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JdSPFC=PRIOR TD A REAWT MWG GRANTED
CITY OF_SALEM
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BUILDING PWW APPLICATION FOR:
Pwmk 10:
(Circle whiclwvw apply) Po. Remdt,In" SWWi& CorwVud Dock. Shod. Pool,
PLEASE FALL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF 6UILDING3S:
The undwaipned hwoby applies for a W t to buUd acoordinp to the foW-g
Owners Name 1 f3LPff
Addrosa a Phone �64 Ah9-5'�� L&-Taj 5r. 521fil
Atchkods Name
Addroas A Phone ( 1
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Address a Phorw 7i5 PoSrd1J 57`= 2-y1t1x,1 (7�/)
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slurs of Applicant
+SKMWD UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DONE OR PERJURY
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MAIL PERMIT T( .
APPLICATION FOR
PERfftf TO
LOCATION
PERMIT GRANTED
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OF BUI NOS
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CITY OF SALS14p MAssACHUSWMs
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Is aoaardasce with the p mvidm of MM co 9 a cooditlos of your
HoitdieS Plermit is that the debdo S!!roar this wok shall be disposed
Otis a penpady licensed solid wvbe disposal facility as delfaed by MCB.
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l e debd s will be disposed of ia:
(Location o(Facility)
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The Dep a addtdf,takpboae and fiat noml w
the Commonwealth of Massachusetts
OWN o(Tnvadpdonn
600 Washington sired
Bo"MA 02111
Tel. #617-727��617-727-7749 7-MASSAFE
Rcviscd 5.26.05 www.mm.gov/dia