21 PROCTOR ST - BUILDING INSPECTION (3) �L�Mt1SiiMi6T�Ef&A D APPROVED 8Y T+IE
.W$P CTDB PWR TD.A.PERMIT 13,ENG GRANTED
CITY OF SALEM
No. Date � 3 - Ok —a
Is Property Located In Location of
the Historic Mulct? Yes_No k� Building 2 / ����, s�Ss�
Is Property located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: /w � 1/
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name 45 /r :
Address & Phone �1���� .4�� s f- (97�'1 3 f 51 Q 2-
Architect's Name
Address & Phone
Mechanics Name i�_S.�-t°�� /� z�i
Address & Phone 5'/d h- ) A"�'j ,
What Is the purpose of building?
Material of bundi g? bz,�o 0 vl if a dwelling,for how many families?
Will building conform to law? ye- S Asbestos?
Estimated cost k c? City License• N A State License N
� Isproveraent
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
// (0, 54-yc/- roe-,C
MAIL PERMIT TO: N'57 e14 � �e
„„ ,
No.
APPLICATION FOR
PELRMrr TO / ex
�/ / =E
C0�5� �/ //61P, �TonP
LOCATION t.
PERMIT GRANTED
/o 5
R
APP OV�D '
INSPECTOR OF BUILDINGS
CAY OF SALEM
BUn DING DEPART1v M
HOMBOV NER UCEDISE E MOMON
Mae Perot
DA71 OO /'t -l9 S
Air
•HOl�aal�t �l `� � � a s• 5 � � Z •
PRE�1iT>dAII.A�O ADDS
7Ae em+a-.CWMFlCn d-AomeowWf WW eoaeadee to brhde wmr-"wpld&mftp OFT"
L1nlu or tes and d aAow smelt hormwwaera to ar+ittV�m bdtvidnllix bbs,rlo does aat pow�
ii«mS pwW�d*Ameewnei.a.e.uPs.,ma
DEFlidTMDFIiCMECWMM
Pena O)who aww a parcel d Lad oa which behha resides of baeadt to tedit=wM*twm k r
m
intaded a be,s as a two lasAl &nMn ,snadted at dwdKd tartreaves M
h svucwm A perseu wbc comvuets macs tLm ems home b►a two-pest period"sot be tAasldaad
a bmwowsv Sttdt-ltontetnrod•tlnff submdt to the Bntldir�Osftdd. >i1s
BWmbq ODidd,that Uhk be nspmn%k to an nxb aodc pcfasmed ?amL
The wAniped-bomeowne aatmws tespotTbft Sae cmuyft :s w whthe Sate BdM4 Code ud
othu app8obic toes by-kws,rsies send tep bdom
The wwmp W-homwwnd'=ufm that hehhe nrdUaLUb tiA C'w of Salad Bdldiad Deparatt�t
nnvv mmo bapc=cn pm=dmes ard agiwem m and thn W&wil co+ 9V w i&said pweedmea ud
Tophombeft
HofaOWM'S SIGNAn=_
APPROVAL OF BVIIDAIG MMICTOR
Sm otba ode for state code
HOMEOWNER'S EXEWffnONI
The code ststa Am 'vw Ii meowacr pafmtatu,�iv-A fox l%%&k s tiu0di�perndt�ret)u�Od drf N . - --
ctempt b=the prudsiow of thb secdm (katow 309J.1-13ecasint of Cosntrucdm sopervtses�
provided$nt fs a hOmeoiaa eta i pasoo tf)for htis to do.such�4 thsn suds hosneowset ehs3 iat •
ss sapavists:'
Maq bomawmn rrho the this ommpdon are msiwate that they we- dwvv=dbWmvts
nTayba(set Appeodh Q.Rula and Re=ubrloa fw lUoeusbg Cotgrwedm Egesvboss.Eee*m
• .119} Ybd(bek o<rnararca elks tauhs in serious pmblaar,pctfevLa�f w�Lea the Loseeosraeshbw
urdtaasxd persona bi thts vase ytim Bard earmo-p ma wd s&&bw the millaeased pafon ss kwvW wl&
Ikcnsed SupavLgs. 7101 bosseowser se11a=su apavlsw Y uWmuse rsajjow�IL
To enum disc the homeowna is!ally aware atmoba•rap=dbodes.mow oommmdtler t wk%.a pact
of the pcmdl sypitodm tint the bcmwwma essdtjr Om b&Wa mdasands the t*+paasibMw da
mpavbor. Yw mq cam to amesd sad adopt sue!a*nukcrdliesdm tw ttss is yessr cmwm dq.
1
ly-�l
- -
l►N�O,.�'lva'od�S QC s�b717 319D'�No7:; -
T
?ems'- -- -
— No a�a�
_
-- -- -- d; /a'tr
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
1. 7A 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 III, S 150A.
The debris will be disposed of at: 0f td' /
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
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 cIH, S 150A, and the building permits or licenses are to
indicate the location of the facility.