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1AISPFl7L{B J1QR 7D� # F R,EWG GRANTED ` '
Q CITY OF SALEM
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Is Property Located In Location of
the Histoido Dlstdet? Ye _No_�- Building /c/Saih ra'Wet: . :
Is Property Located in
the Cormrm qn Ana? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCI111111I llli
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name " ckorrl anc/ /yJaI)=Q lnca2mol >'
Address & Phone /9 Sa6lp rc/WeK7` (97r) 7415- 9?
Architect's Name
Address & Phone L )
Mechanics Name ;_Owls ljnA
Address & Phone (?Prjere �,,9 1J,21YI M110216 SDE
Is«al
What Is the purpose ci b MhV? Ce
. Matadat of hdklnp? I a dwaNk g,for how many fame"?
NAIL kdkbvAWonn to law? Asbestos?
EsWnNed oo l) CRY Warm• N A state Lkwm a
� Iaptowsent
Signature of Applicant �!,
SIGNED UNDER THE PIdN1i�Ii F
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO %a,—WhVcDeho/W /9 _G,41e
Solely OW 019,
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fax 'tir nl- ,
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APPLICATION FOR
PERMIT TO
17
h1�1�
LOCATION
PERMIT GRANTED
A//P/�p+p�ov
INSPECTOR'OF BUILDINGS
A
_ .
Av
Ua PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
i 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: R061C 1 S,t 6overe MO 0,2/5-
/
Location of Facility
Tignatur6 of Permit Applicant Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
A'ar//M" 124 as�IA
Name of Permit Applicant
yl;?o S IJS-A M� 4 C9a2/S/
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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p NOTE:
Y CARE AND MAINTENANCE OF THE CUL-DE-SAC ISLAND SHALL Zit
L BECOME THE RESPONSIBILITY OF THE OWNERS OF LOTS A, B & C .
AND NOT THE CITY OF SALEM . `riJ
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