16 VERDON ST - BUILDING INSPECTION What is"eunW*use of the Building? how ma
/the Bu ny units? —
Ma4Vd at Building? It dwellIcSgM estosT
Will OV Conform toLaw? -
ArahtbcCs Name
Addms and Phone ( , -
Msdtsrtfa's Name
Address and Phone HIC RegMmd n B
Constrt cdon Superviams License N
Estimated Cost of Project i 300- — Permit Fee Cakulatlon
- Permit Fee i
Esdmabd Cod X$7I111000 RwidentW
gsMyftd Coax i11li1000 CarnmereW--__
An Additional$5.00 is added as an
Administrable d►arge.
Make sun that alt fields are property and legibly written to avoid do"in processing.
The underslgrwd doss hereby apply for a Building Porn*to build to the above stated
specilleations. Signed under penalty of Perjury X
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CITY OF SALEI1i
PUBLIC PROPERTY
DEPARTMENT
Klf WEtl6Y D�15COLL
MAYOR
120 WASUNGYM S U"•SMt.EK HAMOWSLTM 01970
71L 978.74S-9S9S 9 FAX;975.740-9646
HOMEOWNER LICENSE EXEMPTION
Please Print
Data 6�= y D 7
Jab Location
Home Owner Address !4 —
Home Owner Telephone 78 7 /— z or—
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.
DEFIMTION 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
APPROVAL OF BUILDING INSPECTOR rv,
See other side for state code
GrT�U�SA.Eti
PUBLIC PROPERTY
$l 3� DEPARTMENT
M.rae 130 WAwuwow sm ffw•3KuyMau2as¢m Otero
Tu.Mris•M#Fix 9rs.r10.9"
APPLICATION FOR TRR REPAIR.RZNOVATIoN_ CONSTRUCTION
DRIMOLTTION,OR OMZ OF USE OR OCCnP,►NCV_ foginn ,
► FMSM
3TRUCTURZ OR BUILDD(G =_ -
1.e SITE INFORMATION
Location Name: Building:
Propeny Addmw_
popery in located in a.Conwvation Am Y/N HlWft Dlsklct YIN
S.d OWNERSFIIP INFORMATION
2.1 Owner of Land _
New ��Piie 1�ic�cF c2
Addreae.
-Telephone 7`el— 23 y7
3.0 COMPLETE THIS SECTION FOR WORK IN MUSTWQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
,Gta uf-�
�PX� Oo �L
— - - Mail Permit to: