13 MASON ST - BUILDING INSPECTION F
ffaa
CITY OF SALEM
r vJ�
Wed vvvJJJJ
=Loom In looms"
DMW
�P�ly Lnowd in
•• rM Oalrll�on NN? . 1h�_ib�
PMmk IOC L XBM Pl APPU ATM PM
(CUde W*ft er a" RDA
WON SM4 COf1�lU0< Co*, vwad P001,
PLUM PN,L aW LR=LY a C0WUM LV TO AVW 0R AV*M PWCR p
TO THE WASPECTM OF MMLDM&Tim .ft +.
PMd I w" 0016 for a P«M4 b buiM a000�d'aq to ft blmWng
0~e Name
AMeee a Phone 12, ry\ r� 4 A ts-�Z
A00h0aly Name
Addien a Phone c
Iftdrnioe Name
Ad*m a Phone c
wWrr■P.POI .a-
'''WMa + Mar..�q,lOrno..Nllwrl101 t2- _ ;�lx
w�WYr rado■i 4l.rt r,d..,,,,
Er>�d oeM o.� 4D L1o�er r�,_�tlowee r
PL 11t IaIALTtt
oP wo�c m � L�IiE
•1 [5
i
MAIL PewNrroc n1lX,�irO�
NIL
APPLICATMFOR
v��TO
LOGATM
PEHAMT GRANTED
Nq 430TO R OF NPLORM - .
CITY OF SALEM9 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 aclmowledge 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 III, 50
The debris will be disposed of at: 74-0V
Location of Facility �\
✓9� W
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any)( ? M/Z"'�(4 ,
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALFM
BumiNo DEPARTMENT
xOMEOWNERUCENSEE MOMON
Pkaw Prot
DA
XBI.00ATION
HOMEO 14M
T
> MALW.G
arwo
two a leis sad m aDow so&bomevwm a 0 enpr m bidiridaiil lsT b3ra wbo doe ant posses t
DEiIIdl M awoOFHONEOW M 00 wLSd►Lrldu insides a bueads m reside.an.&kb anptnm Iti at Y
bucrA lobe,
a an a pveei dwe a=dwd or daudwd straCev=m=mm7 w Web 0ae�
farm s d m bc,s an b two lance sbsa"be consido d
firm so•ocmoet.A persm wbo eoTsauea mwe tMm oa home bta two-7as pad
Building OMeA thatbshbs bcbe nspoosibk man nA�paw ipa=L
Tht midasipud-b &Uwm mv jot wmpftm wide drc Sat Batt Code d
other appSabk goes%-bvj%Toles aad n pbdu L
i be wo sip d'h= oaufa thri bL/ft emdesnnds The chi of Salem Baildtmg Depaoaaa.
m.mg..proecdmss aad ngtmnmems and thst ldshe Will=qq W'*aid Pm dm"d
mqdnmcM
HOMEOWNER'S S1GNA --
APPROVAL OF BURDI II�SPECTOR
G �
Sec aba side for sane code
CrrY CE SA1EM
BumiNra DEPARTMENT
H0ME0WNEIL LICENSE Emvno'N
Plow Pdd
DATI�
>agLOCATIAI
A
HOMEOR9=
TE EPHOI!
pff—gb MALL ADDRESii
�
The nma-vwmpdw d'bvMww�'wa aacadad w be ludo owwr+iwpkd. p T
UWu a kss and to aAow aoeb bona a=PP a lndhida *r Mls vbo does alai pones t
IIocnae,.pnovided dsame ewsei set ss sopsr+Ma
DEF24TMCFHCMEOW1 'M
Parson(j)who owns s pwW d knd as wbkh bekbe asides a bftn&to naift on V&M*An
nk�
baended to be,a one to tom�dvmMA&stacbed a deadood stmetsnes MMO_shs0 sa oonsSdasd
firm sweaoa.A pcsm wfio eo�avoett moat Ilan osx hem►e fA►two- s��ecogubbi s� .
abvmwv4w- Su*-bomtcw•nd' L%oVMbndttotheBad%OJf+CK=a fi�ebnildlgpew
Bwl&g Olf e4 that Wshebt ugons%k to sU mcb weak poftnued
The imdwipad-bo�aw=w sespoasibft fa G=Pft=wWh tfie State Bdit Code d '
other gpgabk`oa by-br%%,mks aad Tegob oat
The undens PW*%MnWW a arssta fia bdit mdas+sods the ow of Salem Be b ft Depnusma.
miaimao iropsuon Po=dma and nq*=xtns and thst hhbc WM W WFV vial►old pmosdtnes ad
*agvi=a
HONMWM'S SIGNATURE
APPROVAL OF B=ING INSPECT aA
See other side for MU code