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I Rroperty Located in Location of
tF a Historic Districi? Yes_No_ Building 1
Is,F�roperty Located in
Ui'e Corrsarvailon Area? Yea No—
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: ln + � �
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:
Owner's Name V1C10 kllf IpFLp C"J
Address & Phone X4 A (97P) Vel S Go"
Architect's Name
Address & Phone
Mechanics Name
Address & Phone
What Is the purpose of building?
Material of building? If a dwelling,for how many families? dhli
Will building conform to law? Asbestos? Avf F-
Hstimated cost /0i M city License k State License #
Hama Improvment
/1 Lic. I
Signature of Applicant
SIGNED UNDER THE PENALTY
4 _ OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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�o CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
., %y, 120 WASHINGTON STREET, 3RD FLOOR
y SALEM, MA O 1970
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, S 150A.
The debris will be disposed of at:
Location of Facility /
Signature of Permit Applicant bate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
V/Cic PCL14 C/lz
Name of Permit Applicant
Firm Name, if any
31 4 A=�Ih�rt
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
B=ING DEPARTMENT
HOMHOWNER LICENSE EXEAFTION
PIC=PrW
DATE . /b3
JOB LOCATION 3 i Lj.
HOMEOWNER
ADDRESS
HONSEOWNM 078' 7457,,,999
TELEPHONE
PRESENTMAILING ADDRESS
The current exemption of"homeowners"was exunded to include ewmr,.oceupkd dwcMmgs ofTWO
Units or less and to allow such homeowners to engage an individual for hire who does la posses a
license,.pronded that the owner ad as superviwr.
DEFiNMON OF HOlvZOWNER:
Person(s)who owns a parcel of land on which hdshe raids or irucnds 10 reside,on which ism
hntcnded w be,a one to two family dwelling,anached or detached stru tut aeassory to
farm srrucw=.A person who cons wm more than one home at a two-year period shall not be eonsdeud
a homeowner. Such"homcov=r shhall'submit to the Building Official,on a form aetzptabk 10 die
Building Official,that Wshc be raponnbhe to all such work performed order the building prsmk,
Tbc undersigned"homeowner"assumes respormbility for compliw=with the State Building Code ttmd
other applicable goes by-laws,rules and regulatioms.
The undersigned"homeowner" ratifies that htlshc unde s ards the City of Salem Bu'WR Dcpamvw t.
minimum irspenion procedures and requirements and that hlshe will comply with said proadtaa sad
requircmCM
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR vL •
Sec other side for state code
HOMEOWNER'S EXEMPTION
I
The code states that "any homeowner performing work for which a building permit is required shall be
exempt from the prmisioru of this section (Section 109.1.1-1�ccosing rrf Conatruelion Suptrvisoss);
Provided that is a homeowner engages a person(s)for hire to do.such worts,that sueb homeowner shall net
as supelllwO '
ivlarty borneowners wbo use this exemption arc iurawarc that thry are assnmutg the tesponsibMdu da
superrtsor (set Appcod'u Q,Ruler and Regulations for Ummsing Construction Superviwrs,Seetioa
1.15} This lack of awareness often rssuhs in seriom problems,particularly when the bomeowner buret
uriliccused persons in this case your Board cannot proexcd aphist the,unlicensed person as it world wi&
licensed Suprnisor. MM bOmeoNDer acting as supervisor b uhimately r+esponsibiL
To cnsm that the homeowner is fully aware of hither responsibilities,marry communities rr qu!M as pnt
of the permit appliczdm that the homeoNvner certify that helshe rmdentands the responsibilities of a
super .isor. You may care to amrnd and adopt such a form/cenifrcation for use in your commuzdq.