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S I" T,E ffL-Er f- APPROVED BY T*IE
1U5P XTDJ3 PEAR Tp A.PEF111A1T.f3EWG GRANTED
CITY OF SAfLEM
No. w 0 -Z o O y ��` '� �'t�` Date
f:.
L` 't Ward
\r�crmNs Zoning District
Is Property Located in Locatiou of e," D
the Historic District? Yes_No_ Building
Is Property Located In
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, ReDlace,
Install Siding, Construct Deck, Shed, Pool,
Repair 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 Ile
/C�C /e �''6 e n f )t o(s i atJ G �wt s 1�a� cJe .
Address & Phone J �Te �Ft ��aJ due.. WS f > y6/- y3s0 -
Architect's Name
Address & Phone ( )
Mechanics Name /a �c;s;vJ /CcaJ JC��i'c4s e„/ �I 71
vc.
Address & Phone 3,7, / Ct-NcV Jf/ -6L) 6/Lc0/F)o 01>f-) s f,1. G 3 02
What Is the purpose of building? �v e o- 2e C ye_ /, 1
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost �� C City License # /90 b State Liceryse #
B� 1rOoement a � _� ,
Signature of Appilcan
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE /�
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MAIL PERMIT TO: Ive c lets. -la/ Co, of o..j ff- ej C/ox(-aj 4 evil
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CITY OF SALEM9 MASSACHUSETTS
,3 PUBLIC PROPERTY DEPARTMENT
z 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
••' ''' - TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. LISOVICZ, 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# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c IIII,r S 150A.
y The debris will be disposed of at: I (? Z-(k �)�(C
Location of Facility
• � lv � �J• III
Signature$ f Permit Applicant _ Date
FULLY complete the following information:
(PLEASE PRINT 1CLEARLY)
P/t L IS t D� /C OJ t_�.� f9 54CRS cT � Ci�t f<,n✓1 �b-L
Name of Permit Applicant /
C3) .39yd
' Firm dame, if any
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.