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CITY OF SALEM
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Perm to: BUILCM PERWT APP=TM POtlk
(Circle whw wr apply) Roof������Rwd InM Sidklp, Cwwbw Deck, Shed, Pooh
�;"( Ogler.
PLEA` SE RLL Wr UNMY A COYPtEMY TO AVOW OR AVS NI PROCESSM
TO THE INSPECTOR OF BUILDINGS:The umbra0lied ,
hereby appNes for a pwmk to bulkd aocordkp,to tf>♦.tkwkp
Owners Name
Address A Phone Zo (9,7e I s9y os4o
ArohkoWs Name
Address A Phone [ 1
Mechanic Name
Address A Phone
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CITY OF SALEM
BUnDING DEPARTIv M
HOUBO WNERLICENSEDMO'AON
Pleat PAN
DA*■ •flue los
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PAESEti7'IbAII.IP!QADDRElS 2� ��r.,aE^� c�flrtJ�. Se�*� .
The eu7ct,owmFdoo of bomsowmicl 'was.mended to ba lnde e.+oer-sfmP�d a*s71i0 af't MD
llnhs es kas and to&low sod kaseowmoa to cnPF In bdividgl lae bite w10 deer not ptw•
iioca,.povided tbo dw owner set as swPervism
DEF94TMOFHCMECWNM
Pasco(s)w►a oe+eY s pan
eocl d bwd on wbkA behhe asides a buesda tw� . �
buerded to ke.a awe to two bmt dwcMsl&snsdrd as dwdKd mum wu 60=5MY 00 Fees
fum svwuct A Pcnao who omwu=mono thm car bc=In a twolm PcrW
a bovommer. Sueh`iameowad'ahaRsubsadt to the Btu7dbi j OlSe3.L oa a rsesP s�p�k
Btuyding off cial.dot baldte be nspomibk to al saeh wok pa ed leem Under din kuildkq PwmL
7M undcsiped lmm mwset"Lw mns=goyjjWV f r=mpft=wldt*9 State BuD ft Code Ed '
otha appbeabk jots by4m.twin and teSukdaa<
The vndasiprd'lamevwner'ocrtifw that helshe mdcstandt the Ciq d Sty m, .
mi n=bopwdon proccdmes and ngtmaoKms and that ldshe va=*
TeguitmeR
HOivWVftlM'S S)GNAnm
APPROVAL OF B=ING TNSPECTCbt n
Sae mba side for state code
HOMEOWNER'S EXEMPTTOI�I
- -- — Tac cock its that •a�i }wmxo.rnn puf=4 vsk!ai whkb a WDdlft permai�re�*A1 tie
cxcmpt fw,a the providoma of tbir secdoa (Secttas 70'.L ;31anslmg of Gmm Kliam Soya wsm�;
provided that k a Lomreowrter caps;�pasam t fa bhs'to dosaeob weei�sbat aneb boaocowaet tisaB aat
o.upartrac•
Mara bomwwnrs wbo we t h era *km are inrwaa to they are mumbs 62 psyomsfbman do
rapa•vim(see Appends Q9 Stubs and Resularfoa far 1 ueslag Coostrwctbm Soperrtsaa,Saes
.2.2146 Ibis 1u#cf nwwwm=dka resahs In acrian pobk=s.porskahr�w5e?the i p 'A M lbba
urilkcnW pesomt bath case yaw Dowd cuma proceed apaitst the mYtoemeo PC*=as ltwonla w!d
Itaared Sapmisar. T►e 6000:owter amhrS a apervMN it ttb)faaie�rsspm�DM. .
To crime dm tht homeorrncr b falb;wars of M%cg responmibTf dm%marq oommtm�de regrta;a Ace
of the permit applicadcA ftt the bomeowner cut*tbaa Waht mtdetsmmda the responsfbDums do
mupavbm Yoo mq are to anmW aced adopt aaik a hnukadfksdan hr un in yoer commmdqp6
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL (978)745-9595 EXT. 380
40 FAX (976) 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 150A.
The debris will be disposed of at: &p#Ajm r
Location of Facility
of Permit Applicant —Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
7-0 unAW Wes. S&LO-1 MA 0l1-70
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 S 150A, and the building permits or licenses are to
indicate the location of the facility.
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35" II 29" 39" �I, I
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All dimensions size designations given are U.
s. This is an original design and must not be Designed: 12/11/04
subject to verification on job site and @p'� o released or copied unless applicable fee has Printed:12/11/04
adjustment to fit job conditions. 's-` been paid or job order placed.
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Designl Fp 1 Drawing#: 1