6 HATHORNE CRESCENT - BUILDING INSPECTION r -
'*L*Nf 1*WT19E fl1i:t*4YND APPROYfeD BY T44E
1I111SPFCM0 PRWI TD A PEJ31W=NO GRANTED
CITY OF_SALEM
NOM U� \ Data
1 o Wane
ZWft Dishid
I&P oWty Located in Location of
ma HW"Ic Dfddct? Yes No_ amuAins
b ProC m1Y Located in
lha
Aiaamtlon Mae? . : Yak__No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, :roof nstall 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 accordwiq to the following
specifications:
Owner's Name V C i F PCs c ,J5
Address & Phone l-14THORAr,6' C -Sc &;'fl >41i 3l%Z7
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
What Is N■papmo a WWmg?
m"W of bWldrq? N a dwoft .for how mmy ImnSm?
WIN bulldrq cmft m`\to law? Aabwtos?
Es mated cotl U Cqy Lk W N ShN •
aaaa� Iaptays t
Ue. t
77
re of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: LLT—,k of l jr o oes '""iyT
.t.
NOD� V�
APPLICATION FOR
,Q PERMT TO
LOCATION
PERMIT GRANTED
19
ArMOVFD
INSPECTOA OF BUILDINGS
PUSUC PROPERTY DEPARTMENT
120 WASHINGTON STREaT, SRO FLDOR
SAL K14,MA O1 Y70
TEL (978)74"595 EXT.360
FAX (978) 740.96"
STANL.EY J. USOVN:Z, J&
MAYOR .
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MG3,c 40,S34,I acknowledge that as a condition
of BWdng Pamit S_ .all debria resulting f om do conatrnctioa Uftfty
govaned by this Building Pewit"be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c nL S1SOA.
The debris will be disposed of atQ5_,��
tooafaon of Fsmllty
Si ofPamit pliant Data
FULLY complete the following m&mm&om;
(PLEASE PRINT CLEARLY)
Name ofPe=k Applicant
Firm Name,if any
Address,City a State
The above statute regmr=that debris from the demolition, renovation,rehab or other
alteration of building of structure be disposed in a propaly-licafaed solid-waste disposal
fidlity as defined by MG.cIQ S 1 SOA, and the building pawns or licenses ate to
indicate the location of the hdlity.
CITY OF SALEM
BIWING DEPARTMM
HOIZOWNEIL UCFNSE Emanow
Pkaac PAS
JOBLOCATION
ADVRM
'HmAEo mt ?7 21 ' 7 V/ V 25`L
TELWHM
PRESENT bdAa.II$G ADDRE!! �Sf7�^�!a- .
• The ew,ott,eaaaptloo d`bameownetaf was cxtcadea to btctade ewoer�wrk+�'�P�'j'�
lloin a k»aad to albw such homeawoera to en=a�s m bdividallix bbs vrbo does aat pwae�t
lk=n pmvim t m.tw ewer ad ssm mpwvlsm
DEF94TMOFHC%ff.OWNM
Pen=(s)•rho mm a powd of Lod on wWch bt/the mside a bmu&to mid%oq wbkk that k or k
buended to be,a an a Two Lmib dvmMn&surd"a detached Muctmea aertoay to Sa*tot sstdI
farm svuc=vL A persm who eonty=mae Ilan one bv=bt a two-year paSod*a0 sot bt=add""
a bcmwwm. StA nwmeow mf shahs Ann w the Suiidist Oltteld ts>midaer W � t;t
Bw7dbts we4 that IaWK bt ttssponabk so all such wwk paSamtd
mm wwc sivnd I mevwne awwttes topora%mv foe compiiana wdt *t State Dvb tb Code fait '
otha appSabk foes by-laws,nda sad TcgWa m L
The wwcmpted 9tomevwne a mfm s that Wsht wtdastandt tbt Ciq of Sskm Baitii DWwoma•
rnioimwo inspavon ptoadaies and 711ito,
and-Omblsbc vAl eompb witb saidpnobtmcm
HOMEOWNER'S SIGNATURE ,yam`
APPROVAL OF BlJII ING INSPECTOR
Sac mba side fm mu colt
HOMEOWNER'S EXEMPTION
The cods:taus tbW •arq ltatneowaa pedwminS-iv*for wbkb a bt Dft pcmk Is ltgobW slrS be
cxcmp ftm the prtriairraa of ibis ucdaa(SxsE.s]t1y.0-1JocasiaS d Comraetios SapaNborA;
provided do b a bcmeosrsa enma p perwo(a)At biro to do.such wedr.that r6a botmcowa- 4004
rqw�„lM..
Mate bon.wwwjmm.rho me thb exaapdoo we mt wm that they are awmobg the PMOM&WO aft
wparttor(see Appeodb Q.Roks and Replatkae for IJocosiaS Coostncdm SuperrkeM Smcd.w
.3.30} Tbb Is&of wwwamst ohm Twobs in scrim pmbkn s.psnkalerI w1Ka tha hooeorrM bier
Uriirm+ed pcnoot In this can yaw Bard ormot proceed agahm the poloo n Itwwla via
lkt=W Strpavbw. The bomeonker sdiat a w it www"m e�stoasl
To emn that die homeonacr b MV awwa of Ulha•tespmsibMdd s.more segdn:r past
of the pcmdl applkadm that the homww na ocnW that bcVw midersme, the respessbumm are
supavb= You may can to woad aad adopt ra&a kna ardliotias for aw is your cosh.