11 JAPONICA ST - BUILDING INSPECTION (2) 1%AAlS*WT19EfiLeB4A9 APPROVEfl BY T44E
Jd MIMIF.1 PfIIIpR TD A PERMIT BEING GRANTkD 60�
CITY OF_SALEM
No \ Data L_
Ward
Is PropwtY tooatad In Location of
Me HWoft Dldrkt? Yes No IIaildins // Ti9)>o vrca
Is Property Landed in
Ifre CWmervatlon Ana? Yea Nor_
Permit to: BUILDING PERMIT APPUCATION FOR:
(Circle whichever apply) RHO 6leroof, Install Siding, Construct Deck, Shed, Pool,
epaidReplace, 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 accordwig,to the following
specifications:
Owners Name MA-�Jf('� r"o m�iL
Address & Phone
Architect's Name
Address & Phone
Mechanics Name
Address & Phone s-r, (g7gl l
what is the FRPoea of brdtdkrg?
Matadal of brNdnO? M a dwaang,for how mutt tamaaa? /
WIN fai ft cWfWM to law? Asbaetos? A-,o
1
Edmated cost 162 bra •00 CRY Ucare e tg.*' F� state ucw N a,
am Iaptosmant OK 7
Sign re of
Appkcwif—
SIGNED UNDER THE TY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: Ili AZP91-:�' Sf. 5i9Ce—:i�7 �19>,
.1.
No
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
Ol9 /e� 19
AP fD
INSPECTOR BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STRaaT, aRD FLOOR
SALEM.MA C1970
TaL.(976)74D-9695 EXT.ado
FAX (679) 740.9846
STANLEY A UGOVKZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordanoe with the provisions Of MGL c 40,S34.I aolmowledge,dW as a emadon
of Buiding Pamit f .all debris raulfmg from the conshuctlon,(dvity
gDvaned by Ibis Building Permit shall be disposed of in a properly licensed solid-wa N
disposal facOW,as defined by MGL c In,S150A.
The dcbris wiII be disposed of st /t-D"
LOCAUM of Facility
aturo of emit App • D
FULLSyY complde the following iafosm den.
(PLEASE PRW CLEARLY)
Name ofPemnh Appac"
Firm Name,if say
Addcw City dt State
The above statute requires that debris from the demolition,renovation,rehab or Other
alteration of building or shuchae be disposed in a properly-licensed soH&waste disposal
facility as defined by MOM ca S 150A, and the building pamits or licenses sm to
indicate the location of the facility.