23 STATION RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120WASHINGTONSTREET 4 SAITM, MASiACHLSEITS0197C
Tr.i.:978-745-9595 + FAX:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft—--- ------— 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 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(aZiciress of facility)
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CM31 isa:f doc
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI�ptFi1EY ORLSI:OLL
MAYOR
120 WAstuNcrow SixM 4$ALEK 5tnt5AaiusETI3 01970
TEL-978-745-959S 0 FAx:978-740.9946
HOMEOWNER LICENSE EXEMPTION
Please Print
Date D
Job Location
Home Owner Address 13
Home Owner Telephone C% a l 0 G f 3
Present Mailing Address
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 procedures4reqments and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATUREAPPROVAL OF BUILDING INSPECTOR
See other side for state code
EI"I�Y-0 � - -
PUBLIC PROPERTY
DEPARTI4IF.�1T
KING&EX yy ORISSANl
WAVOR 120 WASMNarM hMAT 0 '
MXA NAtiS.Sc3f{:5hT1S 01970
Tm-978-745.9S"•FAx 97&740.9616
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUMDIN .
1.0 SITE INFORMATION
Location Name: 23 Building: �.
Property Address— -- - ----- -- - -- - -- -- .. - - -- ---- --
Property Is located in a;Conservation Area Y/N Historic Dlstrik t Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: a ��
Address: c�3 (S
iU
Telephone: 10 c, I
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
— —Mail Permit to: --
IL
What is the current use of the Building? Ih�� . 1
Material of Building? tJ0 B� if dwelling,how many units?
will the Building Conform to Law? Asbestos?
Archited's Name
Address and Phone
Mechanic's Name
Address and Phona 3 < �,j
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S d Permit Fee Calculation
Permit Fee$ 00 Estimated Cost X$71$1000 Residential
Estimated Cost X$111$1000 Commercial ------ —
An Additional$5.00 is added as an
Administrative 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 above s ted
specifications. Signed under penalty of perjury X /
Date
� I
0
N
06
V n
96 s a a