112 MARGIN ST - BUILDING INSPECTION (4) -PL114SiM IST-SE f L'fi N APPROVED BY T+IE
,IWECTDB ,PFWR Tp A_PERMIT BEING GRANTED
CITY OF SALEM
No\L���
,�x "� � Date -�
Is Property Located in Location of
the Historic District? Yes No LSuilding
Is Property located in
the Conservation Area? Yak__No�
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: JeyA"4
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 (l;_n c i WZ,y A
Address & Phone 1 1 2 rnn non St "�c l v:= (q)?l I41 q1 b-)V
Architect's Name
Address & Phone I
Mechanics Name
Address & Phone I
What Is the purpose of building? "Cl r N I
Material of building? /✓o,p If a dwelling,for how many families? /
Will building conform to law? iG P `J Asbestos?
Estimated cost /0 o 0 City License* N A State License rt
Rom Improvesent V
L.ic. / ,AF
Si6naturd of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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�o CITY OF SALEM9 MASSACHUSETTS
3
PUBLIC PROPERTY DEPARTMENT
gj 120 WASHINGTON STREET, 3RD FLOOR
1' �E SALEM, MAO 1970
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 150A.
//
The debris will be disposed of at: 1/to r�4 51ldY
Location of Facility
i'
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Am Cy R ml ,onac ��
Name of Permit 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
L
CT y OF SALEM
BUIIDING DEPARTMEW
HOMEOWMUC.ENSEE MOMON
Pkm PAN
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im to ATag—L 2.rn allg i n U ! J( it) N,� y
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ADMMO
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TELEPHt'iW
PREsENTMAa.MADDUS, ( 1? MOA Q in Sf Sa I rn� ME1-
TAe am,os.eacmptioo d'lamso'r"as".raf emended to brclsde a.oerapwptd dw4mwp 4mrwo
UnLs a lee and a allow safi>!omevwsers ao engage as bdivldagl.�Las•rks does sot psaaes• .
lioc .poovided tbaa ie swsw set d aheedase:
DEFUCTW"W HONEOW"M
pcnm(s)who c wm a peal d ksd on wLkb belsbe reside a bserda to talds,op erldeb k
inwdod to bs,a one to two fim*dwdit shad od a deaclod tans ww 9=90my i sot be oomldas0
farm svwwm A pcnm wbo court wn mote than on berm bt s twtryar paW
a bomoowsar. Sv*jwmww•ad• slaV subnd u ft BuDdSrE ��*
Bwlft OdmLow kkhe be respom=bk so ill stilt weak pabrawd
The undersigned-eomeewme asmmss tespormbMV for eompnu=wit%*A Sate B90 ttg code W d
other sppBobk goes by-bws,rnka sad tephdo L
The mders pw-lwmwwme e=rdf"that hehhe mhmmnds*c ov d lm �.
minimao bspwdou Poccdwa and regtpremcma and that Abbe will oompiy
nqok=wft
HoNmOWNER'S SIGNATURE i2 r n fYl1�4S1
APPROVAL OF BUILDING INSPECT R '
Sce otea ode for state code
HOMEOWNER'S EXEMPTION
The code sums ttat •arq hovwowaer pafcnmb f-iv*fa w hkb a boildt pump b regaled dM be
the ortih seedon lee 3 .3 r Jaasto ar Cawsttsttto�Eo
' exempt Loan Fo''k� (�+ 09 t !e*�t0• ,
Pravided tbst b a homwwna cnMa f pcnm(s)for bfm to do.rwA wedr.that aitd Domeooaa sha>f sst
as Impavigoe
mm4 umwwmu who we us erampdm an"wars to fty an asst mbe the sea
wpervism(use Appeadb Q,Amks and 7t*Vbttow ter' Je:nsio=Ceostrveds SapesrbeM Seeds
.2.24 Tbb belt of SWWCMsa oLa WSWU i4 aerteasi pobk=s.pw*ote� wbca the L R -'m ra 1"
ur�ikcmed persont In Ms eau yoga Board amrot proasd apba the tmoeemed pawm as kvmm va
Ikeased Supa►iagr. TDe Domeoewcr aeYtaS as SupaviaK is a seslnwiiis.
To ensars that the homeovvna is My aware of Mlha responSlbllhiea,msaq oo tsgd�as putt
of an pera q sppUcalm that the bomwwma caft Oat he/she mderstmda the respoeesbitlda ds
nlpatvbm You may an to amcad and adopt and a S wmk crdfattas In m in your ooawmit�