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' CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIIWE[IfY DRISCOLL
MAYOR
120 WASHINGTON STREET♦SA E.0 MASSACHUSEns 01970
lei 978-74S-959S•FAY:978&74&9&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Date /r07
Job Location PP.,J s q- -
Home Owner Address _ e, ,V-P
Home Owner Telephone r? 7 $ 7 y S a -7 ,'16
Present Mailing Address 4' �� S
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. j
The undersigned"homeowner"assumes re
sponsibility onsibili fo esp ry r 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
CITY OF SALEM
, )7%
PUBLIC PROPRERTY
DEPARTMENT
120 •S.1LVM.MASS'AG n.5L 1't]0 P)/:
Tfu:978-7450595 •Bx:978-74G9846
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 ofMGL 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:
—
X3 ek
(name of hauler)
I'lic debris will be disposed of in
r4-4 S-'
(name of facility) ((��
S1NW✓l SC�Sa 'ri � Jw �,
i alures. of fadlny)
- \I_I:atal'd
--- - . a VI XA A"Vi
• • PUBLIC PROPERTY
DEPARTjUL%4T
woo.
t�oe•�w�•
D
1.1 SITE INFORMATION
Laealbn Nww
PMp"AddieeaC iZ
Pmw IN M k►eeNd in a:Cords vatlon Area YM loft OlNtlpl YM
2e OMNER"I INFORMATION
11 Omar orLow G'a r Pn c
Name: 11�S a ov2
Addraer
3ACOMPLETE THIS SECTION FOR IMORK IN'
st"NGE oNLY
Addition
Exlstlrq 2 Rerovadan Number of Storlea RenovatedChange In Use
Demolition Now
Appfoximate year of 6 C6400
04ndn4ftn or renovabon /el og D Area per Noor(sq Renovated
of exislirg buildup
New �
adat Description of Proposed Work:
Mad Permit �a r /�- Z,�.✓/t' — - -