17-19 LEMON ST - BUILDING INSPECTION (2) fL1M61A1l6i qEfiLf kQQ APPROVED BY T+IE
1ltLSP.ECIQB PWOR TOA.PEMIT 9EING GRANTED
CITY OF_SALEM
No. DWa S ii aG
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
spacNicawns: p M
Owners Name
Address SL Phone C i l'l �S VIA
Architect's Name
Address & Phone ( 1
Mechanics Name C C M �1�U'�
Address & Phone Z� it � r
S Imo-
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SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE ,/
4T
MAIL PERMIT TO: Ot�) G )4 kr �od 6-74U CP1 i°
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No.
APPLICATION FOR
PERWT TO
LOCATION
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PERMIT GRANTED
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OR OF BUILDINGS
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Fadue to Setae covaW s required cedar Sacdon 23A of MCL c. 152 can Ind b the ievoridon ofaiauaind penalties of a
&OuP'OS',50aoo=W*tOzwyewkPbDmnMxwdudvapasMa is de flan of a STOP WORK ORDER and a fin ofop to S250.00 a day IIVhW de v101WL Be advired daf a copy ofdi Stat=W mW be gam,"to tre OiNw of
Iavadgationa of the DIA for barma ooveaape vai&mloa,
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Indal Andority(drde oze):
I.Board of Heaith i Buildlas Department I Cltyfravm CWk t tketried tarpedor I Plumbing Inspector 6.Oder
Coated Tema: Fhoate fh
Information and Instructions
�s an alp ,q, adot� a�
rearrest to wm or iav"acal or wriwem , a Alf lwt eaft or may taro or to rs.
ma"s iadiv+doal,pares *aatttdi"Mpa"0e of s deeeard-DVWM Or'do
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or on tba i�orba>7dmL apparte0� aYa�wltYWd Wa wawa or
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tint the sffidavit is eompiete mad p hmA k&iy. lbe Depacomeot pn�vidod Ncst
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of die affidavit far you samba wtita well be mead as a refcam comber• Is add"as BPPg ad
picas be some to$G is the pamit/li�Ncatiesa is amy SWee yaw,need only subsrd out affidavit kdicatiai
that meat sabadt tmldpk paantlliomse wdle aN btadoaa
�, y imfotttoftioa(if nocasaY)mad tmda lab sine Address"the do city a town @W be ptcvided to do
tower 11 aoFY dtb$s}Ndavit tlte$bs b$ea o�daliat tn�mrped oL of� -OOL new at�d"tuftbe filled oat each
s pooddca a vaNd atffidavit is a 81a far ddsa cc panes not related to aa�y beau"or�t veascte
yWPACMd ew.WbM a bonne OvMw a eithlei is ab�efet!ltaaee is permitNrNpi d p CM*je ddl dUa*
(i.,a do{Nemme a gawk w baM lave$eta)sets petttoa
Yba O iee of tavatioM wouli blo w tbab Yea is advance far you coopaariaa mad should Yea have any 4aemtions.
plan do ON belt"a on ss a cafi.
Ibe DeDzQ�°1'a addtesw. bow and fu tmmba
Zhe C=monweaft of Massachusetts
Department of hWastsial Acadanb
Offiete d Iaves*dts
two washingM Street
gostos,MA 02111
Tel. #617-7274900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia