21 SALTONSTALL PKWY - BUILDING INSPECTION A�
s
-PL- M 100ST-BE fIL+-� APkPROVED BY T44E
1pIS,pl=Dpi pSDA TD.4 PEBW S,EWO GRANTED
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CITY OF SALEM
N V -v y� \ Date//e6�
b:
Is Property Located in Location of
tira Historic District? Yes No Building
Is Property Located in
the Conservation Area? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: rs o-r< ., ti� duo 2`�f
PLEASE FILL OUT LEGIBLY rZs 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:
Owners Name /4/V r f
Address A Phone ;Z / .4'a A4�i tf1? 5'1 j T/o
Architect's Name
Address & Phone 1
Mechanics Name
Address & Phone ( 1
What Is the pxpoaa of budding?
MUaial of bulldbgl tl a dwelling, for how many famines?
Witl budding cordorm to law? Asbestos?
Estlmated cost / v Gty License N N A Slate Lloanea K
Some Improveraant
Lic. @ Oy y/
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
uc or 1F o✓ 2,S G o M�j !.c fc� ,r�,c3�Ey f '^' ��-C
MAIL PERMIT TO:
NV APPLICATION FOR
P/ERWT TO
LOCATION,
PERMIT GRANTED
3 2.00 S— ,
APP OVFD
77
—.
PIWTOR OF BUILDINGS
I
a
opp, CITY OF SALEM9 MASSACHUSETTS
�6 PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
L 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, S150A.
The debris will be disposed of at: /V, cd 44 '`-"�
Location of Facility
Signature of Permit Applicant Date'
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
/rar1 a t
Name of Permit Applicant
Firm Name, if any
Address, City & State f�
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.