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r 111SPBCTD-B ,PFUDR Tp'A PERMIT BENG GRANTED
CITY OF SALEM
No. 7(� I- 2 �p� ��t ��ts�; Date
iti< 'roc Ward
I\A"crmne W Zoning District
Is Property Located In Location of
the Historic District? Yes_No Building o0/4 /,f A/
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Consjruct Deck Shed, Pool,
Repair/Replace, Other: l� G=7
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:
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Address & Phone S�AAI-.Iv sT 140 eA�Ll ff? P52 - P6 a 7
Architect's Name
OwtJrr�R, ;
Address & Phone %,t-,S 144\ DEZ ( )
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? If a dwelling, for how many families? 5 "C' L�
Will building conform to law? Asbestos?
Estimated cos City License # State License # C
�r Home ]Improvement
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Signatug of Appllelmlw�C
G� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO:
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
?, c 120 WASHINGTON STREET, 3RD FLOOR
}' c SALEM, MA 01970
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, S150A.
The debris will be disposed of at: //I
Location of Facility
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Signa a of Pe t plicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
D 2e CDN'SZ`G� //C
Name of Permit Applicant
Finn 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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�, ��..� - ✓/re-Po�n�w.ald .%`lam�,/« 6�d
BOARD OF Bt*L#NNG REGULATW)
Licens4 £MS`IRNJCT1O17 SUPER!19 j
NumberCS 051242`.. �' `
ButhclW 04/3061958
Exq 04l30l20,05 Tr.no: 11418
Resiribte6 �00
,- BARRY P MCSWE_ENt.
EY,, _
16 LAKEVIEW DR
:.' LYNNFIELD MA 01940 �--�—�— �I
Administrator r-