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Plans must be filed and approved by the Inspector
prior to a permit being granted
/ CITY OF SALEM
No. � �// Ward
HISTORIC DISTRICT? Y N Dater Z l
IF FOR SIDING, HAS ELECTRIC + Home Phone
PERMIT BEEN OBTAINED? Y N Bus. Phone
APPLICATION
FOR
PERMIT TO
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the
following specifications:
Owner's name and addressZI
Architect's nameA4L4
/�g
—4/ /1'
Builder's name
S torr e
Location of building, No. S15
What is the purpose of building?
If dwelling, # of units? ?J Material of bldng?
Will building conform to law? es, Asbestos? ,t o
Estimated cost g,,p� City Lic.# 173 Stat Lic.#�
Signature of Applicant Cl/F/
SIGNED UNDER THE PENAL OF PERJURY
DESCRIPTION OF WORE TO BE DONE
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Mail Permit to: ?� ��
Ward
APPLICATION FOR
PERMIT TO ROOF
REROOF OR INSTALL SIDING
Location
PERMIT GRANTED
X19
A roved
Building Inspe or
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MEMORANDUM
701 AB Buddtne Oepw=cntsrZlate Buddtat Inspectors
FROM: Charly J. Dinexa. ALI=nntrator
DATE: 091100 r 11. 19353
SUBJEcr. NIC1. c4O. NSA. Added fly efRA. ti9 of the Aett nr 19RT
I he anave.mentmnca statute renalr= that nenm rrSartlne irOm ine demallu0n. rcuisviuO6 rtamodtiis
or either mtermmn tit a huttutne or struCHIM he dtsuMus of in a pmpcmr urchs it :triad who OEM
IJtaaty as uefinett av MGL 6111. S 13OA and that nutusule permns or needs= aro its intro=s tw 613t7tu
,I( the faculty at wnwa the saud deem n to ne uupascu. THIS REOUIRE1MENTMOES Nd
,APPLY TO NEW CONSTRUC':ON.
In diver to simaufv the pros= and to prrmue unlldrmity. we arc 210=10e a cute of a it11t Mtet?c
as citaer mTrmu=and use=it is stn=the mmpicttst form snd be atratated ru the uitiea aipptrf buddh
Permits or ticcnz= or rc mau= it an your tctternead.
In Oscal mantc3naL edmmer=L lnuustt=L ur mulu•unit anuitae conslrucuon. the contractor um ant km
the dumaater suomntraanr at cite time of the eulWme permit appticauon. In suca asa tndatrnmm cal
(If an Affidavit an tic usm.
The mmntete taw Is tmntamen to the Wrcmner issue of C17DEWORD whim wnt he marled W vita OR 1111
nm twn weeps. if vna snouta have any uuettnn. ntease tct to know.
CJD/km
AFFiDA ViT
As a result of the provisions of MGL c 40. 554. I acknowledge that as a condition of Building Permit
Number all debris resulting from the construction activity governed by this
Building Permit shall be disposed of in a property licensed solid waste disposal facility, as defined by MGL
C 111. S 150A.
I certifv that i will notity the Building Official by 2 3
(TWO months maximum of the location of the solid wastdisoosat facility where the debris resulting from
the said construction activity shall be disposed of. and 1 shall submit the appropriate form for attachment
to the Building Permit.
t
Date Signature of Permit Appht9nt
(Print or type the following information)
l
q C L ��
Name of Permit Applimnn[
Firm Name. if any
C�4
Address
In aaardance with the provisions of MGL c 40. S 54. a condition of Buildine Permit
Number is that the debris resulting from this work shall be
disposed of in a property htxased solid waste disposal facility as defined by MGL c 111. S
150A
7be debris will be disposed of in:
.2 � i � f
(Location 6f Facility)
Itr
Signature of Permit nophtant
Jz- 9/
Date