40 RAVENNA AVE - BUILDING INSPECTION a
f1i1M61Y1!lBfbEi L OVEO BY 744E
JAISAECSLIJ3 IGA 7D *P B WiNR GRANTED `{I
r1 \ CITY OF SWLEM
Dab
f®eatlon of
6011 gab Dbt�lcf7n YN_No� 301"iat 41D 1?Q9ke�4 Ave
ft Car oveMpn AIM? YM_No
BUILDING PERMIT APPUCATION FOR:
Permit to:
(Circle whichever sq*) Roof, Remof, Install Siding, Construct.Deck, Shad, Pool
Repair/Replace. Othsr.
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCR
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the foIW&*q
spedflcations: 1 Owners Name ` h . • e 9 vYza
Address A Phone �/o P emtww o raves f�P11 qS3- SS 3y
Architect's Name
Address 3 Phone I 1
Mechanics Name
Address & Phone
� 1` ItIIS A '.
whtl Is 1ha [40 m e2 r+:l
purpose ar twraYg4 1
0i; .
momm or bLd*g4 I 10®CA N a ri v 0 p,W how many amaa7
wr b"v conram to we
r 2S ! II
A
aararw coat. 7®�Cop L iew"•N 81aM • �
aa�a Iagrsoeeaat
9 Signature of Applicant
SIGNED UNDER THE
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Y)stntl LuL l�gf4 13h�� w`�,!ng `J P 7o�*!2
�p _ )
" MAIL PERMIT TO: `/0 I�AVCWAra t)V- -
UA jr"" ���
Ar-
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r.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
7 AOV�D
0 .
INSPECTOR OF BUILDINGS
CITY OF SAum
BUILDING DEPARTMENT
EMMOWNER LICENSE E0TLON
_ Pkasc Prsri '
DA 6
IOBWCATION YO ee�,hd`
ADDRESS
TII EPHONE
PRESMMA]LWGADDRESS CIO L�2(EarKl 4gv
Tht cw•rcm cxenV ion of"borneow•ners"was emszded to include owmr.9=pied dwcll iV o[TWO
Uniu a less and to s11ow such homeowm%to engage an indmd»- fa h've who dos toot possess
license,provided thm the owedset as supervUw-
DEFRIMON OF HOMEOa'SM
Person(s)who owns a pw=i of land on which hdshe resida a intends to reside,on whieh iih=lu=or is
intended w be,a one to two family dwelling,anadmd of dtudwd suvctwa aeeesory
Jim swataes.A person who coratmm more than one home at a two-yeas period shall sot be cmideted
a homeowva. Such"homcoNmf shall avbtrdt w the Building Official.on a fam atmepubk tb*&
Building OffkW,that Wshc be Tcspombk to an such work paia=ncd wda ft building pa=L
The undasipud`bomcowncr"asswm Tcrpmnblbly for complies=whys ft State Building Code and
otha applitabic jots by-laws,ruks and rcguhimL
The undcsignrd"hovwcr r" oaf&=that hdshe understands the City of Salem Building Deparuaat.
minimtao inspcnion proccdwc and rcquircatc and that IV will comply with said prootdmts and
HOMEOVIM'S SIGNAT(IRE
APPROVAL OF BUILDING INSPECTOR
Sec other side for state code
r1 ..
HOMEOWNER'S EXEA'MON
. . � � . . .—. .—... .... . which a building 't is tined alraS be
The code state that arty homeowner performing wodc far ding perms mq
the isions of thissectioa Section ] 1.1-Uansiog of Construction Supervbo�; r
' exempt from prm ( fl9
Provided that is a hm=,A'net engages a person (s)for hire to do.such work,that such bomwwm dMA act
as supmzsar"•
Marry homeowners who use this c)mmpdon are unaware that they arc assam%g the respomtbBh9ea der
supervisor(tee Appcodia Q,Rules and)Irguiations for lictmog Coostruetion Super Ason,Sc*a
.2.24 This lack of awareness often rcruhs in serious problems,panieulariy when the horacowae ltbs
u rikor sod persons. In this case your Board cannot proceed against the w0ccnsed pa;vn U it world WI&
licensed Supen+isor. Tba boumelh-er ailing as svpervbor b ohftsnte y rnpoostbk.
To eustrt that the homeowner is fully aware of 144m responslolities,many communities TWO",as part
of the permit application,that the homeowner certify that wshc wukn ands the responsibfl'aiesiler
supervisor. You may can to amend and adopt sea a form/ccnT=1dm for tat in your
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O1970
TEL (978)745-9595 EXT.380
FAX (978) 740-9646
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 constriction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S 150A.
The debris will be disposed of at: Pok'A-1i S1O e 222.111 h(�i
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
u;
Name of Permit Applicant
0 P
Firm Name,if any
t-/o ReA-uemA
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 cllL S150A, and the building permits or licenses are to
indicate the location of the facility.
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