11 STORY ST - BUILDING INSPECTION r +LIW"S ld d--B E fH. -B� ,APffI 8Y T+IE
U PIrCJ. R ,PFWR TD.A.PERMT .BEWG GRANTED
CITY OF SALEM
oNu r
No.
`:"' � \ Date -z i
Is Property Located in Location of ` J
the Historic District? Yes_No Auiiding
Is Property Located in
the Conservation Area? Yes_No -
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) R of Reroof, Install Siding, Construct Dec Shed, Pool,
epair Replace, Other: �� i '+t t 'r C
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:
C'V-11
Owner's NameT
Address & Phone � f 12 ,2S I _ L b 0 Z
Architect's Name
Address & Phone
Mechanics Name
Address & Phone
What is the purpose of building?
If a dwelling, for how many families?
Material of building?
Will building cornPrtn to law? Asbestos?
C N A
Estlmeted cost. 5 �yc, =� City License # Mate License #
Home Improvement �
O' 1 A—,<l < ` � V v J
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No.
APPLICATION FOR
PERMIT TO
J
i
LOCATION
PERMIT GRANTED
3 //0/ 0i.-, 2.o
APP�OV�D
Y,
INSPECTOR OF BUILDINGS
17
W i
I
CITY OFF BALEM, MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOYICZ. JR. TELEPHONE: 978-745-9598 EXT. 380
MAYOR FAX: 978-740.9846
Salem Buildlna Deoaatn�..*
Debrla %WffiA Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
A (Location of Facility) S� Lo M
Signature of Applicant
U
Date
CITY OF SALEM9, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RD FLOOR
SALEM. MASSACNUSETTS 01970
STANLEY J. USOVIC2. JR. TELEPHONE: e78-745-959e EXT. 380
MAYOR - FAX: 97e-74"S4e
HOMEOWNER LICENSE EXEMPTION
Please Print.
Date 0 (,,2
Job Location S 1 S-A
Home Owner Address S S
OwnW Tetaphoaq
Preae Mailing Address_- I TO(, TTbe ' W
Current C1411TIPtim of"Homeownere was,ute-D"to include owner-occupied
dwellings of two Unite or bw and to allow rxj Leo to engage an individual for
him who does Dot possess a license,provided that the ow
oe as supervisor.
DEFINITION OF,HOMEOWNER '
Person(s),who ow=a paucel of land on which he/she resides or intends to reakl%on
which there is,cc is intended to bq a one or two family dwelling, attached or detached
structures accessory to such use and/or farm sttucttua. 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 fora 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 procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
Sec other side for state code
BOMEOWI�IEIIt.9 EXEMPTiON1
work for which a Building Permit is
The Code stator that. "Any Homeowner�° g on 109.1.1 —Licensing
from the provisions of this section(Secti
o f Cons shall be exempt vided that a Homeowner engs8w a pawn(s)for bun to
Construction work,
S R Pr'o
of C �that such Homeowner shall act as S�801.
do such work
tion are unaware that they are assuming the
Many Homeowners who use this exemp for Licensing
iities of a Supervisor(we 8°d
ppp��Roawofm°wresults in serious
Section 2.15).
WMM
Cougumdon Supacv�m• unlicensed lawns. In this case your
problems.Particula`lY when the Homeowner hirer it would with a licensed
the unlicensed pars as
So�•so t��acting as OPWASOF isWdmstq Me.
To ensure that the Homeowner is hilly aware of his/her a Hon.many that
the Homeowner certify
communities require,as a part of the Permit Application+ n the last Page of this jam is a
helshe under the responsibilities of a Supem�• such a
form currently used by several towns. You may can to amend and adopt
f0,Wcadfication.for use in your community