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DATE:
.s
Citp Df �&afem, �KaS5aL ug;ettE
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building �i f 2 ST JCL f'M
Building Permit,Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding, Constmct D Shed�ool
Addition, Alteration, Repair/Replace,Foo Only, Wrecking
Other. :t
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AV.OED DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a pertnit to build according to the following specifications:
Owners Name: P C' , ?ootractor.
Street If3 Aa'z S fi City < C , Street City
State�(� Phone &V) C , 7 c//-/')} `State Phone( )
Architect:� It u�S City of Salem Lic#
Street City State Lic# HIP#
State Phone ( ) Homeowners Exempt Formes no
Structure: (please circle) ingle Faml�Multi Family# Other
Estimated Cost of job S J�' 60
Will building confirm to law? y s no
Asbestos?_yes✓o / I
Description of work to be done: i N S-�I//it5z, i9!ll �(/D f—Do (a Arty t J <<�e�
Drawings Submitted: yes no Mail Permit to:
X li C' 2,
Signature of Application,SIGNED UKD- R THE PENALTY OF PERJURY
CONSTRUCTION TO B&MPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit?# �� Zoning Map/Lot
Permit fee S —T—
CO!!?ILNTS:
arY OF SALEM
BU MING WARTMEN!
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s honteonas: Sn3'bsmeaaad'sisdf�a dte BnDdlai O�kiaL m�� titi
Buiidl+oS Odldsl.dm LeJdis be teepoadbis to ala saol wosk peforara aide de }cri •.
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To owasipw-bmwuwn 'eadtfe to Lehis mdc=Ldsthe aW Of Saks►Solids fD.4r— t.
pmoedow Ed nqub=Km and to Wft w l vice said poaedem ud
HpbffANRiER'S 51GNATlIRS ' .t �� / �1�S�
APMVAt of B=ING DWW
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B =ING IVARIMM
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HOMWWM'S SIGNATUM
AppROVAL OF BUMDING VWECfQiit
See aba ode fm saes code
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 360
FAX (979) 740-9946
STANLEY J. LISOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAV
IT
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, S150A.
The debris will be disposed of at:
Location of Facihtg
/
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
, 41e�j M �Cr�r
Name of Permit Applicant
—
Firm Name,if any
S c E 15z en-)
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 CHI, S 150A, and the building permits or licenses are to
indicate the location of the facility.