4 LIBERTY HILL - BUILDING INSPECTION i
"PLIM111tWOE f L494AD APPROVED BY DIE
A13PE 11 PWR TO A.PEBW BEING GRANTED
�� -� CITY OF SALEM
Oft a �y
; Ward
Is PIOPOtV LocatNd In Location of
ft I kkmic DkUW Yu—No_ Da dlaa
Is PMPWV LocaMd In
ft Commebon Am?
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other
PLEASE FILL OUT LEOMLY A COMPLETELY TO AVOID DELAYS IN PROCE=W
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build aoconAig.to the following
specifications:
Owners Name TUT
�
Address A Phone "` ( I
Architect's Name mil/
Address A Phone ( I
Mechanics Name il
Address A Phone 2n ,ua, I� (R 797
wh.t a sr wvoN•a e,Nmr,�r
mb"of buldno? 1 , M a dwaanp,for how mmV hmlNs?We fxedYq conform to low? ANbW=? NC) —_--
Et)YIIMad cod oc�o.cDo (:py LkNrrr• ettla UCatIN N S Z
re of
THE PENALTY,
OF PERJURY
DESCRWTM OF WORK BE DON
MAIL PERMIT T0: 2'
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o erg' 'compensatift tasanace Affidavit
i, `
. . wid" pry place of bceisws ass
do hereby,cerdllr under t)u palm and peu Was of pw*ys dm
emwloyer pro vidin f workers' compensation coverage for my emplorew %vakLR M
Insurance Cal"Ps Or Pegg Number
I so a ask propriety and haw no one working fir use k any capscley.
() 1 am a sek proprietor, general concrauor or homeowner (drek osss) sad hove lid sM
cormneson lbsd below who-have this following workers' compemsis:foa polchn
' Conersoter Insurance Cosnpasry/Poggr NuaAbsr
Conencsor Insurance Compaaq/Po Number
Conusaor insurance Com;aay/Poft Number
() 1 am a homeowner performing all she work myself.
I rearaur ort a cUr e1 di aaaesar wa ba je.araaa r ow Oltee A Mradtaewe of dw MA kr ce.arara wAkadan air on tiara a rare
cowrsr at 19e1wr awar feair SSA a(MGL 152 can kse row Wwomins si abobw aantds wweda g al s asa el ea asp i IlGO O abler er
run'�aareeneaa a ya r e.i raastio a ow kme e(s STOP WORK ORDER sea s iw a( s 100A0 a our spot ar.
Signed this . �r Of 2 Q
�L •
Jccracci f cnnittee cyylI ' rat Depa cnt
--censinr Eaarc
Seieamens Office
=calth Dep mmerr
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