20 FEDERAL ST - BUILDING INSPECTION (9) fL*NSIMOST9E f&*B4 APPROViE0 BY 744E
JWPMTDR PRIOR TD A_PERMIT BEING GRANTED
CITY OF SALEM
Date �0/O
ward
Zorting District
Is Property Located in Location of
the Historic District? Yes No Building _ LO A/4_V(
Is Property Located In
the Caneervallon Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install 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 acconfing.to the.following
specifications:
Owner's Name I f1 G
L �1�
Address & Phone 2O % Q L'N1t L S O ZY) 2/
Architect's Name 5 /V'*1�
Address & Phone nn f
Mechanics Name
Address & Phone 3AlGnesml�Au G,e vtLe4On�vo L_57sr) 3 /yS
What Is the ptaposs&buiWM?
Malerlel Of bttlldirtg? f� If a dwelling,for how many famNes?
Will bonding cordotm to law? �/C�S Asbestos?
Ealhrtsted coat 5 S City Ucanse# 0 3 au 7 state.Ucertss e 6 .3 a»azj
haste h�ro�ueat
Lie. e a
ignature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
F
V /
No\
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
�S 19
AP�iOVf D
INSPECTOR F BUILDINGS
'tl
{ PUeuC PROPEMY DBPARTbiFNT
120 WAsmimaTON STRasT, !RD FLOOR
SAL[M,MA 01970
TaL'(976)745-9595 FAY. 360
STANLWY J. USOVICZ, JR. _
FAX (97S) 740.96"
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the FovisiOna of MGL c 40,SM,I acknowledge that as a cmdidm
Of Banding Peamh g .all debris remiting from ft const<nebom' actin
governed by this Building Peamit shaft be disposed Of in a properly licensed soH&waata
dispopi facility,as dewed by Mt3L c
The debris will be disposed of st
/ Location ofFacilky
Signature of eimR Applicam Date
memmUm
(PLEASE PRINT CLCLEARRLY)
n �
Name Of Pcmnit Applicant
. J
Firm Nam4 if any
3l/�/G9r�iso�it-Gi+���r�
Address,City A State
The above statute me imm that debris 5om the demolition, rmovation,rehab or odw
alterstion of building or sbucnue be disposed in a
Properly-licensed solid-waste disposal
facility w defined by MGL CIU, S 150A,and the building permits or licenses are to
indicate the location of the facility.