5 HIGGINSON SQ - BUILDING INSPECTION pL*"Sj T.9Ef*AND APPROVED BY TiiE
Jls<SPJc=PWR TDA.PEBWT BEWG GRANTED
CITY OF_SALEM
No.
is Progeny t ocuea to Location of
Me WMorie Diddd? Yes No building Is i i Ns wi S .
k Property Lomb in
Mre CamerwYon Ana? Yes No—
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct CCDock, Shed, Pool,
Ropau/Repiace, Other: Bu l A l o f t i o 2 vf- a
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name (�o b LAvo,
c�Il
Address A Phone d4S PA2t d sz (�n (7?1 )
Architects Name )IA
Address & Phone f
Mechani s Name f/q /?R 'b e 00 / (/C I'06
Address & Phone
Wtmt is the purpose d bu ? or +�cYioR- oT a-
WWW of bukkQ? Bri(,K jlet-,Mg b a dw*09,for taw n my Ie n*"?
WN trukkig corromi to law? G AGWWS?
Emmm gat Aa�Z6a, do Cqy Worms rr N A State L S
Rome Improvement Vol
Lit. , X;�&OP"- 9-12 ov d26z'
3.wirur® o� „o„t
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
T-440 S�,z4nd( -10 4,-r W09 -L" D��-�; C,C SPAC2
MAIL PERMIT TO:
No.
APPLICATION FOR
PERUrr TO
LOCATION.
PERMIT GRANTED
Z9 . 2O D(a
APP OV
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Name —
Addlesd:
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Are you=Casio C1 t.f'.
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empbsyer wida-_w _ R I rm a Deaeai aaehaetor E
ess M asdhar time}• bave hiid Ss ikd schus assat (:]New
emooy eaa�setfoat
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3*and have so ta> kvw These mb•eontraaos have S. ❑Demolida
wodti stsasinaaplaps 'IN braapos. 9. add
(No wodres'army,atatraece 3. W aaPQr�liaj�W id' .
10.[]Erx0ial�oradditias
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tCa.tu�a eea.�aebsei�ms+Yew..ad8uo..r Are dbvis sr..sererrMa+.aa.rA.r�o�'aaap rosol faAortertla�,
I . a/ awsorjf a.DdfowtotAepolf4y ,WMafar
to wane CMW lyNamx ( N C E ((,� .
I
Policy r or sel�iss tinits/ f7 Fl �f Eapm Daw 2
Job sheAddse�e /0 (i ASCJ/) / . QtY/S�dlip: S rRi-
Attach a copy attic worre a mp®aaela FmlWdedarsdon pap tU�y awsubw aN tapInWas date}
Fare to aeesie oovaaie as requked wader SeWon MA of MCL e. 152 eau lad a dw*ouitioa ofab 6d pwalda of s
Bus UPI*$1,50Q00 anwar onayear hWfb=UNA■wd as dvl p=Wa in me dna of s STOP WORK ORDER and a fim
orup to f250.00 a day apmst the violaft Be advised Chat a copy ofthis atstaaeat my be dxww"In the MW or
Investigation orthe DIA for hwwance covaap vai&mbL
/b Aasby uhepr6es wptaaErle iJ rAer tAt bleraredowtOrov!!s/.bow b awt w a►rses
Opkid m awbt Do gat wrft la 4*core,ti k rowptett/by elldaia"OjWd
CHy ar Tom papa e"M p
Iassiag Authority(drde one):
t.Board of Heahh i Bulldlsg Depa imtot I CHY/Pows Clem 4.Eleetrieai Easpedor x Plumbing Impedor
&Other
Coatad PeMs: Phone 1h
Information and Instructions,
for their aavlayea
Lms�152 regoita=t emgloys4lo p1O� ,ate under tav► ofLia4
_ r'`°Qa1 is de6md s _.every I►�is the atptvica�,
at wbcs�•
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des"
aswdatb4 ampoados cr atia s des atd4►,or IO a the
as"aa f 10019
bdividssl• macb"talw of a dtacasad emploYe4
dt w ixgpb egwdia'3otot�2o'�a+wdadas of oaff 1m1 elft e04
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bmftg bows of sOdW who cog"w �acL emploYmostbe aa�ti Lo as emPlaYa
at as the�arbusldiai tie isnasaa�.•
mm ahspto 152,4�o go stets lies' pW~Is tim for Ow
r seememe�� per"P +redmad � r�iaae eiell
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APpresl" =Vwudmcheohi ac bons tin appbr b ym sspoadw 24 if
afAdavit�ple0dy,by of
Please fgoa lb a aeaat(so sl sddraxpl)= pb ac mttmbe ) aPbS��otiee tires t
amoraaod I.imiled C if as UX or LIP does bwo
artibas or PODee,ass not gaedssiviaed toot this s�dil*,Wbe sdm td to dw Dcpsu�o[
empbyee4 a po q a sa4aW& wd Abe M W e to dde tie atlsdavlL The affidavit at Dquumcct��
ar&=Istobemt=0004 ad do
L �to tba eib�d �wW fis bur a i se -b aro co am��r
ln&WW n�gaambet§WAbebv►- g bsnsd'eompaotia
UK=mum—
t]4 or To"Olsdds a space at dw bottom
i�be sure dO des sMavit is wMiew and ptkW legibly. n *e applleas�t
of lba siBdav,tat ym 0 a oasis the even the Ogee of lavestipa i is swb4 as appucan
pkm ,tie sme a t3N is the IMMU acme m> which wit be aced s n re onlya�am aj&bNk indicating carant
that can sobmit na*Is pamW%Mss app&adom is sag gives yea+and 0°� or
mSormanioa(if aecasstY)and,mdar lob sits Address"the sppNcan should Q°���i�°d b
pone .A spy of�e aoavit tort has ties a� WIF S6094 v[�� -.A . vl Abe Mcd out cwk
mm
s gauntthat a vaW ai4do*is os dk far ttilms penaitt &mined, say or no t veamre
yew.xppgclnt n a to owner or eitba is abfamiot s Scum ar lam ti bum
to buss leaves eta)said pass is NOT requited a CMWkW tics at3�ld"
(i.a a dog Some or pants and sboald you have stsy 4n4
1bs OiBos otlavatigations w�I>7co m tbaah you is advance far your coop
pkase do wl hcdm to 06 us a calL
1 be Departmeas's addsas4 telephone and fa mmDet
Mc ComamwaA of Massachnsetls
Deparmlent of IaduMA Aceideots
Ojfic@ o[IavesadOw
600 Washington serest
Bosuns,MA 02111
TeL #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
gcvaed 5-26-05 www.mm.gov/dia
f
CITY OF $ALUNg MAssACHussTTs
Pt/SL1C PROPCRTY O[PARTMtNT
120 W""'MOTIM *MgCt. ]AO AAaa
SALT M. MAsSA"fjSM fS 01070
TKLsh+OMQ 970-749-9696 &M. 240
'Asti 670.74&MM4
rom
In womim" with the plcovisions of M(X C40 S A a condition of your
BwUnd Prtrmit is that the debris resulting hom this wont d "be disposed
of in a properly licensed solid waste°disposal fa�ality as by MC3L
Chapter III.31 50 A.
The debris will be disposed of in:
D�was-�e� (l:ocadonofFaeility) /89 Ce.a�'f� � �-I- SAu�us.
Signature of Applicant
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