6 SOUTHWICK ST - BUILDING INSPECTION (3) CITY OF &XLEM
PUBLIC PROPERTY
DEPARTMENT
KIfO1ElL6Y D�w•ry
MAYOR
130 WASUNG•TON 9n1EET SALEK MAUAC14USUM 01910
11=L 978-74S-9S95 • FAX 976.740.9&M
HOMEOWNER LICENSE EXEMPTION
Please Print
Date o
Job Location so 0¢L ,r tr 4- 10
Home Owner Address !o So u f 6 w va C I ,gyp
Homeowner Telephone wl-a4r-17:3 3 .r
Present Mailing Address as met Aueg ue
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.
I
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
i
` CITY OF SALEM
I PUBLIC PROPRERTY
DEPARTMENT
I?(}W.�y a\G:J�SIREET 0 SALi'%fit.\Si.\(:btl ILL-IS 319IC
'rFl:978-745.9595 •F%X:978J4CG9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # - _ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 1.50A.
The debris will be transported by:
l 7qer Tts oosa I
(name of hauler)
I'he debris will be disposed of in
(name of facility)
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CITY OF SALEM
t ' I PUBLIC PROPRERTY
DEPARTMENT
N 1.%1 i,K 120 VP.\iI 1[VG:JN$)�EET •SALLl1,St.\ii.\(:art il:l li]i`17C
Tnt:978-745.9595 •f.\x:978.74G9M
Con • ion Debris Disposal Affidavit
Construction P
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNiR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al _ ., ._ is issued with the condition that the debris resulting from ),
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c !
111, S 150A.
The debris will be transported by:
- --- (name of hauler)
1'he !ebris will be disposed of in
_ (name of raolity)
-- )al.lresa of t�.iLly)
])_CLLt LLI'L .)I 7�L17.)C d(7 O.)C 1lI
EI'TY-OF�XLEb
PUBLIC PROPERTY
DEPAR'1'bIENT
Kl%awn"DRLSCU L
�^ 130 WASUNGWN b17EW•SuuN..M&9ACW-ShM01970
TiL- .743-9M•Flue 97474o4m
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
_DEMOLITION. OR CHANGE OF USX OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
ff, Nww
S 1J� SE Building: 51N ( -taddress: ---.- --
in locaW in a;conservation Area Historic DtsMet
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land .
Name: J l ON e
Address: j
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISXM BUILDINGS ONLY
Addition Existing Q-
Renovation Number of Stories Renovated
Change in Use New —
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brae[Description of Proposed Work:
Goad S-f±rva�ura (I Suppor( 4o fnrn,ty roov4 a� "wr o F
h�pvle . S:� ppor�- �o LbNScF ( n t �'�'w�c°N� Cc9�uw�Ns
— -- _ - ---Mail Permit to: awes Penn ve a r %3AQ04 A uem ve sa t eem ma - -
What is the Current use of the Building?
Material of Building? Ifdwelling,how many units?-— - -
"a the Building Conform to law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
5 HIC Registration i/
Construction Supervisors License
Estimated Cost of Pro ed SG�� Permk Fed Calwlatlon
permit Fee S��� Estimated Cost X$71$1000 Residential
.l
Estimated CostXS41/S1000Commercia4
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 Ild to the bove
specifications. Signed under penalty of perjury
Dat / Z�,fe D 7
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