15 HARRISON AVE - BUILDING INSPECTION (3) 1
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CITY OF SALEM
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Parma to: anum SIG PERMIT APPUCATION FOR:
(Chle whichmm apply) Roof. Reroof. Install C Constrtxt Deck, Shed, Pool,
Rapair/Fb *M. Ducar
PLEASE FILL OUT L ENKY i COMPLETELY TO AVOID DELAYS IN PROCESSSM
TO THE INSPECTOR OF BUILDINGS: '•
hereby applies for a permit to build accor>o 1hafollowing
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Owners Named.4 A�?/0 EL �.�C
Address d Pharw
Architect's Name
Address & Phone ( t
Mechanics Name
Address & Phone ( 1
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MAIL PERMIT To:
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
' 120 WASHINGTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL (978)743-9595 EXT. 380
40 FAX (276) 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 0 all debris resulting from the conshuction activity
governed by this Building Permit sball be disposed of in a properly licensed solid-waste
disposal facility, as defied by MGL c III,S150A. (�
The debris will be disposed of st:
Location of Facility
` Sigmture of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
15 / 'g zys'o /n AUQ
Firm Name,if any
Address,City tit 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 ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
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HOMEOWNER'S SIGMA
APPROVAL OF B=ING 1NSPECTOR
See other side for start code
HOMEOWNER'S EXEMPTION
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