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APPROVAL Of B=ING VfWTClC
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MAO 1970
TEL (978)745-9595 EXT. 360
40 FAX (978) 7409846
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL 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-waste
disposal facility,as defined by MGL c III,i S 150A. /
The debris will be disposed of at:
Location of Facility
,
Signature df Permit AppliDate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
b0vp4.> - A�T/,I C4
Name of Permit Applicant
NoN f.
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
• DATE: O's
Cite Df �YE17T, t � ��LYJUEtt
�a
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED rI '
Location of Building 1�i Q '� ✓l d�
Building Permit Application For:
YCircle whichever applies) Roof, Reroof• Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace,Foundation Only, Wrecking
Other. _czns1tn Cr-
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the hispector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
OwnerdName::L�n%,(A Contractor.
Street 1-�Lk4e5 (Z City 'cAe'1v' street city
State I Phone (CiN -2— State Phone( )
Architect: N 0 N City of Salem Lich
Street City State Lic# HIP#
State Phone ( ) Homeowners Exempt Form_yes no
Structure: (please circle Single Famil •• Multi Family# Other
Estimated Cost of job S t 1 9000 -00
Will building confirm to law?,.,Lyes no
Asbestos?_yes "o ` L
Descriptionktobe
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Drawings Submitted: ves no Mail Permit to:
x �IYA ., x
Signature of Applica ,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO B�kOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Perritil, ` _ Zoning Map/Lot
Permit fee 54� T
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