2 FOREST - BUILDING INSPECTION f"1NS1ftW13EfW04MI9 APPROVED BY T44E
WPE=R PPJDR TD A PERMIT BEING GRANTED
CITY OF_SALEM
No.� \ Dab /
Ward
ZW*V DIaW
rw HI District?„ Yat No Location of
aalldias
Is Piopoly Locagd in
i B»COnwrvatlon Arm? Yet__No_
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
RepaidReplace, 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 aocordwiq to the following
specifk:ations:
Owner's Name e'e�k T ,/✓=/� �y
Address & Phone aP�s> i-1 U (720 9 z1
Architect's Name
Address & Phone
Mechanics Name
Address & Phone ( I
Wrest is ow pxpoaa cf wWW
M"W of bt~ n a dwaft for how many Wn as?
WE tarldMq carrimm to law? AsOastos7
EOnabd coat 3(�70 • 0() Cpy i GWW r MM@ U0W=r
Ile. f Iaq►rosaaat
Lic �/ 1 G / I /
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRI ON OF WORK TO BE DONE
MAIL PERMIT TO:
1
No..
APPLICATION FOR
PERI/T TO
Ro o
LOCATION
PERMIT GRANTED
19
AP7vFD _
INSPECTOR OF SUILDINGS
PUSUC PROPERTY DEPARTMENT
20 WASHINGTON STREET, 9RD FLOOR
SALEM.MA 01970
TEL (978)743-9593 EXT. 360
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAV
IT
In accordance with .the provisions of M
Prn GL c 40,S34,I acknowledge that as a condttwn
of Building Permit# all debris resulting from the construction activity,
governed by this Building Permit shall be dis
posed of in a properly licensed solid-waste
disposal facility,as defined by MQ,c III,S 150A.
The debris will be disposed of at: c�
Location of Facility
Signature of Permit Applicant �
FULLY complete the following infommdon:
(PLEASE PRINT CLEARLY)
(fir p l y
Name of Permit Applicant
Firm Name,if any
Address,City&State
The above statute requires that debris from the demolition,renovation,rehab or otba
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIlI, S I50A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BUILDING DEPARTMENT
H0ME0WIE1t UC6NSE EXEwnoN
Pkm Pat
DAMR
i081 OCATION �0IC r s I .
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ii06dlsaarmt �'l 7 �'y - 7
TEaEPHOMB
Pi(FSEHT i'dAL.IIQO ADDAF!= S r3 m r
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w ko tad a snow saeb N meowm a w m Whidul.*r Hm oleo doe teat Pm 0
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DEFft4TlC"Q HONffA WHM
Penoo(s)wbo owm a p nd of kad an whkh bc/dae asides or kateade to reside,op which dace la,oe k
inuaaded w be.a am a"m toady dwcXm&suKhed a dead"wucaves aesemos7 ti WAS aaa=dhe
farm svucwm A Paso►wbo eonmvm more that me bomc in a ewPyaa perkd*A mot be eoa Wk d
s bovaaos m. such lnonwowner sha><sabndt w the BuDdins Offm&Lms b W=Pdbk *A
Buiklias Olfeial,that belslae be tcspomabk to aU sud►work patamed .
The undo 1pcd-bcm ow ndm asovns respans%ft lot=nyn as wide the Stile BaDdt Code md
other appDobk Soes by-kws,rules and teSdkadmL
The madosisaad•homwwna-oatifia that hchhe madosuuds the Cip of Salem BaDwho Depwama
minimmo bdpwdon pmocduas and ngeucnxm and I)W hlsha wall wmply wRh said Aoadmes d
T=Fb=KM
HOMEOWNER'S MGHATURE
APPROVAL OF BlJIIDING D�SPECTOR
See other ode for sure code
HOMEOWNER'S EXEWff-n �I
The code suits that 'wW b=wowaa perfwmiaa wivh for w"a ball ft permit Is Tegdmd dal M
excmp<from the pro+idm dthis seedoo (Section 309.0-1Jecating d Cgmtrucdoa Sgpavisr*.
provided that fa a bomeowaa cW&u p p cnm(s)fu bha io do.tucb wow,tbat sixb bomeowaa dali gat
s apaviaat;' •
MW bomwvKrn wbo use this excmpdoo we &wwase tat they use numbs an I I I INg[t
rupevnor(see Appcadla Q.Pales and Retulnbs for Liocosiot CeoNrreiloa Sgervissra�Eeetlagl
.2.24 Ibis lads of awarcieu cfbat nm tt%tcrios problems.p w&v"w hM dw boneowaa ldsw
Urikeased ptnome In tots am yom Bond a t ptoQed apahm ire wilicem"d pa"U as llwoold via
liaatcd Sope+3w. 71e bomeoe6er saint sa supervlsw It midmost tnpas4lf. .
To same that ft boraeowna Is tally awoe of l%Mcr asponr3bMdek mngt oommmdde as Vft
of the permi{appllodvq that to b meowna«rdfy that b& Ae mdersatr a tfrs responalbulds ds
spavlwt. You mtp eats to atncad aid adopt Fad a kmake dficadM fbr aw%7M eomtood*