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CITY OF_SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof. Remot. Install Skft Construct Deck. Shed, Pool,
RepaidReplace, Other
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOW DELAYS N PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undwaipned hereby applies for a permit to build accordGip,to the.followirtp'
specifications: L
Owner's Name 06,vyl S1 rats
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Address A Phone A-v`e. 0M 7 v_r MY
Architect's Name
Address a Phone '�� f I
Mechanics Name
Address A Phone ( )
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SWmftm of Applicant
SO= UNDER THE PENALTY'
OP PRIUM
DESCFNPI OF WORK TO BE DONE
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BUILDING DEPARTMENT
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APPROVAL OF BUIIDING 1NSPFa" ,
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HOMEOWNER'S EXEMPTION
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
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 III,S I50A.
A6'q- "r.(Si.� c n.Jj�
The debris will be disposed of at: L OC¢�J /(a5 PIs � do �h�Avic
Location of Facility
`1/1 3/06—
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
0011JA ('31r)I7
Name of Permit Applicant
Firm Name,if any
35�f JeA66xi *Ae. a MO MO
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 cM S150A, and the building permits or licenses are to
indicate the location of the facility.