m Or s,`41- ca ri ^ �i �n�tiCO FiCil�tyl (ems ( [!�
I ,
3i ofAppd
6 -22 - o6
Date