117 MASON ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.\itg I2C 5A FU• MAIMC.A.\Ll'15
TFt:9M7454595 •Eve 978•74t:9846
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 780 CbiR section 111.3
Debris, and the provisions of v1GL c 40, S 54;
Building Permit # _ .. __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by %4GL c
111. S 1.50A.
The debris will be transported by:
tname of hauler)
flee debris will be disposed of in
04me of facility)
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CITY OF SOU EM
PUBLIC PROPERTY
DEPARTMENT
IC111M�N Nltl•y�
MAYOR 130 WARONGMN STREET*Sn1 f�Y MAaAa4us,TTs 01970
TM-970-73S-9S9S R FAY:978.7404W
HOMEOWNER LICENSE EXEIMMON
Please Print
Date
Job Location S C 7 S
Home Owner Address
Home Owner Telephone �`
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
GI•I'`YOF� -
PUBLIC PROPERTY
DEPARTM&NT
wumF�nar o■�•�
%"VM
I W Wwvmrc.'tt S w=.Snt�1 wss.�an:slTis 01970
I%L 974743.9S".FAX 97L7469ay
APPLICATION FOR THE REPAIR. RENOVATI N CONSTRUCTION
DEMOLITION, OR CHANGE OF USX OR OCtt'Clp
STRUCTLm� OR BUILDII1rr� FOR ANY EXIS'I'nVG
1.0 SITE INFORMATION "
Location Name: 2v» Building;
Propeoy Address: -- - _
Property is located in a:Conservation Area YM Historic Obbkx Y/N Aj
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
( Cr
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation (>G Number of Stories Renovated
Change in Use ' New
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation
Of existing building New
9dd Description of Proposed Work:
c�t j c) c-t!t� ( re boo �
—- - -- -- -Mail Permit to: __ _ - --- ---- -
o0e
What is the current use of the Building? N dwei11ng,how nY units?=——
,_ , 0
Material of Building? Asbestos? "L a
Will the Building Conform to Law?
Architect's Name
Address and Phone —
Medwlea Name
Address and Phone HIC Registration 0
Construction Supervisor@ License
Estimated Cost of Project permit Fee Calculation
Eatimated Cost X s71s1000 Residential
Permit Fees 2 Estimated Cost X si l/sio0o Ccmmerclal----
- - An Additional $5.00 is added as an
Administrative charge-
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
g
specifications. SI ned under penalty of Perjury
Date ZO e
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