17 OSGOOD ST - BUILDING INSPECTION (3) 7"q a �
CITY OF SALEM
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PUBLIC PROPRERTY
DEPARTSaM
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Construction Debris Disposal Affidavit
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Stdiang Pam&0 _ _ is iswtad with tha cooditios that the debris rtwaldnj Aoctt
this watt shalt bo disposed of ins pcvparly licensed waste digmmd Ataility as de![nad by WIL a
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The debris will be transported by:
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CITY OF SM.EM
PUBLIC PROPERTY
DEPARTMENT
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ynroa 130 wA9"GTM S ffWF•&uM%nssAcw.:w c3 01970
71197L74S-9S"* FAx 971-74696"
HOMEOWNER LICENSE EXEMPTION
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Date / D
Job Location 17 OSGe-)eJ l n yr 6r1910
Home Owner Address_ /7 666606 SJ-
Home Owner Telephone 97S' zf 9/ R-W-9 k
Present Mailing Address S#tn
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 worst 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 requireme
HOMEOWNERS SIGMA
APPROVAL OF BUILDING INSPECTOR
See other side for state code
elTy OF- AtEM—
PL`BLIC PROPERTY
�.16 DEPARTMEINT
XMIFALEVORMCULL
MAYM 130 WwuuNGww 5nLM•JALt71 HAWCt/tShTrS 01970
IU-978-745-9S"•FAIL 973-740-96"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
17 a6001� St- SA-(SA-(gg2, M f o 0
property is located in a; Conservation Area YM Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 1-7 0%00D S+
M O
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIATING 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
of existing building New
Brief Description of Proposed Work:
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--- --Mail Permit to: 17 QS COO) S f �w 1 in I9 0 --
What is the current use of the Building?
Material of Building? Ifdwelling, haw many units?
Win the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License HIC Registration f1
Estimated Cost of Project S IS-()O Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
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 build to the above stated
specifications. Signed under penalty of perjury
Date 1 �/ D
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