22-24 HIGH ST - BUILDING INSPECTION �5
10-79
Ck INAM1AWTIREfNANH D APPROVED BY TW
JdEPFCILIB PWR TJa A P981rlf'IAAM ORANTkD
CITY OF SALEM
No. We z�
wf
Ma FYModc Disto !?n yak-.No of
Is Rowly Loomm in
: NN CwwWvadm A#W . Ysq No_
Pemik to: BlNUNG PENT APPUCA710N MR:
(ChW whkdfewr apply) Roof, Rmd, Ina d SkfYfp, Co *VW Oft. Sho, Pool,
RspairlRsplaoe, 011far:
PLEASE P.L OUT LWIMY A COYPUMM Y TO AVOW DELAY8 IN PMXMBWM
TO THE INSPECTOR OF BUILDINGS: '
The undanipnad haraby apples for a park to bukd sownSV to the bkmk
Owners Name Adlov-1j
Address a Phalle -Z Z- Z 4 111 V ( 1-9 402-Z 5 4-
AnchkWo Name
Ad*m a Ph"
Machanlas Name l/IiY,G1�i�r / i✓1
Address A Phan. /b J�l,A S feu t
whO is Nr prpm a b~
AA�W W of buNdnp9 �n r �iS�R/ 1L11 N a ' for how mmy Min?
we arbrq oorr to hm? /UD
EalwaW t J Clv Uosrw• 91Nfa uo r 6s OS 3�8
J N tgpm at
Soomm m ApoWoM
SIONND INrDER THE PENALTY'
oP PwRNNIY
DESCRIPTION OF WORK TO BE DONE '
w, y - , is scd Ere, ,174 mr-3
MAIL PERMIT TO: 4P4� 1,1bArM +1 f a r J'✓Llc�t� � .���ir/�' �t Il .
� 1 .
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S
. i"ai v',$4
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�.psal.c.d.��.lWriet�eek�ial.
M.
boo w.�..St� •
�awlea l c.aite.a Bial a, M...A.A 02111
Cwn.aaolr
Workers' Compensado• Infante AffUin t
. . wh31.8 prfndpal platy d btdaeaa kit:
AD � � Q
do hereby'cerdfy under t)w paint and peeildes of perjavy, cb m '
(� 1 am an employer providing workeaa' cen*eesadoo coveFsde for MY eiaplvyees wwkieR on
toil Itb.
Insurance Compaq Follcy Number
t
1 an a sok proprietor and haw ne am workblg fir me In aq iaWdq.
1 am a sek proprietor, general eomracso►or homeowner (drde one) and hove liked dw
nsraetort listed below who-be" %be feilkawin workers' eempenzathie�s pe9deaf
Contraotor insurance Company/Po .Number
Consracer Insurance Company/Pe Nusier
Contractor Insurance Company/Poky Number
0 1 am a homeowner performing all the work myself.
• I ra.erae.ow a aq of ei XMFM w.a h fens Poor dt
Olks if M. aeae of or alA for ee.erare.wll adw me ran bare a rave
co.wap a nett"~Stook SSA d MOL 1 S 2 an MN @ mr beeeim of aieinv ecaei cecraiet d a aka el w eai 1SM rWer er i
rcan':"W1110 MM a F7fteta OP WORK ORDER ate a hm of S Io0A0 a era ariel a L
Signed this day of
2„�Na
' icenset/Fcrmittee julldmg Department
�censing Eaare
Selectmen Office
:,ealth Deprrmer-
CAL-" : _ - - -_cc�.r e0e 4Qc, e0e T7e
a .
PUSUG PROPERTY DEPARTMENT
• 120 V"HINOTON STNaaT,aaD FLOOR .
SALMN.MA OI D70
TEL. (276)745-MOS W.300
FAX (976) 740-DMO
STANL.EY-J.USOVIM JR.; — ---- — ---
MAYOR
DISPMAL OF DEBRIS AFFIDAVIT
1a wcmdlmm wim me Provisions of MM c 40.SK I aaimawWV mat as a cooMm
of Bml ft Permit S .aS ddm mulling tram me ommuotion wdft
pvanW by d&Bmlft Permit dM be disposed of is a properly Hososed solid wmb
disposal fealty.as defied by M($,c DL S1St1A.
The debris w M be st - o
Locadm of Faei ft
Side of esmit Applic" Dab
FULLY compim me foUowmS mhmmbm
(PLEASE PRW CLEARLY)
Name ofPasmit AppBcad l
>�ibm Nsm%if any
Addraw.Oq &Sua
The above stabile requires mat debris SOm me demolidM rmovsdon,rehab or odw
alteration of buff ft or str mum be disposed in a propaly_Beam d aom"aste disposal
fid ty n defined by M(M dk S 150A,and the buUft pamb or He mm are to
indicate the location of 60 hairy.