45 MEMORIAL DR - BUILDING INSPECTION s
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�PE�1 IQR� WT AMMO GRANTED
CITY OF SALEM
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Loam
• �sPlMMlo"afmi ONI�h ramtlm of
is Pf"a" umm in
0mminm On An d Y No
BUILDBKi PERMIT APPLICATION Km: '
Permit to:
(Groh whlo ~ GA*) Roo(. Reroof, Install Skfinp, CaWW,pock Shad. Pool,
f. Other:'
PLEASE PILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PIWCMO
TO THE INSPECTOR OF BUILDINGS:
The umbm*W� WSW apliles for a psmik to Wit! a000m" to 8» bin.... E
Owners Name
MOM d Phone 'A�S ► 't0,6-NN4 e%v—
Afd*n 's Name
Address A Phone ( 1
Ms&dmWsName
Address & Phone
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mw w b pApm d twastgV (2 iC 14L,4--
MUMdd d euMigT' W uU3, r a dw�q,lar now Mi4 j
vatOu"aontn btw ? `fie No f
lawal"dmid. A oo N
� cx� Cp lJoww•�_al,A.uoNw If a
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tde.
Slpnawre of AppYoarit
SIGN'D UNi..M THE
OF PERJURY
DESCRIPTION OF Vl=TO BE D"E
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vVNC�M }d� .� (un SLvMu( ...
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MAIL PERMIT T0 Gv�
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APPLICATION FOR
PL�Lrr To t
LOCATION S,y�
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PERMIT GRANTED
APpliavpl
I r OF BUILDINGS
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Crry OF SA].EM
BUILDING DEPARTNIEW
HOMEOWNERLICENSEE MOMON
Pkaw Print
DATE 2 M4 O
Ios�,ocAnoNS
• HOldf.OWNFA ��`
ADDRESS
HOMEOWt�t �7SS 1U1�' (�' C �{
TELEPHM
PRES GADr1PMS
ENT MAII.II? _ .
MA c.a= Y C%cMuon of'bon.wowcas"was exurdcd W iMIUds owac"ccapied dwc=mv of TW0
Units wins vow show such horacownes to engage an indi uhW for b»e wbe does root PoslKaa•
llmnse,.prvvkw dw.6t.owner ad as supervbotr.
DEFIKT1ON OF HOMEOWNDI
Person(s)who owns s parcel of land on which bc/shc nsides m irucnds to reside,oa w4de6 laM
intended to be,s one to two family dwelling auadted m dctadud structmss od sball not be c onsidcmd
farm svucwm A persmt who consmw n ms than om home in a rwo-y PQ'
e hoouowaet. Sudt'home�w tut" shsD subni t w the BurW4 Mcial,on a form Seeeptabk b tit
Building Official.that bdshe be mapotmbk to all sudt work paforsswd nrtda the bus7d'vig permit.
The tmdcrsigned•bomeownei assumes tcsponnbility lot atnp110"with the Stan Building Code wd
other appli is goes by-laws,toles Sad tcgularitmL
The ca�dasigrud'hovteow= ccrd8 that lu she undc=nds the City of Salem BOI&&Dqw mK..
minimwu inspection proccdu=and tegtdremeras wW that blshe will amply with said Wooer and
tcquircumm
HOMEOWNIM'S SIGNATURE
APPROVAL OF BUMDING INSPECTOR
See other sde for state code
HOMEOWNER'S EXEMPTION
The code states tbst: 'arty homeowner performing-vvrk fm which a bu4dir4 permit is required shah be
exempt from the positions ortbis section (Section]op.L,-1Scensing or Construction Suptrvisoss)
Provided that is a homt.mmer engages a person(s)for hint to do.such work that suet hotmeowm shah aft
as sttpatisa�`
Marty bonteowmrs who use this exemption araimawart that they an assmming the tegom oft
supctvisor (a"Appcndla Qe Rulu and Rrgulatioos for Uccosiog Construction SuptrvboM See*
.2.24 This lack of swarmem oflen results in scrim pmbkms•particalarV when tht homeowner hbw
unlicensed persons: In this case your Board Cannot proceed against the mtlloeused poWn as k wvoid wift
licensed Supcniwr. Tbc bomeon'ocr acting as super dam b uWmaie;y tnpon;Pole,
To ensure that the homeowner is fully aware of hVt=respo>LnbiMies.many emmwdties tegsdM.m past
of the pctrrti4 sppli 2tiM that the homeowner certify that hUshe undersunds the responsibilities ofa
supcnisor. You may care to amend and adopt such a forudccnificatioo fa test in yum gyp,
r
PUBLIC PROPERTY DEPARTMENT
• 120 WASNINOTON STREET, 311D FLOOR .
6ALEM,MA 01670
TEL (676)745-9595 EXT.390
FAX (676) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEB=AFmAva
In accordance with the provision Of MOL c 40,S34,I acknowledge that as a comidoa
Of Buliding Permit#_ .aD debris resulting from the cmwb Eton activity
governed by this Building Permit shall be disposed of in s F'Operly liceaaed solid-waste
disposal facility.s.deffxW by M(3L c7$S1SOA. =
The debris will be disposed of at ( f^i IJr C-.,Pn 1
Location ofFwlky
Srgrut(ue of Permit Applicard Date
FULLY complete the following mfo ;
(PLEASE PRJM CLEARLY)
Name ofPennitAppliowd
Firm Neale,if any
�AT (Acr."
Address.City&State
The above statute requires that debris from the demolition, rraovation,mbsb or other
altersdon of baildiog or stt wWrc be disposed is a properly-licensed solid-waste disposal
facility as&TmW by MOM cIM S1S0A,and the building permits or licenses are to
Mu te the location of the facility.