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Mug APPLICATION POPa
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PLEASE RLL OUr L ML.Y&COMPLETILY TO AVOW DELAYIL N PROOINDIftr
TO THE I .NBPECTpR OF BUILDIN08.
The --ft—NIQM hMW q*W for a pu t to build aoo x" to N» IelkwM�
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' PUBLIC PROPERTY DEPARTMENT
120 WASH INOTOM STREET, 3ND FLOOR
SALEM,MA 01670
TEL (976)746-!>596 EXT.360
FAX (076) 740-9846
STANLEYJ. U60VICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ,c 40,S34,I acknowledge that as a condition
of Bmlding Permit 0 .all debris resulting from the ca6sernctiom activity
govaned by this Building Permit shall be disposed of is a properly licensed soH&wub
disposal fac7ity,as dewed by MC$.c ZIL SIXA.
The debris will be disposed of at _ bo
I.ocman of Facmy
0 �i �� .�o 3l 3G/o s
Si of Permit Applicant �e
FUZZY complete the following mtomadon.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City dt State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of butLk g or structure be disposed in a properly-licensed solid-waste disposal
facility as de coed by MCI clli,S150A, and the building pamits or licenses are to
indicate the location of the Lcility.
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CTPY OF SALEM
BUILDING DEPARTMM
HOMEOWNER LICENSE E04TIO1d
Pkau Pda
DATE
JOD XAn0W
ADDIiE53
HOMEOWrI»tf
TELEPHONE
PRESENT MAII•II'!G ADDRESS 5���� .
cu of"borneawnfe was emcuded to imlw&owwe"CwPied dweMs otT11V10
The aurrnt etempti torn an iraiividttgl is bim wbo does am pas" a a
Uniu or ka and to e11ow such Lomoowws pp
liecnse,.Provded that the owner ad as wpuviwr.
Dg'WlTION OEF HOMEOWNER
Pawn(s)wbo owns a parcel of lud on which Iresides or inter�de to residS on wldeb i:s��
injcnded w be,a one to two famDy dwelling anaclnd of dctadKd strvcmu*x od shad not be eonsidesed
farm strucaues.A pcson wbo constructs more than one home ins two-y p=
Sucb"bomeov=f sbell'subndt 10 the Budding OWM54 on a fmm sezeptabk to Ass
a billing tkr, ender the building pa=L
Building Olheisi.that belshe be responstbk to aD sudt work pafornred .
The undenigned`bomeowner"asstmtes responn'bility lot camplia=with the Swu BaDding Code sad
otha applicable Sots by-laws,rules and tt:g192500i.
The m,dcaigrrd"homeowner"eer 6.that tuhbe t,dvs ,,&ft City of Salem sm'ld ag DepuooeK.
minimum imperoon pT=dmea and regltiremems and that Nshe wis comply wi1h amid Foote ttad
nquin� v
HOMEOwpMrS SIGNATURE
APPROVAL OF BLWING INSPECTOR �0 0
s
Sec other side for stau wde
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HOMEOWNER'S EXEMPTION
The code states that: 'any honeowacr performing work for which a binding pertnit is required sbal be
exempt from the provisions of ibis section (Section 1UV.11-15ecosiog of Cotutroetion Supt rvisori)
Provided that is a bonito ma engages st person W for hue to do.suet work,that mcb bosneawsa dell am
as supervitwG' Y •
Many bonseowncts who use this exemption are imawart that they are asnmdng tbt lcpo tin.are
supervisor (see Appcodls Q,Rilu and Regulations for l iezosing Construction Superd*ora,$eestN
.2.14 This lack of awareness oNen results in serious problems,paroeula>t whin tht he nnownerbba
unlicamd persons In ibis ease yore Board tawwt proceed&gaunt tht w0ccused pawn>b it would wfQ
licensed StrytTisar. The homewner sling as supcnisor b okimate>y !cmr sibif.
To came than the homeowner h fully aware of hither responsibilities,rttmq eomnandtiea retool ;as pant
of the perms{application.that the homeowner certify that h&Ww tmdenunds the responsibilides oft►
suptnvor. You may rare to amend and adopt sucb a formlecttifi cadom for tone hr your