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PUBLIC PROPERTY
DEPAR'ItiIF1�1T ��1
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. 'If197t-7ii959S�FNp 97e.7�9�µ . �
. APPLICATION FOR'THE REppIR, ItENOVATrON CONSTRUCTION . �
DE�IOtITION. OR CAANGE OF USE OR OCCUpqNCy FOR ANY EXISTING
3TRUCTCrit�r OR BUILD G
• 1.0 SITE INFORMATION �� ' " • -
Lacatlon Narta: �J PAT7oN Roqp g�;��a
-- - propenyaddresx—t� P�r�oN-rzustn-- - -
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S�LLM� MA . �1��0
Property t�located in a;Ca�servatbn Aree`YM NlaWrlc Dbhid YM
Z.0 OWNERSHIP INFORMATION "
Z.1 Ownu of Land ` .
Nams: S-�V��2T G . M�M�wdw
Addrees: 'J pAT7C�N Rv/iP
S/a���n, MA . o � q �D
reiepr,one: (q?-a) �40 - o�c�� .
3.0 COMPLETE THIS 3ECTION FOR WORK IN EYI8Ill+lp BUILDINGS ONLY '
Addition � ExiaGng
Renovation Number of Stories Renovated
Change in Use New 2„�( LEv�4
Demolition Existing
Approximate year of 2�0� Area per floor (s� Renovated
construction or renovation I
of existing building New
Bdef Desuiption of Proposed Work:
'� 2nt� Fto o�q � D D 17/n�v - BA�dV �n�/1'i Ede ON
�77iG - 7m ,�•iGWnE :
� :
A) 8� u+em oM *
b) �3A7tirr��M '+ �
c ) wALI< - I/y C��st7'
o� � S�oaAUE Se��,�E
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Mail Pertnit to: �v�.e0� - - -
/°.�� � �ITY OF SALEM
�
;; - ',. �,,i PUBLIC PROPRERTY '
���'"� DEPARTVIENT
_�
- n•nwrni.r.r���nucou.
_ \l�.i�nr. LQWAifil]Gl'ONSTRPET �SALLV.�S,\tii:\(:i1l..LfC�QP)IC
"Cf L 978-7�i 9i9� 1 FA:(:978�7+G98i6
Construction Debris Disposal Aftidavit
(reyuired for all demolition:uid renovation work)
In accord:mcc wi�h the sixih edidon of the State Building Code, 7S0 CMR scction i l l S
Debris, and the provisions of'vIGL c 40, S 54;
F3uilding Permit # ______ is issued with the condition that the debris resultin�from
this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c
Ll1,S 1SOA.
The debris will bc transported by:
� : ����� - � �� I � J-��8 - �1 �� - �2�4
-----� (nameuEhaulzr)
flie ilcbris will be dispused of in :
-
(name uf faeility)
.. ....__—._ �aSdrcss of fu�ili�y) � . ��.
1
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i til�l:1[lll'C U� �)Clillll:l(1�)�IC](1[
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- :ci:u,n:l Lu�
� CITY OF S��LENi
� PUBLIC PROPERTY
`� DEPARTMENT
_�
KIlOIFJL6Y DRLY:011.
• Nnvot l�p W,�y��g�yT�Su.e�,Nwct�ai�5�rrs 01970
'IF1:97&735-7595�.Fnx:97&7�t09&I6 �
, HOMEOVWi ER LICENSE EXE,rIPTION
I Pleau Print
Date 5 ����'
Job Location � PF�TTor� (Zop�o, S��E.rn, ,/Y1 r9 . 01�1$'O
Home Owner Addrese S PAT't aN Qo/qp
� Home Oaner Telephona 1��$ ) �4 v -o��1 ) �7�g��4 2 -�1 6��C�
Pre�ent Mailing Addreas A s A so v 6
The current exempdon of"FIomeownera"wae extended w inctude owner-occupied
. dwellinga of two LTnits or less and to allow such homeownecs to engage an individual for
hire who does not possess a license,provided that the owner acts as supecvisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a percel of land on which he/she resides or intends w reside,on
whic6 there is, or is inteaded W be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
thart one home in a two year period shall not be considered a homeowner. Such ,
"homeownd'shall submit w the Building Ofiicial,on a form acceptab(e to the Building !
Ot3'iciai, that he/she be responsible for all such worlc performed under the Building
Permit. i
The undersigned "homeowne►"assumes responsibility for compliance with the State
Building Code and otha applicable by-laws and reguladons.
The undersigned "homeowne�'certifies that hdshe understands the City of Salem
Building DepaRment minimum inspection procedures and requiremrnts and that hdshe
will comply with said procedures and requirements.
. HOMEOW;YERS SIGNAIL'RE • ���/�%1vw" �
'
, ,1 „ APPROVAL OF BUILDING INSPECTOR ��
See other side for state code
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� . Sll�1037�'.�18'lb'.aY�';�"�1..TM�`•3Ci.1031. \ � 1 . . . . . .. ..
CITY of 3��?n,..,aq1a,�a, � `,, _ • S 7 0 R A G E
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