20 PURITAN RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
130 w.mmva M SrM=•Sum NEASLACHUCM 01970
TU.973.74S-9"S• FAx.979-740.9"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date .ZeZ D o
Job Location a40 u ,,2/ le SA •��r�s �// CS � S� d
Home Owner Address oe d SW'4 ice-
Home Owner Telephone 9 7 7 y 4' —5- 6 0 6
Present Mailing Address 7 7 o_ ;5-. A2d
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 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
CTrY OF SALE)
PUBLIC PROPRERTY
DEPARTMENT
at...s Ix i ulkftavtv::a.ncibLer.
To.YOt 46am•fate 97 M"O
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Cunstructian Debris Disp"at AAidavit
(caloNd lbs all ASMIGU a and SOM"atiaw won)
is xcoWWm with the sixth edition at dtt Sett HuMl"Ccda6 730 MIR soctias It LS
Debg%and dw provisions a(MOM a 406 S 34
euililiq Permit A is iswtsd with dw eonidos dust dw debris resulting; i m
this wart shall be disposod*(in a properly iicans"wash disposal facility as donned by VIES.a
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The debris will be transported by:
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rhoAcbris will be disposed ofin :
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PUBLIC PROPERTY
DEPARTIMEI 1T
KuroF•L N oW5[uu.
MAYOR 130 WASMNG'TnN+MEET unity,MAttA0lLSkllS 01970
To,978-74S-9"S 0 FAx 976.740.95%
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: p 7�.ve� Building:
Property Addresr.
v vrL/ G
Properly is klcated in a; Conservation Area Y/N_[t O Historic DMict Y/N D
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land c- S
Name:
Address: a v JOv� ct
Telephone: , z4zji 4.22 is
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation �LFjdl�'! Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation `� ��
of existing building New
Brief Description of Proposed Work:
Pe. m Oth? -4 We,(" 1 H-Ge— e,91ViL Cf�
13tiYA QD O m-
Mail Permit to: .'Z[�
L
What is the current use of the Building?
Material of Building? if dwelling, how many units?
Will the Building Conform to Law? )e S Asbestos? b
Architect's Name
Address and Phone t
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost Proj i % Permit Fee Calculation
Permit Fee i Estimated Cost X$7/$1000 Residential
Estimated Cost X$i 1/$1000 Commercial
An Additional $5.00 is added as an
Administrable charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to
build to the abovestated
specifications. Signed under penalty of perjury /� !J? �XN��✓'c�
Date o2 � v8
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Or T y
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all Il 3p
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