11 HARRISON AVE - BUILDING INSPECTION $d
iaLllffSiYlllST13EfB-E� APPROVED By T44E
.WSAECJDB PWR TO A PERMIT 1BEWG GRANTED
�\1 CITY OF_SALEM
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No. Date /3
l
s:
Ward
�. Zoning District
Is Property Located in Location of ��JJ the Historic District? Yes No Building
HP
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(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 according to the following
specifications:
Owner's Name nVMAA�W) e66kiklL}:,..
Address & Phone I A-kt Q, t-o W A ti (178) -1 q q -04 91
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? /L-0 p rQ If a dwelling, for how many families?
Will building conform to law? ice G _ Asbestos?
Estimated cost 1�0 (7 City License N State License#
Bane Improvement
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
f Pj00 �l/ten/� �19 4
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MAIL PERMIT TO:
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
AP V D
INSPECTOA OF BUILDINGS
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PUBLIC PROPERTY DEPARTMENT
• 120 WASHINGTON STREET, 9RD FLOOR '
SALEM,MA O t 670
TEL (878)74ss-6365 Orr. 860
FAX (976) 740-6846
STANLEY J. U60vICZ, J&
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ,c 40,S34,I aelmewledge that as a condition
of Mding Permit 0_ all Ildmis mating from the consMwtion activity
governed by this Building Permit sball be disposed of in a propaiy licensed solid-waste
disposal facility,as defined by MCIL c 13L SIM&
The debris will be disposed of at skL12j4 Tr4tkTTr=r �o a
Location of Facility
Srgaat=of Permit Applicant Date
FULLY complete the fonowmg information;
(PLEASE PRINT CLEARLY)
'T �atmIS KID .Bow1"
Name of Permit Applicant
Firm Name,if any
_�� ���Q.�.45c3W Alf SAI,e-t1 01�110
Address,City&State Mua
The above statute requires that debris from the demolition,renovation;rt:hab or o&w
alteration of building or sttucture be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 1 SOA, and the building permits or licenses ate to
indicate the location of the facility.