16 PURITAN RD - BUILDING INSPECTION i i�L 91117e7i $E f�Lf ND IMPROVED BY T44E
utS cTc�t PFaln 'Tv?.# P t T 13EWG GRANTED
- ; ITY OF SALEM
No. -4dd� �3 'y Date 5 ZS -C3
i
/i � . Ward
\"crrnnko°' Zoning District
is Property Located in Location of p /
the Historic District? Yes_No ✓ Building j� I srrraw �_
Is Property Located in
the Conservation Area? Yea_No✓
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, F ro Install Siding, Construct Deck, Shed, Pool,
Repair/Rep ace, Other:
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 L!cc' c l% GV_0 O Uk
Address & Phone ({, P,�,k� �_�L 1 - L�l��l 11`L/ - /6:1 I
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone 2,�-
What Is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cos!S 00 City License• State License 0
/�� liana Improvement iV
J` / Lic. / \3F5icant
S THE PENALTY
O
DESCRIPTION OF1 `WORK TO BfE DONE
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i
OF .5ALEM.
PUBLIC PROPERTY DEPARTMENT
• ° 126 WASHINGTON STREET, 3RD FLOOR
r. SALEM,MA01970
TEL. (976)745-9595 EXT.380
FAX (978) 740-9846 .
II. STANLEY J. USOVICZ, JR. .
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA I acknowledge that as a condition
't# all debris resulting from the construction activity
Perna
ofBuil ' _
governed by this Building Permit shall be disposed of in a properly licensed solid waste
disposal facility,as defined by MGL c III,S150A. 1
The debris will be disposed of at: Uc-S I-4-
Location of Facility
Si Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applican
Firm Name,if any
�S W s =— —
Address, City & S to
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 cM, S 150A, and the building permits Or licenses are to
indicate the location of the facility.