16 ORNE ST - BUILDING INSPECTION (3) a
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEIMMON
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Date / b
Job Location Le O/ s A ( e rh 1Fi
Home Owner Address 5A",�r.
Home Owner Telephone
Present Mailing Address S www
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 hNshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and uirements.
HOMEOWNERS SIGNATURE �----
APPROVAL OF BUILDING INSPECTOR ,.Q
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ .. __ is issued with the condition that the debris resulting from
(his worst shall be disposed of in a properly licensed waste disposal facility as define by .MGL c
111. S 150A.
The debris will b/e� transported by:
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ptamn of hauler)
Tha debris will be disposed of in
(llame of facility)
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PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR THE REPAIR. REJS4ygkTION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTINGI
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "
Location Names. Building:
- -
- Property
Property is located in a; Conservation Arsa Y!N Historic DF&G Y/N
2.0 OWNERSHIP INFORMATION
/ 4.1 Owner of Land `
Name:
Address:
Telephone: ']
3.0 COMPLETE THIS SECTION FOR WORK IN EYIATINQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation I D
of existing building New
Brief Description of Proposed Work: p
t4
---- ----
--Mail Permit to: l G l G D✓ 5'f S� (e - -
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What is the current use of the Building? `
Material of Building? If dwelling,how many unitaT�---
Asbestos?
it the Building Conform to Law?
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Archit ds Name
Address and Phone
Mechanic's Name
Address and Phone HIC Registration S
Construction Supervisors License/1
U ' Pemd1 Fee Ca ifftiOn
Estimated Cost of PJsI�S Estimated coat X$71S1000 Residential
Permit Fee S
Estimated Cost X$11/51000 Commercia4----
— - 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 lid to the above stated
specifications. Signed under penalty of perjury
Date
N
96
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