471 HIGHLAND AVE - BUILDING INSPECTION (3) r ,
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fKAB4010 APPROVED 8Y TiIE
MPECCMM PWR It A.PREW BEING GRANTED
CITY OF SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repair , Other
PLEASE FILL OUT LEMLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a pwmk to build accor&lg.to the following
specifications:
Owners Name Uiu{#14e0Ner
Addrm 6 Phone 1 G,LaA16 /M �l WQ {&A j�?BI S3/-/S/`>✓
Architect's Name
Address & Phone ( )
Mechanics Name �fte arYe'a6rf,2 ;rgeS
Address 6 Phone A6aHt, 6 QfALdt7✓�fq (9 1 s/-/�ft9
What Is fins PupoM it b~
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THE PENALTY
OF PEIUURY
DESCRIPTION OF WORK TO BE DONE
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MAILPERMITTO:
APPLICATION FOR
PERrT TO
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LOCATION
PERMIT GRANTED
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INSPECTOR OF BUILDING
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Workers' Compensadon insmue Affidavit
. . whil.a Principal Place of bostaso ate
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do hereby'cerdly under tIve pais►s and ponaldes of pssilyi dmia
(� I am an employer providing workays' compensation coveta fe for my aarloyees working eat
ddr jsM.
Insurance Canspnly P NsmsbM
1 an a sob proprietor and haw ne one working fdr me in any npandq.
0 1 am a sole proprletore general contractor or homeowner (drde one) and haw hired daa
contractors listed below who-have the following workers' con4mrssatksn POW=
Contracoor Insurance Company/romw Number
Contractor Insurance Companylpo Nimier
Contractor insurance Company/Polley Nunsbar
() I am a homeowner perforating all the work myself.
I vn.arww.ew...r/of ri aa.sww h fon.reh mew Ooze A I.roAPaow of tam OK kr ca.rrsp.rrlarades mean whirr n..earn
rs.wap at town.we Secir.ISA d MGl 152 can kid M w ireonsa It 06.iM.rw.ia Cermw.t d•hw el..=41,5COM=Wa►or
tram':or.etnew a v,o as cw awww in de kma of a STOP WORK ORDER an..hat of S ICCAC a an slim=L
Sites this . day of
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accn cci'Fc hue 6u►ld►nf Department
:icensinf Ecarc
Selectmen Office
�talth Gepsrmer:
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