197 JEFFERSON - BUILDING INSPECTION r
gPbW1AWT4111E fKA 94ND APPROVED By T414E
JMSPFCZOB.PignmR TD A PERMIT-B1EING GRANTED
CITY OF_SALEM
No. [\ VA-
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Permit to: BUILDING
BUILD PERMIT APPLICATION POP:
(Circle whichever apply) Roof, Retool, Install Sidlnp, Construct Deck, Shed, Pool,
RspairfiWo a, OtMr
PLEASE FILL OUT LEGIBLY ik COMPLETELY TO AVOID DELAYS IN PROCESWA
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build aocortLig.to the f Howklp
speoiHations:
Owner's Name
Address 3 Phone 19 '� AvE ( m-) ni- 4$I
Architect's Name -e- .
Address A Phone ( 1
Mechanics Name so,V. .
Address & Phone ( 1
Whol n s»was•or b~ it p d4A--e. CS a-EV\ _ ('row //a -ro 4-u i I
momm of billdrq? M a dwaarq,for how many Imam?
Wa buY v Isar? ?
Wd 600 - o CRy Licana r BtaM pawns r
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J �J stun Applicant
SgNED UNDER THE PENALTY'
OP PERJURY
DESCRIPTION OF WORK TO BE DONE r
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MAIL PERMIT TO: l sl J o Vic. /4 0 '. Sa 2 mil '✓
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Cl1Y of SALEM
BUIMING DEPARTMM
HOMEOWNER LICENSE EMWO•DON
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a bonseowaes: Suds 9wmwwxc'Oaasutmsli to rho Buslft tm8et lose
Bw7dbsi Odsdd.tht belslse be aspormbk to all ands waels pQfanaed ••
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otha appLobk too by-kws,Hies and=9WW' wL
7 be wdcsiprd-M-Wwnd•=US"that WSM wWcatasds the CIV of Sakti t'Jaildbg Depaonal,
minissma kap=m proesdaet and soscatcros and that hhhc wig comply w i s am Pat& t adagoiresssaa -
HOI.MveR'S SIGMA n
APPROVAL OF BUIIAIMG wS crm
Sa seer side fa srau code
HOMEOWNER'S EXENEMON
-- - The code sutas floc 'atq oa owner performinj fa svh(cb s bnDdius permit is tegoit�d 1 M - - -
' cxcznpl from�c po�isioro of this sctdom (SeeWa 70'.L1-13aasiml of Casutraitttoa Eapesvlsaa�� • .
provided that Is a Leeaeocrrxr ewes�perseo(�)Sor hhs to do.socL weul4 that sisc5 hossaowaer shalt act
MwW hotaeowma who ON this erampdca are imware that*AY art atst mbg the VVcmdbMdO da
svpovim(sec Appcodls Q.Roles and Replstloa for 2Jes aslol Cssatrnedsa SgeavboM S"AM
L25)6 Tbb bck a[rwarc ca alien tcwlu is ac&w poblcm pw*i-6lsr� �lsea tbt 1- , R was .I"
onileea+ed persom[ In dis oast yaw Bard ammm proceed&Saba the musoe -O mm at ltwa>>a wlds
liaased SopavLa. 71e homeoemcr sdhss as suptrrb�r b aglmste�!tsliewalL
To easmt that the hmaeownes b mV swan ctMroa esDonrfbffide;smq a p�
of an penall spplicadm that the homeowner cuft dw hr/shic - denss I the mposslbum"eta
mpervbm Yoo mq art to amesd wA adopt weh a lormA =2Modaa lsr tsw In your
CITY OF SALEM, MASSACHUSETTS
y PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
4& FAX (978) 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# . 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 R S 150A
The debris will be disposed of at:
Location of Facility
Z"--�
Signs of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
CfG: /
n ( a '7 4, -
Name o ermit Applicant
Firm Name,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 ca S150A, and the building permits or licenses are to
indicate the location of the facility.