SUMMER ST - BUILDING INSPECTION gPh1mfItlST1Efndm4 D AIMiOVED 8Y Im
JdtiFU=.PWR TO A PEIMIIT BXM QRANTkD
CITY OF_SALEM
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BML.DING PERMIT APPLICATION (IOC
Pennr< to:
(Chb whW wr apply) Reroof, Install Skfirlp, Conttruc P&*, Shred, Pool,
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PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILOING& ,
The wWW60-Ad hereby applies for a permit to blrlid somaft fo to fokm"
Owners Name A 124a.ckk 11
Address a Phone 7 I 5 u m rn.f-r (97 st -7 yi/— 16 0,3
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Address A Phone [
Mechanics Name
Address a Phone ( I
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SIGNED LL THE PENALTY'
oEscRIPTION of woac,ro sE Dow
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MAIL PERMIT T0: >` '
No. .
APPLIrATION FOR
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LOCAT
PERMIT GRANTED
IPO
OR OF/B
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
J' 120 WASHINGTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL (976)745-9595 EXT. 360
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,1 acknowledge that as a condition
of Building Permit# .all debris mmiting 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 IIIS150A.
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The debris will be disposed of at ( � 6
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 cM S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALSA
BU=ING DEPARTMM
HOMEOWNER LICENSE EmArno i
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