463 LORING AVE - BUILDING INSPECTION IP40MOgS OR 49 t I94M APPROVED 6V ;NE
1D A''VRMW UNO ORAWb
CITY OF SALEM
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Psrmk to: BULDM PEW APPLFCATRON FORM
(Chb whiftM apply) Roof. Rsrod, InsW SM ft Construct Ds* Shsd. Pool.
Rspam%phos. ORhsr.
PLEASE m L OIRT nmy&OOYPUEMY TO AVOW DELAYS N PR0NI�
TO THE INSPECTOR OF SIJILDIN08: '
MW undsro*W hemby oppin for a psrmk to bulld a000r&q to ft lokorMrq
spsoftatlorra:
Owners Name L) t It FC
Addrsa a Phone (9�k 19 S1 ,1 n
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Addrom a No AA __
Modwdm Name
Addr«s a Phone a qr a� t kml ;L) 3 �4
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DEacaRvnoa OF WORK TO DE DOW
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TIM. (270)748-MOB OR.Sao
FAX (OM 7404N"_ MAYOR
D1210 L OF DF.BR>S AFFIDAVIT
h aeeasd="wi&dw psovidons of MM c 40.S34.I aclmowledpa dart r a magUoa
aDmum Permit/ .all debriarenWmS itom to coomoodon acdvW
Vyawd by Ilan Bmfl ft Fmnh abaN be dlgxmd of in a popmlr Nomad soNd warb
diaposal Shcity.err defined by)dOL a EL 8Ilt1A. /
The debris wM be Agoaed of at
caUmofFacEWAR&W Polls/
r 6 �
FULLY laps dw fbNowigS k*unsdon:
=Z4W CLEARLY)
APP� /
yle-- X-/ eA l /�`oG/� / A"f Ile -
i&Nam%Way
3 a M D/�L±�z
Ad;;z city Sbte
7be above atstale requires"debris fmm the demoNdM ra nvadoo,rehab or odw
alteration of bodit or sbucdne be disposed in a properly-liomsed aoNd4vasle dbpmal
5cUity as dedaad by UGL cDL S130A,and The bwl ft pesmitr or Neensaa am to
iudieats 60 loesdan of dw faa tj.
�G/n/n,p/LftlalR.iiA 0`�e�fiLALfaiafl .
600 w.s &V.And
�saas�ce..asi &i e. MuaA.& at I f
co..enw
W,orkert' Comperwdion Imorsnce AffMWk
. . w10J.8 principal pbla of basiswas so
Ap
de?erebr'cerdy smdo t�rs pabu sad psnildss of pvjnq, flea .
(Y I am an employer providlnR workers compenwt mi covep/s for my siap� werkiil;on
tkls W
=( "' do- 113/0 DLO
Inwran" Compeer Few 1"Umbef
r
I am a sole proprietor and have no one working fir nee in saw esptadq.
p 1 am a sole proprietor, general contractor or homeowner (drds am) sod how hbd da
comtrocsors Ibted below who-haw the fopowb* workersa cemp.raaasiosa Poll"
Contrsaw Inasranis Cora;sry/► N
Corarsemr Insurance Cosnpury/►o N
Cauraolor Isturamce CAMM"UYIPGft Number
O I am a homeowner performing all the work myself.
•1 wrww.e awa a aaaf d Oi ANWO M.e k fer..wme M/w 01in a wouges o of ON obi M oerwaee vo&aesa are an faauo M Metre
ae.wgr a rmwto~Seciw 21A of PILL 112 cad lead M M wee of aeI iaa wads snrrMt of a Na Of Is ni i.1000e=Ww 000
►earn•waarwwewm a ad a ms mow in du lore of a STOP WORK ORDER am a bw of s t00AC a an 4ia.a
Signed chit day of /U
:i scti Fcrmiftce 6u114dfng Departnrsnt
jcensinf Ecare
Seleamens Office
!iLsIch Deptrmer.'
- _ Ye : _ ace opt epe tic
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