10 PURITAN RD - BUILDING INSPECTION lith
�L�4QS�e+IiiST BEIF
f1iH '.'PWiOVE{) BY T+ia: ',,•
1US�P IAJ3 F' AR . p;A P T gEWG GRANTED
CITY OF SALEM it
) \\J Data :3
Is Property Located In Location of
the Historic District? Yes No Building
Is Property Located in
the Conservation Area? Yes_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 PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Address & Phone 1D \�rA'4.nRa
4Architect's Name
Address & Phone S. (��U I ps , r� !J•,Nf 9��i g
418 (36l S
Mechanics Name
S �e
Address & Phone
What Is the purpose& building?s ra
Material of building? 1 I .w,' m f lkl if a dwelling,for how many families?
� �II
W"I building conform to law? Asbestos?
( o City License N N A State License
Home Improvement Xjtu�e'of
Lam. Appli t { • i
SIGNED UNDER THE PEN44TT
OF PERJURY i^
tPON OF WORK TO BE DONE
n
� hI
MAIL PERMIT TO: u V 1 M +
- sr
.,
APPLICATION FOR
P
E
RMIT TO
LOCATION
/ l/ �/ .'Tb✓/ /` lei'(/
PERMIT GRANTED
2-0
APP VfD
INSPECTOR BUILDINGS
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o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
r 120WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 ExT. 380
FAX (978) 740-9846
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 construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
The debris will be disposed of at: 1 u-r n-!r n L I
Location of Facility
Si afore of P plicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicait
Firm Name,if any
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 cIII;S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BUII..DING DEPARTMENT
HOMEOWNER LICENSE EXEI&MN
Please PrW l
DATE III b
JOB LOCATION '� o
HOMEOWNER 16 . r �V�a-h�
ADDRESS
HON EOWM �1 L� y la - l9 6 .
TELEPHONE
PRESEW MAILING ADDRESS,_ (9 2v r,}'t -\
The aurClArmemption of"homeowm a was emended to include owner-occupied dwdGSgs of TWO
Units or kss and to allow such homeowners to engage an individual for Lire who does not pow=a
license,.pronded that the.owner Set its superv%"-
' DEFR,TMON OF HON EOWNEFL
Person(s)who owns a pm=l of land en which hdshe msida or intends tc resitk,on which there is,or is
intended to be,a one to two family dwelling,auached or detached strucnaes Stxrssory 10 web we andlar
farm strucams.A person who constructs more than one home in a two-year period stall nol be considered
a homeowner. Such`homed Ame shall'subnut to the Building OfficK on a form acceptable to*A
Building OMdal,that Wshc be responstble to all such work performed wider the building peradt.
The undersigned`bomeowner"amanes responnbility for compliance with the State Burld'mg Code and
other applicable goes by-laws,rules and regulations.
The undenign d'homeowner"certifies that Wshe understands the City of Salon Building Dewy a.
minimum inspection procedures and requirements and that hlshe will comply with said prooedwa and
requirmreta
HOMEOWNER'S SIGNATURE 4 It7 NkA
n
APPROVAL OF B=ING INSPECTOR � 'Le
See otter side for state code
HOMEOWNER'S EXEMPTION
The code states that "any homeowner performing work for which a building permit is requircd shall be
e;ccmpt from the provisions of this action (Section 1Q9.1.1-lliceosing of Construction Supervisors);
Provided that is a homeowner engages a person(s)for hue to do.such work,that such homeowner dtall aU
as .'
Many bomeowncrs who use this cacm non are unaware that they we assuming the ttsponnbih'ties of a
supervisor(aer Appcodis Q,Rules and Regulations for 1;citnuog Construction Supervisors,Seetim
.2.14 'Phis lack of awareness often results in serious problems,particuiartp when the honwowrrer bhu
urJiccnsed persom In this case your Board cannot proceed against the unlicensed person as it wtanld witD
licensed Supervisor. The bomeorver acting as supervisor b oltimatdy responsibh.
To ensure that the homeowner is fully aware of hi4=responsibilities,m:arty corium pities regkim as put
of the permit application•that the homeowner certify that hdshe wukrsta*ds the responsibilities of a
supervisor. You may can to amend and adopt such a formiccrdfication for use in year eommrAp.