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10 PHELPS ST - BUILDING INSPECTION CITY-OF-SALE PUBLIC PROPERTY ��al-7DEPARTMENT AI%IHMEY DRISCOLL MAYOR I-V WASHINGrON SIREEr•S A1 I:i WtiS.SCHI:St"CIS 01970 TFL,978-745-9595 4 FAX 97&750-98" 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: /O 41,115 ui Building: S I l Property Address: �d r,� ziPS Sr^�t 7- Property is located in a; Conservation Area Y/N Historic District YIN 2.0 OWNERSHIP INFORMATION . 2.1 Owner of Land j� Name: C-r- L"-; I I) 5 Address: /o Pw ti i oS CJ r r- �— S, ni/9 Telephone: — L/ -J 700 5-0 / el 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition ✓ Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: I li q � ^ Mail Permit to: What the current use of the Building? 19 W is Material of Building? �` °� If dwelling, how many units? will the Building Conform to Law? a— Asbestos? Architect's Name Address and Phone t Mechanic's Name Address and Phone 9 Construction Supervisors License# HIC Registration# Estimated Cost of Project$ c? oQ 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 tothe above stated specifications. Signed under penalty of perjury X I 0 N O 4i d � b 1 a. d' L w 4t is �C t7 XIp O Or aO y IOU F cL u ►. cL '` CITY OF SALEM PUBLIC PROPERTY J �- DEPARTMENT KIMBERLEY DRISCOLL ,�� �1 , �JL MAYOR - 120 WASHINGTON STREET• SALEM,MASSACHUSEM 01970 A, C -C Tm-978-745-9595 • FAx:978-740-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name ornauler) The debris will be disposed of in : �Gw� uv M 19- -- (name of facility) (address of facility) (J( , signature of permit applicant date debli S21TAM CITY OF SALEM 1 PUBLIC PROPERTY r DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WA.SHINGTON STREET♦ SALEM,MASSACHus=s 01970 TEL:978-745-9595 0 FAX:978-740-9846 HOMEOWNER LICENSE EXEMPTION Please Print Date / Gb Job Location 16 5 5 t r te_ Home Owner Address Home Owner Telephone 1, I -7 7 fsb Present Mailing Address /b 4Ar_ 115 SfH­zT 01/9 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 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<::::�02e-- APPROVAL OF BUILDING INSPECTOR G Ti See other side for state code 4 Homeowner's Exem flon 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 — Licensing of Construction Supervisors);provided that a Homeowner engages a person(s) for hire to do such work, and the Homeowner shall act as Supervisor." Many Homeowners who use this exemption are unaware that they are assuming the responsibilities of a Supervisor(see Appendix Q, Rules and Regulations for Licensing of Construction Supervisors, Section 2.15). This lack of awareness often results in serious problems, particularly when the Homeowner hires unlicensed persons. In this case your Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The Homeowner acting as Supervisor is ultimately responsible. To ensure that the Homeowner is fully aware of his/her responsibilities, many communities require, as part of the Permit Application, that 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.