104 TREMONT ST - BUILDING INSPECTION Su
.f,'wL�_lM_�SiMI_lS*`BE VED BY T41E t
D PM P}
BRING GRANTED • Y!..,.;
,CITY OF SALEM
Dide
is Pmpwty Loomed in d motion of
Ile i NOW oletdot? Yes_No Doi]dias
Is hoputy Loomed in
Is CW@0rA99n Am? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Chle whichever apply) Roof. Reroof, Install Sidlnp. Construct.peck, Shed. Pool,
fta visa sr•.'
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROOF
TO THE INSPECTOR OF BUILDINGS:
The underslpnad hereby applla for a pemdt to build according to the tollawhp
speolfkations:
Owners Name
Address 6 Phone _/0 :/ 7`i e1;,e,-, 4
AmhksWs Name
Address 3 Phase L )
Madmi w Name
Address d Phase
vhat Is In pupas if buldrg4
,y.
MIe1MW al ls/dnp'a /a dwaft,for how mwq hmNes? '
wN k"q=ft.. to"I li
EedmeMd eat. OU atY LIoMw e N A` atite UWSS 6:2 i;7 4
a
tans I '"
e `
ua. ,
Signituto of AppNcan—
SIGNgD UNDER THE P
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
i
MAIL PERMIT TO: t"� ADD u
lg—
•
1
APKXATION FOR
PERdaf TO
LOCATION
PERMIT GRANTED
2.0
APP717 .
INSPECT.. F BUILDINGS
ri PUBLIC PROPERTY DEPARTMENT .
• 120 WASNINGTON STREET, 3Ro FLOOR
SALEM, MA O1970
TEL (978)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,I aelmowledge 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 soH&waste
disposal facility,as defined by WX c ID,S150A. Q
The debris will be disposed of at /0, -r c' u I
Location of F
/ Sf o C
SisnafizWPennitApplicaut DW
FULLY complete the following information:
(PLEASE PRINT/CLEARLY)
r!Jfl � lT o! 06�.21i'
Name of Permit Applicant
--A 1 Y s - '�Z____ .
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-wage disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.