131 DERBY ST - BPA-2004-253 ROOFINGr
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IM-*M IftfST-BE f l.{-B-i!!D APPROVED BY T*IE
.II�PEC7'DB .PF fl TPA PERMIT B,EWG GRANTED
CITY OF SA�LEM
No. —S�J-2Qt�cl `t .. ,x ri Date
� C/hIN6 .
Is Property Located In Location of )
the Historic District? Yes_No L---� Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, QL9r , nstall Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
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:
Owner's Name 6y,1 -C
Address & Phone 1 /5 6 4 -51 IIA17 rrs(
Architect's Name
Address & Phone )
Mechanics Name
Address & Phone l cvc�� �� 1 ✓is ��/�
What Is the purpose of building?—1 �s
Material of building? If a dwelling, for how many families? _
Will building confonn to law? Asbestos?
Estimated cost G. City License rt N State License 0
25 3"b Home jr�ovn �
Lil 1�L0
�,Z zq Signature of App(cant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ci? r-e- �✓ U
MAIL PERMIT TO:
No. 2 S3 - Zp0 ` (
APPLICATION FOR
PERMIT rTO
LOCATION.
�-
PERMIT GRANTED
.0 03
APPROVFD
INSPECTOR OF BUILDINGS
4'
l .
�oxryT pF SALEM. MASSACHUSETTS
PWS LIC PROPERTY DEPARTMENT
120.WASHIN.GTON STREET, 3RD FLOOR
a .3•
gp SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
�arnr� 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 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 Facility
�l
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
nrm Name,if an
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.