19 WARREN ST - BUILDING INSPECTION 1d&UGT-BE f4L-E9-Ai40 APPROVED BY T44E
WSPI=GT•fDR ,P=fl T-0 A_PERNllT .f3,EW G GRANTED
CITY OF SALEM
No. I I Z.- Zo p Date
Is Property Located In 1/Location of �n rr
the Historic District? Yes '_No_ Building �/ ytl xl 6 t)r,g $7
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
V"'Owner's Name W illlnit d (Aw hftif ) qq
Address & Phone �.�I AfS�i�u S7• �171) 711-1117—
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What Is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
4
Estimated cost 000 City License # N 4' state
t License #
Home �roeement m�/3�/'"
`� rl Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE / 7
be y &35u2t 166rge) wdyL As At'ydn R1TQ��u, �fb Pel'0,9
C61Nadr h��SeeN fr)"A
J MAIL PERMIT TO:
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
z3/ is I
APPROVED
ivy
INSPECTOR OF BUILDINGS
CITY OF SALEM
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please Print Jy
DATE 7/ h3
JOB LOCATION CI PAl Af�hPv ST•
HOMEOWNER J64 f-
ADDRESS rr77 qq d
HOMEOWNER
TELEPHONE
PRESENT MAILING ADDRESS
The current exemption of"homeowners"was extended to include owner-occupied dwellings ofTWO
Units or less and to allow such homeowners to engage an individual for hire who does not possess a
license,provided that the owner act 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 to 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 subrnit to the Building Official,on a form able to the
Building Official,that he/she be responsible to all such work performed under the building permit
The undersigned"homeowner"assures responsibility for compliance with the State Building Code and
other applicable goes by-laws,rules and regulations.
The undersigned"homeowner'certifies that he/she understands the City of Salem Building Department
minimum inspection procedures and requirements and that h/she will comply with said procedures and
requ
HOMEOWNER'S SIGNATURE
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 109.1.1—licensing of Construction Supervisors)
Provided that is a homeowner engages a person(s)for hire to do such work,that such 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 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 petson as it would with
licensed Supervisor. The homeowner acting as supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of hiAter responsibilities,many communities regtrire,as part
of the permit application,that the homeowner certify that he/she understands the responsibilities of a
supervisor. You may rare to amend and adopt such a form/certification for use in your community.
I
co ...-, i OF SALEM,- MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
° ® 120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
�prnra FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S150A.
The debris will be disposed of at: Location
cation of Facility
71�b163
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
19 ujAOht
8� ��le Qjy7U
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
disposed in properly-licensed erl
alteration of building or structure be a p p Y-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits Or licenses are to
indicate the location of the facility.