2 UGO RD - BUILDING INSPECTION EITY-OF3 IL
PUBLIC PROPERTY
/ DEPAR'I1b EINT
NAYOa 130 WASNNGiCx hftEg'r• - ;_ "= N(MtACHt:set'ts 01970
1Fi 97e-745-95"•PAX 978-740.93"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTLNG
STRUCTURE OR BUILDING
oix SITE INFORMATION
Location Name: O )eOA—,� Building:
— Property Addre —
Property is located in a;Conservation Area Y/N Historic Dl*k:t YM
2.0 OWNERSHIP INFORMATION
2.7 Owner of Land _
Name:
Address:
Telephone: 6' 7� - 7`y -ff.37
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation kj Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation 1 q&tl New
of existing building
Brief Description of Proposed Work:
�A c K'uco�+i jeenrova�o A-" —V ro �racQ 2�o
�•P i�nfx�i°G i�
Mail Permit to:
What is the current use of the Building? G iJy',U/VC
Material of Building?__Woo j) H dwelling, how many units?
Will the Building Conform to Law?
U Yam_ Asbestos? IV JP
Architect's Name
Address and Phone
Mechanic's Name 5 e L i-=
Address and Phone R 7 �_ 7 V-H 7
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ p 0 Permit Fes Calculatim
Permit Fee$ 3 G o Estimated Cost X$71$1000 Residential
Estimated Cost X i11/51000 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 stated //Q/ Y��I
specifications. Signed under penalty of perjury /� ✓
Date l `� 0,b
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PUBLIC PROPERLY
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is soeardsea wirb drs shut e�dos a[dis 3tses Bsi{dla�Cody 7tl0 C3Q ssedera 111.!
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this wor!sbsll� otbt a proper �sei vases d[goset dw�s dsQaed by lds;3.�
TVA debris wiu be bampor W by:
The debeis will be aisoowd of is:
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due
`CITY OF SALEM
A PUBLIC PROPERTY
DEPARTMENT
KIMBER EY DRISCOLL
MAYOR 130 WASHINGTON STUM•SAI F K MAssAcHLserrs 01970
TFL-978-745-9595♦FAX:978-740-9&t6
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location o2 (t 4 o E0
Home Owner Address 1 , a2 q0
Home Owner Telephone R 7 f-- Z 1f — 3 7
Present Mailing Address S o9 rn e—
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 procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE e�
APPROVAL OF BUILDING INSPECTOR
See other side for state code
Homeowner's Exemption
The Code states that: .,Any Homeowner performing work for which a Building Permit is
required shall be exempt from the provisions of this section(Section 109.1 —Licensing of
Construction Supervisors),provided that a Homeowner engages a person(s) for hire to do
such work, and the Homeowner shall act as Supervisor."
Many Homeowners who use this exemption are unaware that they are assuming the
responsibilities of a Supervisor(see Appendix Q, Rules and Regulations for Licensing of
Construction Supervisors, Section 2.15). This lack of awareness often results in serious
problems, particularly when the Homeowner hires unlicensed persons. In this case your
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require, as part of the Permit Application, that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this
issue is a
e to amend and adopt such a
form currently used by several towns. You may car P
form/certification for use in your community.