14 STORY ST - BUILDING INSPECTION (2) " ' *What is the current use of the Building?
Material of Building? If dwelling. how many units?
win the Building Conforrn to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S I ov Permit Fee Cak elation
Permit Fee t — Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commerclat
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date ��Q
o
N
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x d G a
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PUBLIC PROPERTY
DEPARTMEINT
.i.QWJUXV MWOLL
MAYM Q 0 W&*"NGnxt h nkM.Sutx WtisAaa;s&-1'rs 01970
TM 979-745-95" 0 Fxx:976.740.9246
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 1 AO , S i Building:
Property Address: I S {
Property is located in a:Conservatlon Area YIN Historic Dk&kx YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: Z'1 L4
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIMG BUILDINGS ONLY
Addition Existing
Renovation k 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
Brief Description of Proposed Work:
j„as•1 ��� n{ik? 1 S+0 ae
-- -- — --- --- g — -
Mail Permit to: t`f Si c~`t
CITY OF S.3LEM
PUBLIC PROPERTY
DEPARTMENT
1'-0WASU�. OM SMENT 4 SN.EKWASfA00-YM to197o
1I1:976-745-9S"•FAX 978-74e."46
HOMEOWNER LICENSE EXLMPTION
Plea"Print
Date
Job Location 1`1 S }o-I S 1 SAID. , N
Home Owner Address i,, S --7 S I
Home Owna Telephone S"—S z 1-i
Present Mailing Address i q S-1 an,j 31 c'A l yhA
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two units or less and to allow such homeowners to engage an individual for
hire who does not posse"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 then is, or is intended to be,s 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 procedures and requirements and that he/she
will comply with said procedures and re -rements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code ell