10 MEMORIAL DR - BUILDING INSPECTION What is the current use of the Building?
Material of Building? W�y 11 If dwelling.how many units? _--—
Will the Building Conform to Law?
U Asbestos?
Architect's Name
Address and Phone
Mechanic's Name lci n aJ
Address and Phone HIC Registration S —
Construction Supervisors License 0
Estimated Cost of Project S o� Permit Fee Calwlatlon
Permit Fee$
Estimated Cost X$7/$1000 Residential
-_- - -- - Estimated Cost S11IS1006 Commercial--------
- --- 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
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specifications. Signed under penalty of perjury X i �-
Date NkA:�06?
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
�am��oR�:oLL
MAYOR 130 WASMNGTON SlRM•S.uFx.AcsAalusEns 01970
'ILL 978.745-9S95• FAx 978-740.9P6
HOMEOWNER LICENSE EXEMPTION
Please Print
Data acO c
Job Location R\f-rDn,AA 0 \.y - .Sq ry\A�_
Home Owner Address
Home Owner Telephone `7lit 7 Ll J
Present Mailing Address 10 e L v /Yl
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
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
110 WAS]tNG.i ON S`REET •SALF\1,%1ASSAt:,it.:L I-IS C 19IC
Tu,978-745-9595 •FAX:978-740-98-t6
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions ofMGL 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
Tlie debris will be disposed of in
(name of facility)
ia,i,�ress of fanlity)
urc of ; crnat applicant
,iatc ---
PUBLIC PROPERTY
DEPAR'I14IE,yT
MAYOR
t W' 'rREET*S AK NAMACKSLI-M 01970
TM 970.745-9S"•FAX 97L710.M6
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPAIYCy FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "
Location Name: Building:
--
io
mox \V,9-
Property Is located in a;Conservation Area Y/N Historic DWkkt Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: Li Q
3.0 COMPLETE THIS SECTION FOR WORK IN 7Stcries
VSUILDI�138
Addition
Renovation Number Changein Use Demolition Approximate year of Area per floor(sf)construction or renovationof existing building
I � I j
add Description of Proposed Work:
----—-----Mail Permit to: -- --- - -.-