16 CLEVELAND RD - BUILDING PERMIT APP (002) DATE:
Gl-a
�itp DfA�EIIi, a� aL U�Ett
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED pp
Location of Building /�, e LL1 C.4r�f� RC91+b
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alt ration, Repair/Repiace, Foundation Only, Wrecking
Other: AFff h'�i.sN� lj�L F
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name: J-4VAZS 4--ZlIV13 - V50 fAtor: MUVSI�- f/-f AC9 -74tlo
Street 16 eoLf tlT-Z 4A/� kkity S;4aa4 Street 68-Id RIA Avg City S4-(Q v"
State--W,4 Phone (y7k 744- , Z7 ' State jl�A Phone
Architect: /1if City of Salem Lic#
Street City State Lic# HIP#
State Phone ( ) Homeowners Exempt Form __yes no
Structure: (please circle mgle Family, ulti Family# Other
Estimated Cost of job S r .� 0 r
Will building confirm to law? ✓ yes no
Asbestos?_yes moo S/W1A- (— 2�'ra, / 5 r X r
Description of work to be done: t �.
Drawings Submi ed:_yes no Mail Permit to: I '
r X NO 1 % op tangy iAx >°-
X [ attL OaU,64-cry,.
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit il
oning Map/Lot
Permit fee S
C0HMMS:
/
APPLICATION FOR
'PER/W TO
�OCATION
i
PE nM�IT GRANTED
/yt4�2� Z2
kEC
VFD
TOP. OF ILDINGS
CERTIFICATE OF ocGuPANCY =
YES
NO
1 (1 ittj II� f11PIII, 4RII55c'tLh1ISP 5
publir prngtrig Erpurimtnt
� l
$uililing i9rpzinmrnt
(oat tiatrm Grrtn -
509.745-9595 Exi. 300
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, 554, I acknowledge that as a
condition of Building Permit 0 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 hIGL c III,
5 150A.
The debris will be disposed of at:
location of facility
f
3��
zu u
Signature of Permit Applicant Date
Fully complete the following information:
(Please print clearly)
A o 116 m l- (rlil n<
Name of Permit Appi=cant
Firm Name, if any
Address• city b State
The above statute requires that debris from the demolition. renovation, rehab
or other alteration of building or structure be disposed of in a properly
licensed solid waste disposal facility as defined by MGL cIII . S150A and that
building permits or licenses are to indicate the location of the facility at