11 WEST CIR - BUILDING INSPECTION t
-PtSWSlftSt EfiL{ G APPROVED BY T44E
.II PFXTD-R PRIOR TD.A PERMIT.B,FJNG GRANTED
CITY OF SALEM
-ON
No. ' *�� Date I o _
'sue:. �
n y�ii�' SS
Is Property Located in Location of
the Historic District? Yes_No Building I I ;A)Lkt, C tV7-(,Lz
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) *epair/*
Install Siding, Construct Deck, Shed, Pool,
c , Other:, rnA�S �sn�—S
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:
Owner's Name l'l rZ�,y� V1wt },a rns.P
Address & Phone 11 lkltcL 0'rr ti kf�) "0• 3nZ
Ar piName 'I V to� F� vrc l
Address & Phone Sit-+ n1 . (to 0) V?91• ZSZ-FN'
Mechanics Name
Address & Phone II ( )
What Is the purpose of building? W d �( n ,nr91/G�hlsvlC
Material of building? lti If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost / D City License a N A State License S
Home Improvement
Lic. i X
Mignaturd of Applicant
2oc>3 SIGNED UNDER THE PENALTY
GI'- 3 t o 5 OF PERJURY
DESCRIPTION OF WORK TO BE DONE \
I
i
MAIL PERMIT TO: 9 I Lll �sKL (' r✓C r �c��. i e1/�/� D15. c�
�4
No. 2 00+�
APPLICATION FOR
y� PERmrr To
LOCATION.
PERMIT GRANTED
APP D
INS TOR O BU LDINGS
t .
....�Y OF 5ALEM, 111E
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL. (978)745-9595 EXT.3BO
FAX (978) 740-9846 _
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,1 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: , l n Facility
Loo cation of Facility
Signature of Permit Applicant D
ate
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address, City &State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE L'IL 'y�
JOB LOCATION I i A ) b C c rr e hi�A 0 l,,
HOMEOWNER I l ti C 2—C,_r ___2, Nl�
ADDRESS
HOMEOWNER 2-40 3i� Z
TELEPHONE
PRESENT MAILING ADDRESS t ( lti1 css'ir Li rC -� e k" ✓�1� C� L` �—C7
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 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 submit to the Building Official,on a form acceptable to the
Building Official,that he/she be responsible to all such work performed under the building permit.
The undersigned"homeowner'assumes 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
requirements.
HOMEOWNER'S SIGNATURI(����
APPROVAL OF BUILDING INSPECTOR
See other side for state code
i
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 10.9.1.1—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 assurtting 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 yourBoard cannot proceed against the tnh'ceased person as it would with
licensed Supervisor. The homeowner acting as supervisor is ultimately.responsible.
To ensure that the homeowner is fully aware of hi/her responsibilities,many communities requiM as part
of the permit application,that the homeowner certify that he/she understands the responsibilities of a
supervisor. You may care to amend and adopt such a form/certification for use in your community.