56 MARGIN ST - BUILDING INSPECTION (3) MR m A'VMW WW WlAWb
CITY OF SALEM
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b ONEWWOoa ANO . Yt_No
UNAW P1111W APPLAATM POR
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(Chb whiftrar apply) �M of CwwV Oaok RoK Pool.
chCaU-� Done%`rn.o�
PUIM PU our IAGMY A COMPLAIIILLY TO AV=oIILAYi M PIIAX lfl
TO TIDE 1N8PECTM OF BURDlN(l{fi::
ft wW*@*ad hw* applies for a po" in baled awwft I* fha.Win
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MOW d- �,-- *t A-i" r u e a for haw armor Iaail�t
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cod 33a6, arVU msrr ft*u1 71
am J� 0
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fro uMo�1,lft P111w�TY
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1euate. ALdow. Mom" Osll1
Workers' Compenu dow Inman=AffWvvk
. . whAl a pri"*W place ed btdlws au
do hsreby'cerdy under,the pahts and posildu of paienye tbses
Q a an employer psovtding worinn' comma adim covepie for my employqo woekling a
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Insurance Compaw Po Numsber
I so a sole proprietor and have no one wurkbw fear me In any ooader.
0 1 am a sek proprietor, general eoratractw or homeowner (drek one) ad he" hied tM
com anon lined below who-have the following workers' «impJa saxioe po6dey /
(rczcaf'
etor i insurance r-empany/roft Number
Contractor Insurance CompauyJPo Nsmber
Cosuxaesw Inswanee Connpnry/Policy Number
0 1 am a homeowner performing all the work myself.
i reevrLaee VMS aeq of di a MMM wa ae forWWftd as ow Ofiee Si Yw'wdeaeea of aw OK for ee.erase.e ikulm arw oo flee r Wesre
aerwaer AS IOOW98 ewer$KAM SfA of MOL 15 I an NN w ow i+wia of vkWra eeeaaeo ee wdm of a ace of ee a•{1JMM awler one
rrn'%aereer.mel a„s a tlN esMrie a rhr lone of a STOP WORK ORDER aiw s few of s IOOAo s M spies sae.
Signed this . day of
iz
.iccrseei'Ftrmistee 6md1 g Gepartrw t
iEensin{ f oard
Selectmen Office
=calth Gepsrmer,:
...-.._: , .sFCC' Ye : _ spa e05 ape 175
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rusuc rmurum f DNK%Wmpfr
120 M ANINWM a� s11e PLO"
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b eooadmoe wft e1e pew 4dm dLM a Ia Sri adasewWp dW m a emMm
dBa mbs yc"d- -e1 de61b feedllep eam me ooeebiotiaa aodld�r
P by Thor�e
ry !unit rhea be d kpmd dk a popsllr Boded Had no
dtapael3attigr.r delloed b LQ.a>�ell0leti .
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FULLY oompleb The t bhm wdm
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Addnel�dq!Je1b
IU above SWM ngafiw That debde Sam The damoNda%resoaafioq,nheb a Ave
abmdM dbai ft a aTra w be dkpoed is a poperlyy-Bcloaea solid omb d wad
elelhbr r de�nd by MM A 8130A.aad The bnMft you b at Ramer ale b
"No The had=dam haft.
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