159 NORTH - BUILDING INSPECTION (2) "PUM011111~11E4%494ND APPROVED BY T44E
IWPZ=B PR OR TD A.PWWU ARJNG GRAAMb
CITY OF SALEM
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Is Praputy Loeara ' in Location of
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Permit to: BWLDIWI PERMIT APPLICATION FOR:
(Circle whichever apply) aReroof Install Skft Construct Dec*, Shed, Pool,
PLEASE FILL OUr L EMBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accordLig.to the.following
specifications:
Owners Name
Address & Phone I�C�
Archknfs Name
Address & Phone ( )
Mechanics Name
Address & Phone ( 1
what is to pup of eWldrg9 r'•ex-C)r"lac
m"m of bwav_Lk-zn yoc� n a dwNkg,for how nw.M tomen?
WA hilft conform to law? Afl eWS? YN,)
Edkn"cop m uk • �3 stria iJoNwa r►
SOUtureol'140m.
SKDNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
`n cz o& r r-Q& Ls-)k� a5 p r rrx& 'S1n,r�g UPS
MAIL PERMIT TO: 01?—Ic 5 6e'z1 S�
�S� �• ems`
S-4le�r � ��S7o
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
99
t R
INSPECTOR OF BUILDINGS
PuaUG PROPERTY DKPARTMzmT
120 WASHINGTON aT1 M,aRD FLOOR
d SALM MA 01970
TaL. (979)745-M95 6uT.300
FAX (V76)740 96"
STANLEYJ. LN N Z. J11.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In wmdmm widt the psovisicros of M(L c 4%M I wlmwlo*fat as a conam
of Buo ft Permit/ .aD debris ramping ftm the comskootion scbvity
governed by his Bu1Ddmg Pemit ad be diapered of in a p vpaly hcmaed solid waste
diaposel haft,as darned by MGL c UL S13QA.
The debris wM be disposed of at yr kk�g\fie C
-1 Locataca ofFmi ty
SiSaatmeofP Appliast Dab
(PLEASE PRW CLEARU L ) .
Name ANHew
.
Fam Name,if any
Address.City dt Stou
The above statute mp m that debris from the damolition, renovation.rehab of other
skasaoion of bW ft or sbuchm be disposed in a p vpcly_hcaoted sogd-waste disposal
facility a defined by MGI.cBX S15K sad the buUdinS peamita or lieawa as to
iadieate 60 bestion of tha hd ty.
afy OF SALEM
BUIIDING DEPARThOff
Ii0ME0WM UCENSE EMdrT10N
Pkase PIM -
DA7E�].�"�1� .
70B1OCAT]ON
xorgO�Wl�t 1'"�`�
ADORES}
'HONlEO'p9� L1�1 '14� a► 1\`l . .
TELEPRONS
PRESENT MAnVP ADDRESS �L �F
The cwraa.mm don of'hac�aoagers�was aztcnded m i hde owoe d ll d eW0
Unlm a lot and to albw tach horacowm a m OWF an bmVvidoW iat P�
,.provided thn dre ewaKr aet at wPervita�
DEMMON OF HOMEOWSM m reside.on�Dias
Pcnoo(s)who owns a parcel of land on wbich be/sbc resides es bucads sud 1x ardltts
intaded to be,•one m two family dwdlbaR amdsd w dcudred stru�twas_im0 aol cau �
farm svvcnoes.A prnm who cotaVv m moos than one bcmc in a two 7 w� t
a bonreowaer. Sucb I=Iww•acr' sha>l arbmit m the Bwldir�018e+il.tadu the b �
Bw'ldinf o icial.that be Ow be=pom-bk w an such work pafar cd
.Tm tmdcrsiptd-bovwuwrra awwfi s responsrbi ity fcn=MPiim'a wi4rtlre state Bn Code aced
otbu appgcabk joa by-kws.nda sad*Kubdom
Tbc tvrdvsipred-Mmwwsme=rdfm that hdOw mdersw&tht a4'ofak= •
miaimma impaction proocdwa and rcgtmcmtnu and that hlshc wBl b w
mqwmmcm
iioNmv lmR's SIGNATURE
:2
APPROVAL OF B=ING INSPECTOR ` � o
See other side for ataa code