20 VICTORY ROAD -BP APP 04-1152 SHED t
"PL*M MW T-9E ffLf� APPROVED BY T*IE
INSPE&ToFI PSWR TO A_PERMIT.B,EW G GRANTED
CITY OF SALEM
Date
;N #
Ward
'�AFCIry�"E� Zoning District
Is Property Located in Location of
the Historic District? Yes—No_ Building do
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: L4ez
PLEASE FILL OUT LEGIBLY & 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 Name A))��OL
Address & Phone Za U &rwr2% P-3 OM) f%Y J-0->,y
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? Leoci!) If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost City License # State License
Home Improvement
Lic. I
Si atur o p is
IGNED ER H PENALTY
OF PE RJ RY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
t
No.\,
APPLICATION FOR
PERMIT TO
cca-7
LOCATION �f -
cj
PERMIT GRANTED
9
PPROVPD
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASMINOTON STREET, 3RO FLOOR
SALEM,MA 01970
i TEL. (978)745-9595 EXT. 980
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGI,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-wwW
disposal facility,as defined by MGL c kII, S 150A
The debris will be disposed of atr CA(z o 1 k)C-7
Location of Facility
Da
FULLY lete the foll rmation
(PLEASE PRINT CLEARL
W/�0S S�7�Zj l�Cni.YS(vtJ
Name of Permit Applicant
Firm Name,if any
,Z U tcr0iz .` !i�,)
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.
CT y OF SALEM
Bummri DEPARTMENT
HoleoWNEA LICENSE E?MAPMON
Please NO
LO
l
I�LOCATION
• , HOMEOWl�7i •
ADDPXU
.HOMEOWNffi '
TIM PHO"t
PRESENT MARN.0 ADDRESS
was uanded to include oe ocrseea*d dwesiv OtTWO
71c cmrcri.c+umpdon of'lwn ra"Units a less and to allow such borseownaa to c osa an bavidm}lfar biee wLo does a al posses a
agate.provided tmtbq*wow act as auporvber.
DEMMONOFHOWOWta7L
me CC k
Pcrsoa(s)wbo owns a pw=l of land on which Wsbe msides a iruecds to reside,on wndelr b
intaAad to be,a one 10 two fink dwe"M shaded a dctsdred saucwa oda�O17shaS sqt De ooasidoad
farm svt cwm A pcscn who constructs mote than me home in a two-y T
a bomcow•aa. Such`iwmeownct" shaft subnut w the Building ofBdal,on a fosse a=qtabk to to
Building offici4 that bc/ahe be tcspombk to aD such work pafatmed unda t m building pats.
The tmdcrsigned-bomeownd M mus raponnbility for wmplianec` the state Buiding Code tttd
wha applicable goes by-lava,rules and regttlauoM
rred-Mmeownei'artifice that helshc `/ iq of Salem siidiaiDepar and
TUC WAmig
minimum iygc� on Fvccdures and tegtcrcrnctns tl�§tfilshtrwill comply witA said A0°
NONZOWNEFL'S SIGNATURE //
/7A APPROVAL OF BVI ING P 7PEC�
See otbct adc for state Code /
HOMEOWNER'S EXEAI?TION
The code states that: 'anY homeowner performing vm*for wWcb a but7ding permit is regttbed shd tie
Mulpt from the provisions of this seCdon (Section IOPJA-1Jcensing of Constructtoo Snpesriaerv)
th
Provided at is a bomemmer engages i person W far hire to do.such w=k that sock bomaww3w shaD aR
as
mmM bomeowners who use this excmptiou are iasrwau that they are ass m&s the ate
supervisor(see Appcndh Q,Rolo and Regulations for Ve msiog Coostruesioo SaperrboM Sa*m
.3a n 71is lack of awareness ohen resuhs in serious probkmsk paraevbrV wbm the bomwwaabbai
unlicensed pemaoe in this can your Board cannot proceed aphm the miliocased pa�on as it warhl wft
La licensed Supen*- 7 bomeow�scr acting as supervisor it ohhwt*sssrmrs '%
To curve Ow the homeowner b hilly aware of hvhcr respoanbiihim mngr exrmQnnrdtia regrdrs;as past
of the per n it appli®doa,that the homemvmr ccn*that hchhe understands the tesponsi awes are
supervisor. You may care to amend and adopt such a foraJe crtifieation foe m in year ooutmmiq,