426 LORING AVE - BUILDING INSPECTION i
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CITY OF SALEM
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Ol�.D81G POW APPLICATION FOR: '
Permit to
(Chas vthW wor apply) Roof , In" Sid kq, ConsJW.DooK Shad, Pool,
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PLEASE FILL OUT LWKY a COMPLETELY TO AVOID DELAYti IN PROOttWo
TO THE INSPECTOR OF BUILDINGS:
The wdwdWad hstoby applies for a pwmk to build aowft g to to foinjus I
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Address a Phom 4 0rl;4/G Si.' 6?lf
Afd*oc 's Name 1tx9;�_ 19t c/f!i r0 1 R11 D i S o N
Address 3 Phone 3 1%0 t)>s o zv 3? 3 - /a (l�_
Msolmics Nam o�
Address a Phones
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Signature
. SIGNED NOER TTi!
OF PERJURY
DESCRIPTION OF WORK TO BE
DONE
It I
MAIL PERMIT To. `I ✓P L o�21
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PUBLIC PROPERTY DEPARTMENT
? 120 WAsNINQTON STREET, 3RD FLOOR
t r t SALEM,MA 01970
TEL (970)743-9595 EXT. 390
FAX (979) 740-OS46
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFWAVff
In accordance with the provisions of M(X c 40,S34,I acknowledge that as a condition
of Building Permit if ,all debris resulting fiom the consftction activity
governed by. this Building Permit sW be disposed of in a properly licensed soH&waft
disposal facility.as defined by MGL c M S1130A
The debris will be disposed of at
Location of Facility
Sion@6 of Permit Applicant Date
FULLY complete the following bhnnation:
(PLEASE PRM CLEARLY)
RIcNArD . ,i �i`1140/S0
Name of Permit Applicant
Firm Name,if any
Address.City&State
The above statute requires that debris from the demolition, renovation,rehab or otber
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.