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�T TD APPLICATWN FOR
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LOCATION
PEF"T GRANTED
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CITY OF SALE49 MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTO14 STREET. 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANLET J. IrEOVICZ. JR•NAYOR TELEPHONE: 978-743-9595 EXT. 380
FAX: 978-740.9846
HOMEOWNER LIOLNt 3E EXEmFnON
Please Print.
Date j a a o06
Job Location a1D h4or4 end r}
Home Owner Addeeaa. a o N o, �t c„d 9
Home Owner Telepllogee '1 -I-q is o -� y y y y
Present Mauling Address P o �oA s �� 1a W 01 go
The current exemption of"Homeowners"was.dwel extended to include hags of two Units Or leas and to allow O�-Oeeupied
such
hire who does sot a to mga�an individual
possess h for
tense.Provided that the
ownea'` as supervisor.
DEFINITION OP HOMEOWNE] 7
Penwn(a).who OWrer a Pa ul:of land on which he/she resides or in
which there is,Or is intended to be,a one or two tends to reside,on
structures accessory to such use and/or fans �w or detached
than one home in a two eons more
"homeowner" Y�period shall not be considered a homeowner. Such
Official, that hatshe be submit to the Building Official,On a foam acceptable to the Building
Permit. ponsible for all such work performed under the Building
The undersigned"homeowner"asaurnes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The under"Sued"homeowner"certifies that hedshe understands the City of Salem
Building Department minimum inspection procedures and he
requirements and that heJs
will comply with said procedures and requirements
HOMEOWNERS SIGNATURE
n
APPROVAL OF BUILDING INSPECTOR 2� tier
Sex other side for state code
HOMEOWNERS g, MPTIONI
work for which a Building Petmn is
The Code Aatd "Ar►Y Homeowner pig on Section 109.1.1 —Licensing
rM�shall be OEM$from the p� s en�a person(i)for him to
of Construction Supervisors �° shall ad as S�rvisor.
do such work.and that such Homeowner
sre asavt»g�
Many Homeowners who use this ex�Ption �es and RePWA0Oa for
Licros>z�
rious
�Onsibilities of a S (2.1 S endix() This Ik of awsrenw o� lu this cam m
Construct �sOw when the Homeowner turd unlicensed p ticec
problems. the unlicensed P as it would with I�ponsible.
Board camA Proud
14 dti,,,,,�
SUPcrvisor. The Homeowner ailing a< ""
To ensure wner is aware of MAW res��ilitid.�Y �
that wire, as a part of the Permit Application. the Homeowner certify a
commumti the respons ism is
ibilities of a Super � of this
formhrJsh used b9 several , Yon may
form currently �nunity.
f���II for.use in your
Ito `I 30 I Sao s
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
9TANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resultingfrom this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
S IL AA (Location of Facility)
Signature f pplicant
Date