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ASPECM013,PWR W A'PEBW AWING GRANTED
CITY OF SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Cinde whichever apply) Roof, Reroof. Instal Sidkrp, Conn JW Deck, Shed, Pool,
Rspair/ o*=. Od `)
PLEASE RLL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROCEMW
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build aocordieV.to the,folbwkrp'
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Owner's Name '-w I✓ c• J�
Address a Phone ISV IWgIU(?040 af- '/ (g7F1 7Hy—� 7
Architect's Name
Address a Phone
Mechanics Name
Address a Phone
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OR PERJURY
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MAIL PERMIT TO:
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APPLICATION FOR
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LOCATION
PERMIT GRANTED
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# .all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c
The debris will be disposed of at: \
Location of Facility
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Si of Permit Applic Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any �i d
Address, City& State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
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CITY OF SA1EM
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HOIMEOWM'S SIGNATURE
APPROVAL OF BUILDING wspEC'TOIt
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