30 NORTHEY ST - BUILDING INSPECTION (2) i
N pL-M6-jA" -qE f%E94MD *PPROVED BY THE
JMSPZC=PWOR TD A.PEBAf T JONG GRANTED
CITY OF SALEM
NO. \ Date
IS Pmperty Loaded
to WNaic Did"?� Yap V No_ Location 1"as 13
of
Is Property Loaded In
the Cerarnatton Men? Yss No _
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sking, Construct Dec(. Shed, Pool,
Repau/Replace. Other: 1 Fly Ada:f"CA PW- D-e�L
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name flora 'Ty-\TkL-
Address & Phone 30 LoLk S-f r 7
Architect's Name 2)a4d I 5� 'I'm4L
Address & Phone �� i �y ON)
Mechanics Name I
Address & Phone ( )
3 what is us p mpore a tmaidkp? CwLkes i �m D LA,.,,yJ2
maiww of WOW ", a a a dWWQ,for now R ►y twRYiw? 62 _
Will ixddinp conform to law? ye Am""?
4� E*mUd sort ?t-j/ my uomiw r N A sr a License N
� t
Lie. ,
Signature of Applicant
SMW UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO.
• a
„
No.
APPLICATION FOR
PERMIT TO
* /
LOCATION
PERMIT GRANTED
APPeOWD
INSPECTOR DF BUILDINGS
r
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVIC2, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740.9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 0 A'�
Job Location
Home Owner Address. 30
Home Owner Telephone
Present Mailing Address°_ 0 /l� k ev s�f
The current exemption of"Homeowners"
._was extanded to include owner-occupied
dwellings of two Units or less and to allow such homeownap to engage an individual for
hire who does not possess a license,provided that the owric acts as supervisor.
W ..
DEFINITION OF HOMEOWNER a
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 11 p
APPROVAL OF BUILDING INSPECTOR
See other side for state code
HOMEOWNERS EXEMPTION
The Code states that: ,Any Homeowner Performing work for which a Building Permit is
required shall be exempt from the provisions of this section(Section 109.1.1 —Licensing
of Construction Supervisors); provided that a Homeowner engages a person(s) for hire to
do such work, and that such Homeowner shall act as Supervisor.
Many Homeowners who use this exemptio unaware
�Re��onss for Licensing
responsibilities of a Supervisor(see AppendixQ,
Construction Supervisors, Section 2.15). This lack of awareness results case you
us
problems,Particularly when the Homeowner hires it
ed d with a licensed
Board cannot proceed against the unlicensed p responsible.
Supervisor. The Homeowner acting as supervisor is ultimatC�ly
To ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require, as a part of the Permit Application,drat the Homeowner certify that
he/she understands the responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in Your community.
R�✓ �Igolyao s
i
C�
CITY OF SALEM, MASSACHUSETTS
53 PUBLIC PROPERTY DEPARTMENT
a.
120 WASHINGTON STREET, 3RD FLOOR
gm SALEM, MASSACHUSETTS 01970
STANLEY 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 resulting from 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:
Wk 5-m-c 6&4� (Location of Facility)
Signature of Applicant
/%/a�
Date