14 VICTORY RD - BUILDING INSPECTION • � Y • f: / Vim.
What is the current use of the Building?
Material of Building? ln/D B dwelling.tow many units?
WIN the Building Conform to Law? Asbestos?
Address and Phone
Mechanic's Name -�
Address and Phone
Construction Supervisors Ucense 0 HIC Registration#
Estimated Cost of Project S O o Permit Fee C- elation
Permit Fes S S 'O Estimated Cost X$71$1000 Residential
- --- - - -. - --_ _. __-. Estimated Cost X$11l51000 Commercial
AnAdditional $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�P(ermit to iki to the above stated
penalty P d ry //A�Ean « ��
specifications. Signed under na of e u
Date f
(� of
.r N
�J 4V
a T
a a
a a
ar End OF-
PUBLIC PROPERTY
DEPARTbIEEINT
►uaFy.sr owacuu. Z�
MAYOR 130 WAMUNGTM VIEU• .
yum.WAttAow561'R 01970
14i 978-74S-9S"•FA=97{.740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY E2aS A I
STRUCTURE OR BU"VLG
1.0 SITE INFORMATION
Location Name: Building:
J
Property is located in a.Conservation Area YIN v ` Historic DbMd YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land T
Name: -77, de v e tc c G
Address: y/ /J
I Y
Telephone: O
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation 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
l3riel Description of Proposed Work: y
-- - ---Mail Permit to: - - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.A.\I:::NI r.Y'''06%.VIL
l?C •SA UM.at.\\Yu::u *111i%WC
To.vw4s.-n" •F%x:9MAC-944
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
P
In accordance w ith the sixth edition of the State Building Code. 780 CNIR section i 11.5
Debris.and the provisions of vtGL c 40. S 54.
Building Permit N _ . ._ is issued with the condition that the debris resulting ftm
this work shall be disposed of in a properly licensed waste disposal facility as defined by.1GL c
t 1.1.S 130A.
The debris will be transported by:
GJ �i.�5 Q cA CD w?; lose
Il�me on touter
me debris will be disposed of in
1 uJme�Y ixillty)
or
CITY OF $ALEIM
PUBLIC PROPERTY
DEPARTMENT
�twroa 130 w..vnrWr0N STW=• Meu .MAQAOfI'SE77S 01970
T EL-979-73S-9S"0 F.UG 978-7.44U6
HOMEOWNER LICENSE EXEM"ION
Pieria Print
Dace / y
Job Location
Home Owner Address T4 Y.-,-e
Home Owner Telephone S�> S 4
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.
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 "homeownel 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
See other side for state code