5 PIONEER CIR - BUILDING INSPECTION APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
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INSPECTOR OF BUILDINGS
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f�iil IbEffL4"M APPROVEID SV THE
IWEC=PF" TD A PE9Yrr BEING GRANTkD
CITY OF SALEM
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Rmd, Instal SidMtp, Construct Deck, Shtld,
Repair/Replace, Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSWG
TO THE INSPECTOR OF BUILDINGS: '
The undereiynsd hereby applies for a permit to build accordwip,to the foNowinp
specifications: _
Owner's Name JoKrl R�C�C�1 R2 t
Address & Phone S JI 75 5 t4 5-15o
M:hltect's Name MA O 19^7 p
Address a Phone
Mechanics Name
Address & Phone ( 1
What is Ma pipet ar eurdrq? R -CCC- �l �
MOWN a1 bvydrq?._ ��idc0 .dwattMp,for how many famasa?
Vm trriar,s coda m to law? T c MbMoa?
Etfla.W wo+3 t)0. C)C� CRY Ltosrisr r Uosrtsa r
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S not Applicant
1.9111361111 THE PE 4ALTY'
of PERJURY
DESCRIPTION OF WORK TO BE DONE
E I � !mot E W— Sl-fED F120 94 .SEP-, IzS
MAIL PERMIT TO: 0 W fJ
CITY OF SAL91149 MASSACMUSKWS
PUBLIC PIR0P61 w De.FAwrmFNT
120 W"NIN.TON eTI M. 3*0 Fwan
fAL.N.NA 01!70
T.L (976)748-MM W. 300
FAX (970 71011"S
STANLCY A UWVICL JIL
MAYOR
DISPOSAL OF DEBRIS ANWAVI?
In amgda000 wilt the peoviaiaoa of UM a 4%M I wlnowlo*that m a cAoditiao
of Bm' ft PenalR 0 all ddoia raauNq lt+am the oaa.te cbm ere"
Sovemed by tbib Build ft Permit anal be di*m d of in a peopady lieeo.ed aOH&waste
diapud Bdit,Is dedoW by WL a 11;SIX&
Mw debd.will be disposal at* �D E-niS i DE Cam-n N
Location of Padtity
-------------------
Av r—r- 2c�o�
Si .tole of it Appliemt Dam
Y comp the&Dawiq in>3ormad
(PLEASE PRDrr CLEARLY)
--- JCH I
Name of Pen»it AppHe t
Film Name,if any
5 pi 6 fN EEC Ct M A;c O 19—70
Add=i6 City at Stme
The above statute rgwm that debris from the demofiuM renovation, rehab or other
altetstion of building or stm un be disposed in a pmpaly.He msed solld-wuw disposal
facility w dedaed by MGL caX S15ft and the building permits at licmm are to
wdiwe the loeadoo of the famMy.
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date P— + — O
Job Location 5- p/OfjEl:,�Fj2 GI
Home Owner Address t 1
Home Owner Telephone <] - g ,3 4
Present Mailing Address 5 f!rp,.j E-V, CI 2 C A c sh LE►'1
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 inspecti procedures and requirements and that he/she
will comply with said procedures anIre irements.
HOMEOWNERS SIGNATUREAPPROVAL OF BUILDING INSPER �j-
See other side for state code
HOMEOWNERS EXEMPTION
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 109.1.1 —Licensing
of Construction Supervisors); provided that a Homeowner engages a person(s) for hire to
do such work, and that such 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
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 a part of the Permit Application, that the Homeowner certify that
he/she understands the responsibilities of a Supervisor. Can 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.