19 COUSINS ST - BUILDING PERMIT APP 9E4HST-BE fiL-lRD-A*0 APPROVED BY T44E
LN3PECJ4A ,PR1pB TD A PERMIT BE1NG GRANTED
CITY OF SALEM
NO\ `t�. .'� iir\ Date a D
aryl ' ir �� Ward
'� ornne e� Zoning District
Is Property Located in Location of
Q
the Historic District? Yes_No fL Building ( ��pUSCt.
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding Cq s t Deck, Shed, Pool,
Repair/Replace, Other: I1n.5 3` U ka.±L
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: r
Owner's Name &�i S,L e L
Address & Phone �� T6rm e - 42Lft l- 6 -
Architect's Name d UA 78(4-
Address & Phone Ll-xrje .!Aeol 5�i., Z14 9q_7T
Mechanics Name «nLN�S C� Cfiuc��nt�
Address & Phone
What is the purpose of building?
Material of building? &;Ok .41.p�qf a dwelling, for how many families?
Will building conform to law? V O"� Asbestos? LgP
Estimated cost 7, 100 0 7 City License# stat ' e #
Home Improvement `
Lic. I
S gnature of Appiic
SIGNED UNDER THE PENALTY
Of PERJURY
DESCRIPTION OF WORK TO BE DONE /
��� SGt oi.,a r,�_-�-IiLPT► 1'2 1'a ek:S i i%A
-ibL G�es�f
MAIL PERMIT TO: i/`.f�,1Fi/��p�rr!sbin—
No.
APPLICATION FOR
ERMIT TO
LOCATION
PERMIT GRANTED
A ZD44�j
INSPECTOR OF BUIL NGS
w
W
r
0
j
PUBUC PROPERTYIIDEPARTMENT
IZO WASHINGTON STREET, 9RO FLOOR
SALEM, MAC 1970
TEL. (978)746-9S396 EXT. 360
FAX (978) 740-9846
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 constriction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-wSSW
disposal facility,as defined by MGL c 13%S,150pA.
The debris will be disposed of at: o�
on of Facility
evil
Signature of Permit ApplicaV Data
FULLY complete the following infonaation:
(PLEASE PRW 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 ciu, S 150A, and the building permits or licenses are to
indicate the location of the facility.