17 CHESTNUT ST - BUILDING PERMIT APP (002) iM�Ns �lE fN*WMD APPROVED BY T*E
Jfi18PJEC=,P4W W A'PIFAWT 9FJNG GRANTkD
CITY OF SALEM
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Permit to: BUILD= PERMIT APPLICATION FOR:
cards whichever apply) Roof,_Rer q Install Skfinp, Construct Deck, Shed, Pool.
idReplaoe• Other: v.�tt'k4 n , I ,0-.d?,,�,
PLEASE FULL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSMq
TO THE INSPECTOR OF BUILDINGS: '•
The undwaipned hereby applies for a permit to build accoftig.to the folbwinp'
spedficafto:
Owner's Name r(ZAluc66, 614 uvW
Address d Phone n (:of -6
Architect's Name
Address A Phone ( )
Mechanics Name
Address A Phone ( )
wha M to ps"m it bumw un l n4,
m"W W modes w Oct e•)'\U Nall m-1 br how many mm"? a
WE bwwft cmft" to law? ���,� Ambsom? QC)
Gafillalad ODaI `-Er,C>00 CNy llONfaa� 8Wa LbwIN M
� t
i wwre of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DE8CRIFTION OF WORK.TO BE DONE '
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t.
MAIL PERMIT TO: 1q C4� cr vv�. y sa ti 4 l A G1 Pi '
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W i i OF S/'II EM
BUILDING DEPARTIAM
liMaOWNER LICENSE E)MOMO
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DATE a nos r r,u <� •2�p5
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PRESENTIdAIIIIiGADDRB� 1`T C�\PCT iU_ U7- �A cAa . iN4
The CWm a.exm dm d'Aomeow•noti'was eats to lWhAt a rmem•sfeuPW d'900O OtTw
Ut>♦u a ka aid b a11ow each Lomeowvos to cnPsPs m .�bia wko does aol paws• .
Vocwt,.p wided thm tke ewmes set ss UVWVbM
DEFDancmOFHOIZOaIf
• Pcrsoo(s)who owm s psral d Lad oa�hkh hchhe resider a krends to tmside.ou �k� .
intended m bk a ons a two LmOy dwcVla&shad"a dcad W suttctmes sM¢a7
farm strewvet A pctsm who comtrttcts mm gm cm home in a two-yat POW Ila 10bt taaddoed
a honteowaet. Suds 9wmeorAd'shall ettbttdt to the Bstildbt�Oatds�m a lbtsR ts>•s
Bu Wbg Odteid.thse W tte be mpom%k to an mdt weak pabrmed wAutaboaft4pulmL
The mA=Ip W'bmwowaa"usumea mPon+9lMV for wmplist=v th la Stab Bt nft Colt w d
otha appgobk Som by-kws,ties ad tepdad=L
The u We psd-Mmwwne arty n lho la/she midaa ods the Cid of S!� >
miaitmva bdpw ioa proadmes wW regtpteasems and that W"wig=0*
re9uiremeaz
HOI�OWNER'S SIGNATURE ,��0 i�/J J" ��i��_
APPROVAL OF BMDING INSPECTOR c
Sm mba sick for tote code
HOMEOWNER'S EXEAPTION
-
cxcmp from do ptodsi m of*b section($coke 20 aa..-IJccasiog Of Coastrwetka S wrol eo
provided dw b a Lomsowna es�«p pas=(a)for bba to do.mA wcdl6 tM tdt�1 eo®eowaer d"iat
Maq wmmwmn vft we tb aamom are mawate I&A daey an awambs an Impemsibm"its _
aTavim(see Appendbc Q,Rules and Regutadom to IJacmbig Ceostrwedm SapervimM Seca
13eJ} 7Lis Lc![a[awaerien eSea tesnfts iA scrSaf prnblcros,pctieuhr�w Lea tits lloneoevm hbo
unliaased person 1A tLb snit yom Bard cario�ol proasd ajairsq arc IDuecemed peeps r llwo via
lioenud Sopen". 71e bomeoww &cling as apervber la wWaaalebi rsw ML .
To emme dm da botneowna is futb aw wa of hiller aspomibMde%tmop aotmSmddea tegsdre;spat
of dhe ptn J{appilcal ,dot du bmneowna ccnW do bWWw wA=Smnda*a tespeoa1b111dm eta
mpavbm You m v eats to anal and adopt Suitt a kna asdlksdm in mt to 7asr aossmssft6
,
CITY OF SALEM9 MASSACHUSETTS
f PUBLIC PROPERTY DEPARTMENT
. .. 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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, S 150A.
The debris will be disposed of at: f.A AS-rF, I _ I L`I Nri y ti/g
Location of Facility
c[A 2 9,005
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.