0043 MARCH ST - BPA 05-254 INTER. DEMO 44. 16111111WI EfRM94ND AVIAROVED BY 744E
ASPJ:C 8 PR10R TD A PERMIT BMG GRANTED
CITY OF SALEM
No. (T�j � Date
i. 'k/0
7 arc Ward
Zoning District
Hidaic Dbtrid? Yas No ration of
Nw
ST
Is PIO Mty Lacded in
tM Caeeanadon Arm? . Yo_No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) -Roof; Re , stall S Conatruct Deck, Shed, Pool,
epair epla" or:
idiP � /shim
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build aocorcMg.to the following
specifications:
�cr v
Owner's Name /
Address & Phone eld3
Architect's Name
Address & Phone f
Mechanics Name _
Address & Phone
Whd lama WoMrP 01 WIlding7 sic fz�Y
MaWW of bklldlrp7 IPiXJLV <X21N6 R a dwraft for how many WNW
WIN Wilding conform to law? Afbados7 /�/�-h
Edmat`a/-�coe 3./\OOD• city Lkaw n Slats M Cr D d S�Z Z
v��dV Nava I.P:a..ae.nt
I.sa. of
Signature of plicant
SK3NED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�nAA/A P�
MAIL PERMIT TO: i�,ke VeYG �l
r/o3 Le6cw.UV V,
�.o.Ab� N1H 4�9Gv
.t.
No. v �
APPLICATION FOR
(/n PEpR NT/T_O /7 .
LOCATION
PERMIT GRANTE
AP vfD .
INSPECTOR OF BUILDINGS
I
PUBUC PROPERLY DEPARTMENT
' 1$O WASHINGTON VMM, 3RDFLOOR
SALKM.MA O e S70
Tm.(979)745-M95 EXT.360
FAX (S78) 740.96"
STANLEY J. USOVN:Z, JR.,
MAYOR
DISPOSAL OF DM=AFFIDAVIT
In accMdance with the peovisions Of MGd,c 40.SK I actmowWP that as a coodhim
of BmldinS Pamit 0 .sll debris reaultb:Ig ftm the coma activity j '
govaned by this Building Permit shah be diapowd of in a*Wily&eased solid-waate
disposal sty,as defined by MUL c W.SIMA.
The debris wM be disposed of a
Load=of Facility
Signature merit Applicant DaOe
(PLEASE PRI r CLEARLY) � �
Name ofPamh Apphcam
Firm Nam%if ate►
03 how -C� . /* 0/ 960
Addles%City a State
The above Statute requires that debris from the danolitiM remvahM rehab or other
alteration of bmldmg or Str mun be disposed in a
facility as defined by MQ,cnL S150A,and the burl - cr solid-waste dispcuai
iadreate the location of the 5cility. 1 M or licema are to
i a
eoo C w�a..L.,z.
doon t Csaaasl � Mu .A .W OZl 11
oasoasar
Workers' Compuwdn inwrance Affldsvk
. . whil a principal place of bodseo ac
do %arebr'cendfq under v)w pains and pencil" of perjarit, thm
() a�emp�sr providing workers' compemodan coverata for mY aaoleyea wwkbg M
ddo Insurance CasnpaSry Poliq "waber
r ,
1 am a sole proprietor and haw ne one workbag fdr me M vary opaday.
() 1 am a sole proprietor, general contractor or homeowner (click mail) and haw hind dam
consranon listed below who-haw ahi following workers' compensation pollchn
Conaacoor Insuranie Company/PolIV Mum"
Conasam, Insurance Compaary/Polity Number
nC'onaaaor Insurance Company/Poilq Number
109 1 am a homeowner performing all the work myself.
�'��I VA"VaM rna a CM of I*assa.sM we N farWWO" IN Or ORc.A 11+ *sww.f Or PM.for ce..raee+wiase.e ass.1a Whow a::Mare
COM811 a nown art Satins 2SA of MCL 152 van lose w or Wmew es of ariei oesa de c.ru.int.1 a er of M M I,f00.00 MW r eas
a no a d.i sa w o in Ou lane.f a STOP WORK ORDER ae.a it of f ICCAC a an qiw ae.
Sign Is . O�6 day of ofDO
.httnjieiFcrmit et fsuilding DeparxrovIent
icensinf Ecard
Selectmen Office
ricalth Gepsrtntrt
-- r - — —.eeC.r ye : : 404 40e 405, �7-C