31 HAZEL ST - BUILDING INSPECTION (4) 1MSIMSTI�EfiL*D-AM APPROVE{) BY T44E
.1WFXTD_]3 ,PFWR TD A.PERMIT B,EWG GRANTED
CITY OF SALEM
No.
Date
Ward
� mns�y Zoning District
Is Property Located in Location of
the Historic District? Yes No_ Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roo f I tall Siding, Construct Deck, Shed, Pool,
Re air a 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 o tom k (Z. LOL1OVI)
Address & Phone 3i 1->P�2F-L _Y7 ('�2g-)
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
What is the purpose of building7 i F1ry
Material of building? Q>k'> If a dwelling, for how many families?
Will building conform to law? f S Asbestos? ro O
Estimated cost eo . o0o City Licenser state e r_C3 031G73
Rome Improvement —
Lic. 1
1 tgnature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
(Uci,J QCt'�1= Q��l�it2 l�c�S�w-�12�
MAIL PERMIT TO: 14p; -Z_ t_ 5i 3p Lam..,.
No. —
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
� s/07 ,s
APPrV�D
INSPECTOR BUILDINGS ILDINGS
d ..
y
CITY OF SALEM
BUbDING DEPARTIv1W
RM&OWNBL LICENSE EXF ono''N
Plan Prier
DATE -7
IOBLOCATM
HOtrl£CiWtiFJI S.
ADDMM
HOTgOWIia Sr 7 L/I L/ 1 °�—
TELEPHOIC
pR>:sENT>,eAnnao ADDRESS S'A'`^�� .
The currae.c>,,pdci of-lwmeowWC was nacaded w bch de owner 4w=pled dwcMep ofTiVp
Unlu or ka and to aDow each homeowwn w a>gp an btdtvidhgl log hba wm don am pow=a
uccim provided that de ows a at as svperrbea
DFFRGTION CF HOMEOWNM w reside.oa w4dd►thaa b,ee b
Pcnoa(5)wbo owns a parcel of had on w•hkh UWA resides of baends mY b sum tse auodhr
intadd w be,a one to two family dwcliin&smdsd of dcudod saucoaes sha aeit be aonsid w
farm stracwmL A penm wbc eonstraets mac than an bent=in a two- s� softas
ad
Bw'ldia=Gffuid,
a homeowner. Stttdo WOow all sad vmh pabrawd wda t a bu"Av w= L
-- --- with the Sate Eaft Cobs one
The andas9gned'hoaeowna"ass�ahha resp°ns+bi>30'Sor�pK =
\� other appGobk goo by-bml.nhia ad TCZWsdcft
Tbr�yi�-Mm wne>r'a Ufm thri Wft wdashsrds th<a9 of Salem Bafldbh�Deparuoeal.
ma and req ' and that hhht wmp>,with said P
• minimtoa inspa-ti pmad
nqwycncm
HOMOWMVS SIGNATURE APPROVAL OF BUJIIDINgi
C1 OR
See other sick for state code
PUBLIC PROPERTY DEPARTMENT
120 WASNINCTON STREET, 9RD FLOOR
SALEM,MA 01970
TEL (976)745-9595 . I
EXT.380
FAX (979) 7409846
STANLEY J. USOVIC7, JR.
MAYOR
i
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 ae4Yity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MOL c III,S 150A.
The debris will be disposed of st
Location of Facility
.. - Z-aLl
ijnatuz6 of ermit Applicant Date
FULLY complete the following infomlation
(PLEASE PRINT CLEARLY)
i-s
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 c1I1,S 150A, and the building permits or licenses are to
indicate the location of the facility.