15 PLANTERS - BUILDING INSPECTION fL�g6M11�t�EfKM*MD RPPROVGD By 1W
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CITY OF_SALEM
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:• OUMMMNIN AM? Yer.No
aL11160 i PERMIT APPLICATION FOR:
Permit to:
(CkW whiotwwr apply) Roof. R*W Install Sicks CarWW Deck Shed, Pool.
RspairlRepisoe. Ottwr: ,eymlb.> � .�w�/.v�a ,,..o
PLEASE FILL OUT LEGLML.Y&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDING&
The wtdwsiprwd hereby applies for a permt to bWW aoow*V to the IOWW tp
specification
Owners Name
Address A Phorw 1,� t�lp�2ZL�u S s f1 1
Ardti ores Name
Address & Phone f 1
Mectwnics Name -
Address & Ptwm L 1
No Is ft Papoaa if btYldbp4
M*Admi a btrltlYp4 N a oNew ,for how wad lems"?
VYr buildYp to lfw? 7
Earmwd a cry Uo 0 N A elate Uow"•
0 5 t9. 0 Appficartt
11110 D UNDER THE PENALTY
OF Fall,IURY
DESCRWrION OF WW TO W DONE A
k a - -P
MAIL PERMIT TO: WI1�n ,
No.
APPLICATION FOR
PERIfT TO
�1!/5T4GL /�F (�e%ot�.vT GJiAlDO�-S
LOCATION
PERMIT GRANTED
2).
APPSOVED
OWWCM OF BUKMM
CITY OF SALEM9 MASSACHUSETTS
n i PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
i
41 S,i-e (QV K Y1' W(Location of Facility)
S ature of /pplicant
Date
' CITY OF SALEM, MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
y SALEM. MASSACHUSETTS 01970
STANLEY J. USOVICZ, in. TELEPHONE: 976-745-9595 EXT. 380
MAYOR FAX: 979-740-994e
HOMEOWNER LICENSE EXEMPTION
Please Print.
Date
Job Location f J h �ry S (S
Home Owner Address.
Home Owner Telpho
Cl
Present Malhng Addtees_.L`� /J /.—�
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings Of two Units or leas and to allow such homed to engage an individual for
se
him who does not posss a license,provided that the ow as supervisor.
DEFINITION OF HOMEOWNER .. a J
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 conatructa mo
than one home m a two year period shall not be considered a homeowner. Such re
"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
APPROVAL OF BUILDING INSPECTOR
See other side for state code
HOMEOWNER3jn.m,rnON
ing work for which a Building Permit is
The Code states that. "Any Homeowner perfo rm m
shall be prompt from the provisions of this section(Section 109.1.1 —Licensing
required 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.
don are unaware that they an assuming the
Many Homeowners who use this exemption Q.Rules and Regulations for Licensing
responsibilities of a Supervisor(see Appendix lack of awareness often results in serious
Construction Supervisors,Section 2.15). This in this case your
problems,Particularly when the Homeowner hires unlicensed persons.
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as supervisor mh'responsible.
;A
To ensure that the Homeowner is fully aware of his/her responsrbilides,many
as a part of the Permit Application,that the Homeowner certify that
communities require, On the
h she understands the Lesponsibilities of a Supervisor. page of this issue is a
form currently used by several towns. you may cam to amend and adopt such a
form/certification for use in your community.
Ito `I fp yao S