4 PIONEER CIR - BUILDING INSPECTION p, iI11P alLl
J I
W=;7==T44EJAIS!? L1A NTED
J1Jl CITY OF SkEM
Data "T -dj-64-1
Is Property Located In / Location of
tlw Nlstoric Dlstdct? Yas_No_ Handing y Q1 a n�eP re C t 2 .
Is Propwty Located In
Its Conservation Ares? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other.'
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCKSONG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name N a-v'-,\ o p- ' e 8
Address & Phone 4 t v w p e t +2 ��g t 7�H-5 3 o
Architect's Name
Address & Phone i 1
Mechanics Name
Address & Phone ( 1
What Is the p,rpoee a tadlding?
m"W of to rld m? ti a dwatikp,for tram many lamYla? / "1
WN building cWorm to law? s Asbestos? iv O
Estimated cost. c�SD O -6 G Cky Uosnw s N A State Lkmm s
t1c.. rapro....nc I.
Lie. tl
Signature of Applicant l
SIGNED UNDER THE PltIlf
OF PERJURY II
DESCRIPTION OF WORK TO BE DONE i!lil�
C' �T Csv-- cvNii /w I l / N pZboyn Yblo� k ;:ii
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MAIL PERMIT T0:
, 'I�i{ ' a I CM IiWI�II•.•
Irx
wl tq 'o c 4 7 C
III
I
No.
APPLICATION FOR
PERMIT TO
LOCATION
`l
Pe/'
PERMIT GRANTED
VOLT4 2-0 3
AP7OVo
INSPECTOR OF BUILDINGS
s
CITY OF SAIMd
B=ING DEPARTIAM
HOMEOWNER LICENSE M04MON
Pkase PrW
DATE N—al—d
IOBLOCATION
ADDPX4 o
HOMEOWtg3t I S — -7
lIIMPHONB
P�ni�rrL C/2 SA.,onn ./� 01176
PRESENT MAII.ING ADDRESS � ,
The avremt ctempdon of"bomeowocrs"was cncuded w include Owmr.ocevpied dwcMvP OfT►VO
Un9u a ka and to allow such hoawowncrs to cnpage an irdiMmal fa Dire wbo does not POSIM 9
liccnse,.provided that the owap sd as suptrvkw.
DEFa MONOFHONZOWSM,
Pcrson(s)who owns a panzt of land on which hcJshc resides Or i cn&w reside,anwhkhlh=it= �
fa
intended w be,a au io two rv7y dwelling attached or dctachW atrvcnua od sba)1 nol k considered
farm strucwm A person who consuvw mac than one home in a two-? P�
a honwo Rma. Such'homto Awe sh-J'subrtul to the Building O15cia1,on a form a=ptebk W*4
Building Official,that hclshc be tssponsiblt to all such work pafortued mulct the btu']diag Paul{.
The undasigtxd'bomcawnct"asstmues mspor�-•bility for complitma with the Sum BiM&g Code w d
oiha applicable jots by-laws,roles and njohlitmtt
The tmdasipned'ltov=wrta"mrdfles that heam under�the City of Salem Bwld'mg Depa v=K
minimum bqc-lion proccdum and regmtremcnts and that Wshe will comply with said ptoadma and
mquiretnmi
HONIEM ER'S SIGNAT6E
C
APPROVAL OF BUII DING INSPECTOR
See other side for stau code
HOMEON"ER'S EXEMPTION
The code sate the `wq homeowner performing work for which a buDdmg permit is requbcd shall be
exempt from the prmisions of this action (Section llf�11-.Ucensing of Conatrvetion Supervisor;
Provided that is a homeowner engages a person (s)for hue to do.such wort,that such homeows a 60 am
Marry borneowncts who use this exemption we imaware that they an asstaa'utg the TespvmibMdu eta
supervisor(sec Appendix Q,Rules snd Rcgwlsriow for 1.Uecosing Construction SuperviwmSo:*%
.1.14 This lack of awareness often resttlu in scriomn problems,particularly when the homeowner biro
urikensed persoas In this rase your Board cannot pmc=d against the milieensed person u itwvA wif
licensed SupcnixF. The bameon ccr sling as superviwr b ol8mstely rtaEoos%bL
To ensure that the homeovrncr is finny aware of MFhcr respon_nbilities,many c=unwddes regime;as pant
of Arc permit spplk:a6 ,that the homeowner eernfy that hclshe undcstands the rupousibiiida of a
supenisor. You may care to amend and adopt such a formlecrtificatim for Use in your cvu==IV.
I
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
sALEM,MA O1970
- TEL (978)745-9595 EXT.360
FAX (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# ,all debris resulting from the constriction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S 150A.
The debris will be disposed of at: S t}Ao wi
Location of Facility
L a!-o U
S of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
_ c . -
Firm Nam , . .any
y V i b Q �f -7 G
Address,City&State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cl3L S 150A, and the building permits or licenses are to
indicate the location of the facility.