10 LINDEN ST - BUILDING INSPECTION G[% P q
gPWIN61 WT19E fNA9 A9 APPROVED BY
JMSPEC=,PRIOR TD A PERMIT BEING GRANTkD
CITY OF SALEM J/
No. Dab
r1IN C Wald
�- Zatlng oimd
IIM Hlstoft District? Y
„ es No D'simion of
�� _ram
Is Properly Lcgbd in T
d»Caroarntlon Apra? Yew No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, � Skid 9 atruct Deck, Shed, Pool,
Repair/Replaoe,�t er
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accorcLig.to the.followingi
Specifications:
Owner's Name _A)y' %2f1JOf�
Address & Phone /D G.iy 1Je,-,/
Architect's Name
Address & Phone
Mechanics Name
Address & Phone f
Wha is in Parpm cf tadi*W
Atsbrbl of baaYdrrg4 G✓Do� �/�q�c,� M e dwNNq,Itx how mmy famllw? J
WIN INAMN conform to low? ` Asbestos? /L/
Ewewed cW 61=Cory l ms• sAM LIMM
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M( OU � 6Co 2 arF �3.eo� gnature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE ,C loo ms 64,v A.-p,3
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MAIL PERMIT TO: / 0 4 57 7—
S Le
l
APPLICATION FOR
PERWT TO
LOCATION
M 1-t m lt,,N st
PERMIT GRANTED
APPROVED
1 TOR OF BUILDINGS
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Ban op m St.swoo awar one year m we0 m dv0 p=Wa is As form of s STOP WORK ORDER and a floe
of ap to S2%00 a dry apiost tb violator: Be advied tint a copy of thk rtatemmt my be ibrwatded r tie Office of
hwadpdaae dike DIA der iunaasce aovaap vaidcd[OL
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City or Town: rermwumma 0
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1.Maud of Heakk t SaWal Department J.Cllyfrovra Clerk 1.Ebmical imped L llombiag Inspector
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M=Uauum Gcoaal Laws dapta 132 requite aD=VIOYeo b Pwi*wcdm'=qMuaom xff 1m.' `••'�•••��.
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please doom ae � aMk%,b amtplebly►.by deetiet aeboM that apply to yo.r sibadow dt it
aeoaarry:ssppbr AD-4 )aamdal,A"HoOd d pbese a=W*)ilons wia weir apiAab(s)of
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spas a parsaaa,are not tegaiad b catty w�adome comp andsa h m m tts.=or Lt?doe It"
employee.a polity is regnbed �'d ant tlis atidsyit mfy be mbm ad b ae Departmat of Tedliisaid
Aocideab for coofbmd�pf iafmanoe covaapa Afw ba fine l*dP aM date the atlldavlL Mw affidavit fboald
be m med b ae dW a lOws aft doappNcadoa ibr sa gaeoitar liaaaa i bebrp ttegaeted,ad ae Departtaeat of
lndwwW AWOM Sboald yros bve nay 4m" the bw er 3tyaa are ngpited tp abbia a wortew•
wmpeotedoepolielh>1 +�at ae Deplrtmat at a1 aorabar listied below< SelFieatd oompoeia flosld eaaer tbeie
telFisaaratice Boeafe aaniss a tM apptopfeb lEas
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please be ass ant Abe affidavit it aWleb and pdobd>gb'. The Depanaeat 1 �a fpeoa at ae boeba
of as afAdavl ft you b fM oaf is ae evat ae Offi a oflwestipa*m Iles b contact you tePati�ae app}kaot
place be fare b fit in ae pamiHticease emabw wbid wit be afad e a fcfxmw der. is adds ^m appiicsat
oat mot sabma=UVIa pamitlBeeote applkWm is my eves yar,aced only mbmit one MWA m9caft oarreat
PolicY iofbrmdoa(if necasaty)d adder"Job Sib Addraf"as applicant sboald wrtib"at bathe is_—Jcib cc
ooaa}'A mpy offt dOw t ON boa bes ofJ Wit stmiped of mmk d by ae stir or bwa ma be be poovided to ae
applicant as pmddo s valid affidavit h as flb Ex firma parmib of teaaa. A ww afidavit aatatbe fflfed out eaeb
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Tie Offloa of i vadgo ono would bee b tbml you is advam ikr your mopaadw d d=M you bays my gdooa
plane do not befidse b�at•eaL
The DMaromeat9 addM blepbM dad&Z Wombs:
The C mm=we8a Of Mas chus"
Depallmead otlndoabfial Aaldeab
Olsa Of b veadpftn
600 wathin"Strut
Bookik MA 02111
TeL #617-7274900 eft 406 of 1-MMASSAFE
Fas#617-727-7749
Reviled 5-2" warw.mass.gov/die