119 FEDERAL ST - BUILDING PERMIT APP 1
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CITY OF SALEM
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Permit to: BWLDWO PERMIT APPLICATION FOR:
(Chle whMmw apply) Roof. Romof, Instal Siding Consbw Deck, Shed, Pool,
RoWf loplace, Other: ��z j'Y--
PLEASE RLL,OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSWO
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build aocorckmg.to the.following-
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Owner's Name W-M -//e ✓-Lf
Adass is, Phone 5^— L
Architect's Name
Address A Phone ( )
Mechanics Name
Address & Phone ( )
wtw is n.PEPM it m~
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EMInntEd Wd �G`� W Uo E st b •
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Signagtre of
SIONED TY'
OR PERJURY
DE OF WORK TO BE DONE `
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MAIL PERMIT M.
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APPLICATION FOR
PEFAIIT To
a
LOCATION
PERMIT GRANTED
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INSPECTOR>OF BUILDINGS
CITY OF SAIMA
BUnDING DEPARTMENT
HOMEOWNER LICENSE EMOMON
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IOBLOCATION � �o / �� Gt�l7�
PnFSErfri�eAa>r!ciADDRES= � �� f=PCX �Prm ( ��I /�! i/ A'-/, 'C
Ma cmamd owmpdc i of-bumsowgWr e$wcad�>o brinds ewaer P ao.n voCr+ow
Umia a td&ad b&now Sol bomeowmas w emg&r on bdfvidirll for Mm wbo does mot power a
iksa�,.p,o,idea eft ic.wser,a es. fw Awls
DEnwrio"W HOMEMM
Persom(s)wbo owm a penal of Lmd om wbkb bebhe asides a brads to tesld%o ""t 1%w b
bmaded w be.&am a two Lm1b dwcMa&smadad a dea6W Muctmes scummy
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firm soviw m A persam wbc eonsovets mat:tlmm cme bamc 1st s two-year perkd 0 mol
ad
s bomw:owW. Sttek nmaowmf slantEsmbndt w the Bmldb$ ��Oft
Btu Odical,that bLWw be aspommbk tm sii sock wait pafafmd totdet
*a banThe todusipmd-bomwwnef&n m u respomsibifby Sol wmplba=Vft the Ststc BuD ft code Md '
otha gpoc*k goes by-kws,rinks sad tegobdm t
The wWvwp W-%mwuwnum on ufm that helshc mdersta As the c*of Smkm Dandling Dwwums•t.
m mmam bmpwu m P=rAwa WA regmmmtam&rd that hhbe va wick said pro c"m id
HOMEOWNER'S SIGNATURE
APPROVAL Of BVIIDIING INSPECTOR
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Sec other side fof sou cock
HOMEOWNER'S EXEMMON
The cods stna tlaC -aiq iroaeeowma pafort wvrk fa i 6o�diu�yamat�ere�od�ea art M -
exemptfrom the provisions orthis recdon(Senior 70yJ.1-LacrisinS of Gssnrnnisa Eapervlsea�so
provided this is a bemcowna enpgtr D pecan(s)fer ldm to do:nrL waelr,1ba!rirk Lomeowa m dA gat
• Mq bomww u vrho nee this exempdom are imiwwe>b+t tbey we assombs to papomsumn de
evpuvbw(see Appemdbt Q,Rm4s and Rquistiom for Ummalog Cemtrwcdm SNesvissra,Samme
This leek cf sWNW= ess ohea uraft im sc ko pembkmr.pvdeola w a*go - a m bble
mdicaned persmra Im tbbt east yom Band eamrgt proceed&Sabot the milkemed pa�oo at Swadd�mld
lieamsed Smpenisec. 74 boommucr sdhng as wparvlsar Is abll�aieb rsaptoowSflL
To enema that the homeownu h fatly swat ctu% s aspoasibmtia.*aoq oommo�de=qW*-r vA
of the permii appikatIM%bat the bomsowna oudly that haWn mrdarsat , the saspmslbDldn oft
smpavbm Yaw mq can to arnow and adopt sai3 a*nnkcnVAadoo*c tea io your osammmlr.
'N\
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J CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 ExT. 380
.00 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 M S 150A.
The debris will be disposed of at: `r,P
Location of Facility
/ 'Signature of Permi cant f Date /
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
>2
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.