11 SURREY RD - BUILDING INSPECTION 'PL*N611*116TISE fILMI&MG APPROVED BY ne
MSPECIAf1,PPMR TD A PERMIT BEING GRANTED
CITY OF_SALEM
No. J DAM
7 fl c Wald
zm*g DlsMet
It PmpeAy Doodad ti _ Location
°1
the l-StW
Mletmk Dbbbt? Yas No
Is P awy Loceled In
Au Caaanadon Area? YN No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) RnC
RPLEASE FILL OUT LEGIBLTELY TO AVOID DELAYS IN PROCE881NG
TO THE INSPECTOR OF BUILDINGS: '.
The undersigned hereby applies for a permit to build accorcktgto the.following
specifications /
Owners Name I ) I a.Vle. i J C41-ry'l >�l �j( A-
-Address & Phone { !' SGI-We ( R4 Sit
Architect's Name 0— m 65 CU K.i,
Address & Phone 1ST
Mechanics Name
Address & Phone
What Is tlla PrPoae of
mme"of taYdNg? A a dweAMlg,for how nmW tamest?
WAN bukbg conform to law? Asbestos?
EaAmated COY 0 O CAy Licmm N State Llumme e
>�
t
Lie. ,
4Signatu of Applicant
SIGNE UNDTHE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
}CPS 0 I,.RrJZ dl , /nJ "JA0 CA-7
MAIL PERMIT TO:
No
APPLICATION FOR -
py�//Jq PERKW TO//(/
LOCATIr
PERMIT GRANTED
�3�19
nPPRnfD
INSPECTOR euILDIWGs
, a
PUBLIC PROPERTY DEPARTMENT
120 WASNINQTON STREET, aRD FLOOR
SALEM,MA 01670
TEL (976)746-D595 EXT.360
STANLEV J. (160VICZ, JR. FAX (976) 740.9646
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MM c 40, S34,I aelmowledge that as a condition
of Building Permit# all debris from w"
��8 construction
governed by this Building Permit sbali be disposed of in a properly licensed soH&wam
disposal facility,as defined by MGL c III,SIM&
The debris will be disposed of at A)Di- az*vArj • �f/�
Location OfFacim
440fPermitApplicant Dots
FULLY complete the following in&MMUM
(PLEASE PRINT CLEARLY)
Name of Penait Applicant
NO✓h%5<4.e
Firm Name,if any
�JGcs(Yr►1�2e�� � �
Address,City Bt 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.
CITY OF SALEM
WnDING DEPARTIvlENI
HOlaOWNEIL LICENSE E?MOMON
Pkaae PAN
. •7051ACAT]ON � �GGfl�'� S�-/e.��
ADWXW
TELEPHOMB
W.SFff WA WO ADMMI / '�e Gar � 'd
Tha eimo�l.eoamptimi d`bossmowme was easrwa w I=%&ewmr-"MPkd d'Coop dTMo
1)silt a kas snd b allow ssch homcowsea to ea�isic e► .�hdrs vko lees set pones•
Ikease,piwrded tbsa�e ewrsef sel u apervbes: .
DEFV4TMOFHOhffZWt '=
• Pcrsos G).rho owm•psra)d land os while hehhe aside a beads to reside.oo wkid!dws k 4 r .
rounded w be,a am w wm f mgy dmgm&suadmd at deadad stracsses sssenosp s WAS tse aodlYtr
farm stnseaae.A ptnon wbo eon vuen mom the cac home in a tw olm Peied*4 sot bt eomW d
a bosesowm. Suck`lnrmemmf shaRsabmh do the Bus7dips Ods3al mda tbt ba�ias ptaaiL�
Bm7dios OdieW.that belslee be reponmbk to aA sur!►wask perfasmed '•
The urdasrps d`bomeowveer'n:tmee tesponsibrUp for eomplimea withthe Stan Bla ft Cods:ad .
other spocabk Sea bylaws,rake amd icgWw iast
The mdasipeed'homwwnef=dfie than hrhh wwc=nds rice Ciq of Salem Bwwbg Dgwumat.
minimmo becW m pro Wwu ad /rcgvi oKms and ftt Wft will mu*wMh said pasd�oa ad
HON i)!GlGst
HOMEOWNER'S S1t3AiA7'IAtE
APPROVAL OF BUILDING INSPECTOR
See mba side for sae cafe
HOMEOWNER'S EXEMynom
The coat states that •.try bcmmwaa yerformim 4vdt fa wdtich s buDft Puma b lc*W da M
• c:ccmpl 5vm►tlrc pev�isiont o[this scedom csenio.]cyt i-u«osioS a(can.+rc+k.Smpn•vises�• .
provide_d lt�bffi b a bemeeow3m cripaia f pmm W to Um so do.such wvult,Clot sigh bosoeowaa so
Maq bomeoerot>s wbo ase this etcsmpdoo are mowate that they at:ugambg d►a rwombmu Its
supavisa(sea Appcodh Q.Roks and)te=ulatiom for VeissloS Como rwcdw Sopesvbmm Seeta
i]S} This hKlt a[.warcrco olkm ttsuhs is sctfw problems.Pm deula w�a tht llooeosraerLlsr
l,rjkcrued pcson. In thht can yaw Bead arntot praxc0 sjsirst the mtdoemed pafoo sa kwwla w!S
Ikemcd SvpervSsmr. The bomaiv c7 wing as sopervlsw
To esmn that the hmmeow ua h flab aware of hllbes ropamsibD dck tong oo lde tsq&%-n post
of the permli appikadM out the homeoana ccn*that bt/sht mtdessmr I tbs tesponsbulds aft
aVavlmt. Yom may can to aneed aid adopt sml a knakcTd5=dm fw on in yma eomnml0.