74 LEAVITT ST - BUILDING INSPECTION (3) 14;*M IM11STIBE fIL Af"OVEG By T+IE
,Ml5PECT0.R ,PR10R TO A PERMIT BF-l.NG GRANTED
CITY OF SALEM
^,\ s
No. 'qy Date
. j ward
Zoning District
Is Property Located In Location of
the Historic District? Yes No_ Building
Is Property Located In
the Conservation Area? Yes V No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck Shed Pool,
Repair/Replace, 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 `f ��
Address & Phone 7 7 ���1 /y I r ( g?S) -7 y`{" 7 z Z_
Architect's Name
Address & Phone )
Mechanics Name
Address & Phone ( )
What Is the purpose of building? S�c9 IZ�e7 L f
Material of building? GVp 0-D If a dwelling, for how many families?
Will building conform to law? GS Asbestos? !NU
Estimated cost cm� City License S State License k O
Hone Improvement
Lic. / pI z94
Sig ature cl Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No��\ V�
APPLICATION FOR
PERMIT TO
LOCATION \\
PERMIT GRANTED
I\
APP V�D
INSPECTOR OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, HRD:FLOOR
SALEM,MA O 1970
TEL (976)745-9595 EXT. 860
FAX (978) 740.9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGM c 40,S34,I acknowledge that as a condition
Of Building Permit 0 all debris resulting iiom the construction activity
governed by dlis Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL ch IM S150A.
The debris will be disposed of at:
Location of Facility
ignature o Permit Applicant APP NW-
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if say
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, S 150A, and the building permits or licenses are to
indicate the location of the facility.