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Citp of a��YEm, IA���L�U�Ett
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
�l (/Location of Building ��171061i
Building Permit:Application For: IV
'(Circle whichever applies) Roof, Reroof• Install Siding, Constntct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby a plies for a permit to build according to the following specifications: ll
Owners Name: /!! sty/d �I/OZ� Contractor .M* � 0 l �S Q n1 l ck'
Street_/ / F�y S/ City' Street- Y2o c.,I-- �Y�CityZ1�-
State Phone State l�L. Phone(C-7-'o
Architect:_j»,�oZ o�l"$�` City of Salem Licit
Street City StateLic# " O Ev 133$`l2
State Phone ( ) d -- • - Homeowners Exempt Form__yes no
Structure: (please circle) Single Family Multi Farnily# Other
Estimated Cost of job S
Will building confirm to Iaw7_yes 11 �1?r h� /• /
Aabertos?_tea__o0 1 �1 lC Id�� /D-
Description of work to be done: �--
Drawings Submitted: yes no Mail Permit to:
X
'Signature of Application,S GNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION_TO III XOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit'#\��� Zoning Map/Lot
T
Permit fee S
COMMMS:
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL (979)745-9395 EXT. 380
40 FAX (978) 740-9846
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge that as a condition
of Building Permit III all debris resulting from the construction activity
governed by this Building Permit shaft 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: 1VO kI• S/r b ^ f—A L:JZ
Location of
T\Y i?�2 � e ��
Siinature of Permit Applicant Data
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.