4 MOFFATT RD - BUILDING INSPECTION �y o�
CITY OF S.0 EM
PUBLIC PROPERTY
DEPARTMENT
TO.M74S-9S"#FAX.971-740."4
HOMEOWNER LICENSE EXEMPTION
Plea"Print
Date
Job Location `/ Mo r F R %l R AD
Home Owner Address
Home Owner Telephone
Present Mailing Address Xa/no
The current exemption of"Homeowner'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 licensk 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.
i
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR 4a-41
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMIENT
IIII
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at�ua l.'Cr.�aev::ahtiswwR�luam.lt►vlww.t�la::�
'ht:W'�7�1'fti �f.�9�Ie7gleK
Construction Debris Dispo"i Affidavit
(reyuiml for all Joinalition and SMovatian worlt)
Ia=wdsncc wish the sixth edition of dw Stam Huildins Coda.7SO CN111 section 111.5
Dela<is,had the provisions of MGL a 40,S Sk
swans pennit p _ . _ is issued with the condition that the dobtis awltins Am
this wort shall be disposed of in s properly licensed waste disposal facility as defined by%lGL a
111.S INA.
The debris will be wmisported by:
_._ Inome,�hoW�
rho -bds will be disposed of in :
1 ante ur fa.titty)
I
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7AR
PPDTMENT
A!Pl.IICATION FORTH= REtAIR. R�NOVATteN_ Cnercrr[-rrnul
DgHOLI'PION.OR CfMGR OF U3z OR OCCLn xrv_ FOR ANY KXM NG
�UC?UA! OR BU LD G
1.0 SfTt INFORMATION
Locs*w NOM Z -
--- .. Propeny/WdrMc - --- -- — - --- - - - -- - -__ _ --
Prop ft Is bcsbd In a;Cawsnailon Arne YIN HwAft DMW YM
2.9 OWNERSHIP INFORMATION
2.t Owrw of Land -Q ZA4. ✓ 2
Na"W r., 174 e
Address:
TNsphorwa
[Approximate
A COMPL.ETS THIS SECTION FOR WORK IN MMMING BUILOINOS ONLY
I
dition ExisWq
novation p/ Numbw of stories Renovated
ange in use New
moudon us�g
yew of Ana pw now (of) Renovated
struction or renovation
of exi" building New
add Description of Proposed Work:
Sr/liG' / eA /QcP RdeF
--- -- ---Mail Permit to Auf t Fr
What is the eurmt use of the fuming?
w ��r r o0.NOIM many untts9 '
msWm of su�1r+0�
P c
vw" AC"Conftm to L"? -
fi - aabagoal�
Atdgw
e NWA
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Ad*eM anti Phon.
MedwdeS NO"
Addraa and Phone HtC Ragiaha6on 0
Candnwkn&Wwvisws License 6
Eslimatad Coat of Project c -Vv o Pam_Rae Cabmorr
Pemdl Fee i Eadmated Coat X$71: titl
1000 RaNder
-- -- - Eslrnalad Cost X:11/:1006 Cmmnwc at----An Addltlond:A-0®is added sa an
Adndnlstratlw dfr9a.
Melee sure Mat all flNds are Properly and IsW*when to avoid delays in Proceselno
The undersigned does hereby apply for a Building Pamlt to build to the aWW stated
spoditsoom signed under penally of Pe"
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