1 SUMNER RD - BUILDING INSPECTION -Pt MS WTOEflbaW*AD O PPROVED BY THE
IN-QPACM P40A TDA.P.F. 3j fT AGING GRANTED
CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR:
Permu to.
(Circle whichever apply) Roof. ero 9 nod Congn� De� Shed, Pool.
a.ri,`Lod-
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS.
The undereigned hereby applies for a permit to build aocord% to the following
Owner's Name Aleg ImaR/ f 6,4&aL z%lr, s�
Address A Phone /Scrmrir_/
Architect's Name
Address & Phone j 1
Madm cs Name
Address & Phone / L
who is on purport at WNWSi o9LG "c-am,1u, asc ' G/c
wMrW a buYdkrp? a dwWq.for how many%non?
we bei*v mda n to low? yG s MbM=? A141
t alYrratad ooaSv oo• ciw uk • KI/0- am Limm r
uc.
S re of Applicant
SIGMED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MNL PERMIT TO: Al�Y-Dal-iSSL
/SuL�a�el.e .
Sala L� pyo. O/97®
No.-L (o
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED -
ltita
APPROVD
/JNFWTOR OFAUILDINGS -
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CITY OF SALEMO MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-743-9393 EXT. 380
MAYOR FAX: 978-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print.
Date 11 if,GLS
Job Location Ale,/,2�
Home Owner Addresa_ / Srrin..ror
Home Owner Telephone 912f
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings Of two Units or less and to allow such Homeowngs tO engage an individual for
hire who does not possess a license,provided that the owlii akts as supervisor.
DEFINITION OF HOMEOWNER. ,
Persons)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, attache{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
Oficial, 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 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 req it ents.
HOMEOWNERS SIGNATURE /
APPROVAL OF BUILDING INSP CTO
( ��
See other side for state code
Ho11ZOWNERS EXEMPTION
The Code states that; "Any Homeowner performing work for which a Building Permit is
shall be exempt from the provisions of this section(Section 109:1.1 . Licensing
required of Construction Supervisors);Provided that a Homeowner engages a person(s) for hire to
do such work, and that such Homeowner shall act,as Supervisor.
\. '..,
Many Homeowners who use this exemptio4*0 unawsre that they are assuming the
responsibilities of a Supervisor(see?ppendixtQ.R es Regulations for Licensing
Construction Supervisors,Section 2.15). Tli a ices of unlicensed
in renes serious
problems,Particularly when the Homeowner as it would with a licensed
Board cannot proceed against the unlicensed p responsible-
To
The Homeowner acting as supe is ultimately
ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require, as apart of the Permit Application,dist the Homeowner certify that
he/she understands the responsibilities of a Supervisor. on the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.
R� GI3p'yaoS
o
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978.745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal 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. Qura�s f- s fj j, ,aQ,I z C'Z"F OV�- f
The debris will be disposed of in:
?1aiysFe/ .?7ai11: / (Location of Facility) C�J�l4Ssa�/�q
Sign re of Applicant
Date
SEE �lC: (106/ Pl�r 3Z7
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