38 SCHOOL ST - BUILDING INSPECTION illST-BE fiL-EGANO APPROVED BY T*IE
WRIEXTD-13 PRIDIR TD.A PERMIT BEING GRANTED
CITY OF SALEM
No. z Ll 1 -20 O N F:t� "L ��\ Date
3.. .
Is Properly Located in Location of
the Historic District? Yes—No Building
Is Property Located in 7
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:
Owners Name' /,/b ( t%, J
Address & Phone ,J0 Sll t cl I 1� ( )g17P) 'A4 1 — 3 2 3 S—
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?
Will building conform to law? Asbestos?
Estimated cost &6 City License # N�A Stale License # Ar
$20 QAsq Home Improvement 1
Lie. i /
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE I
&dd Olulrill?,I2,rn
G l Via) i
lN� ) RZ LI
MAIL PERMIT TO:
Q
No. 2,t 67
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
CITY OF SALEM
B=ING DEPARTMENT
HOMEOWNER LICENSE E?O&TION
Please Prim
DATE
JOB LOCATION
HOMEOWNER Yyu.
ADDRESS
HOMEOWNER �n� 9(4 1 - 3 3 -
--TELEPHONE [[��
PRESENT MAILING ADDRESS
The cwrtnt exemption of"homeowner"was r-ncrrded to include o,rocrvoceopied dwelGcgs of TWO
Units or less and to allow such homeowners to engage an individual for hire who does not poom a
license,provided that the,owner act as supervbor.
DEFINITION OF HOMEOWNER:
Pcrson(s)who owns a parcel of land on which hdshe resides or it tn&to reside,on which there is,or is
intended to be,a one to two family dwelling,anached or detached structures accessory to PXb Use andkr
farm strucwes.A person who constructs more than one home in a two-year period shall not be considered
a homeowner. Such"homco A ree shall submit to the Budding Official,on a form saxptabk to the
Building Official,that he/she be ttsponnble to all such work perfortaed under the building pcmmit.
.The undersigned`homwwncr"assumes responsibility for compliance with the State Building Code aad
other applicable goes by-laws,rules and regu bticm>`
The undersigned"homeowner"certifies that he/she undaatands the City of Salem Building Deparnomt
minimum inspection procedures and�9(nrcments and
tsas. , that hlstu will comply with said procedures and
rcquirrct j�
HOMEOWNER'S SIGNATURE\ (J
APPROVAL Of BUILDING INSPECTOR �'
See other side for state code
i
HOMEOWNER'S EXEMPTION
The code states that "any homeowner performing work for which a building permit is requued shall be
exempt from the provisions of this section (Section 109.1.1-licensing of Construction Superv►sors);
Provided that is a homeowner engages a person (s)for hire to do.sucb work,that such hottteowner shall ad
as strpervtsas."
many bomeowners who use this cnxr pdon are tmaware that they are am=ing the Tcspoastbthties Of i
supervisor(sec Appcediu Q,Rules and Regulations for Ucxusing Construction Supervisors,See'tim
.2.14 Tbis lack of awarrness often results in serious problems,particularly when the homeownerhi3et
unlicensed persons In this case your Board cannot ptoexd against the unlieeused person as it wvuld with
licensed Supenisor. The bomcoxocr acting as supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of U4=msponsrbilities,many eommtmities tequim as PA
of the permit appliodon,that the homeowner certify that helshc rmdersumft the responsibilities des
supervisor. You may care to amend and adopt such a formlccrtification for use in your eontmuniq.
FORTY - ," OF SALEM,- NIASSACHUSETTS
-PUBLIC PROPERTY DEPARTMENT
' 120 WASHINGTON STREET, 3Ro FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT. 360
�Gyra 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:
cation of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
1 In A I Mdt-e _0
Name of Permit Applicant
Firm Name,if any
C.h"'CWi S� SQu(Yl m(j(� �
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.