15 WILLSON ST - BUILDING INSPECTION u
1 1� I�II,EIi' aeI
Ll
fL11itI8i1Mi6T13E WAND OVER BY T44E
,,,. .IdSIP:ECIY�A ,t1DIA •rk D°,�➢#.P. RE1NC GRANTED
:tug:i
CITY OF SALEM
No.�)Q -J �) ,� . Date O /
W Pn""Located to Location of,,- / ' � r .
the Historic District? Ye _No_ &d ding .1W I L L 50/0 �r
TIT'
Is Property Located in
tie Conservation Are? 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 PROC11,66NO
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name L i�lM is C rj
Address & Phone W i i;L o S (97fi -7 '1 S� -72 j $-
Architect's Name
Address & Phone N L f
Mechanics Name
Address & Phone L t
I kh
What Is tie pwpoes cl Wtildinp? 2 t I)-e A)'Ti Q-
MaterW of bWkHW /0) (9 b Ir a dwoft,for Crow many famMles? 1 j g
W kbv cordon to law? Asbestos?
W W
Estimated cost. Ctiy Lkarw s N A "'tense
AI
,
Rotas Iaprom at `
Si nature of Applicant
S GNED UNDER THE
F PERJURY ,i�� ,
DESCRIPTION
w F WORK TO BE DONE y�
\Cc W1 I PO �N SFA &L
—�-.—I lu
I L T2 [�A-m
11
� e nti unill�f�i i
Pr it
MAIL PERMIT TO:
{
r
No.f
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APP FD _
INSPECTOR OF BUILDINGS
13 2 '
•` CTTY OF SALBM
B=1 NG DEPARTM NT
Mb EOWNERLICENSELNEWMN
Plem PM
DATE
JOB LOCATION
NOMEOWNFA •�� L—L So ) S
• ADDRESS t
TELEPHONE
PRESENT MAl1.A?G ADDRESS I� � � c_ C S� .� .
The crmcnt ctempdon of'homww=C was c-=Mcd to include o+rocr-occupkd dwcMip of TWO
Units of km and to allow such bommwncts w cngagc an v&vidual for kilt who does nol Posses 0
lictim,.providcd that tkt ovrecr act ry 5uperY6w-
DEFiNMON OF HONMOWNM* ix Is
Pctaon(s)who aww a pm=l of land on which hc/she resides or intcn&to reside,on wluckht is
intrnded w be,a ox to two family dwcllinL anached or dctschcd smtctures od sh 1 not be st wAh ed
form structures.A person who cornvucts mom ilm one home in� PaS
s boummuct. Such'homcowirf shall'subrrdt w the Binding on a form a m lSliC
Building OfficW,that IrJshc be respotmbk t0 all such work paimm d or the buMmg P=ft
The undasipncd'houw7w="asswncs rcSpoM'bility for complianoc withthc Suit BUB&g Code tmd
other applicablc goes by-laws,ruts and rcgulatioats.
The tmdmigrud'homeowntt" catifics that helshc tmdcsw&the City of Salem Buildmg Dcpwmma.
nurumum mspavon pn=dtucs and rgm==nts and that hlshc mP1P txatlt °Od
rcqui =MM
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INS ECTOR
Sec other Side for were code
HOMEOWNER'S EXEMPTION
The code status that.• "aM homeowner performing work for which a buD&4 pant is Tegimed shell be ..
exempt from the provisiow of this sccdon (Section JOf.l l-1�ceosiDg of Contaruetlon Supnviwri), .
provided that is a homeowner engages a person (s)for hue to do.such work.that such botmeowaa*hall 84
harry bm=wnrn wbo use this cxcrnpdon are iutaw-ac that lhcy arc assuming the TespoasrbM6ft d• `
supcniwT (see Appcodb Qr Ruks*Dd RtgulatiODa for lictmAD&Constrvcdon Supes•viscm secdat•
.7.14 This lark of awareness ofltn nnilu in serious problems.pardeulary when the bcMwwner HM
unlicensed pcnsom In this case your Board cannot proceed against the=-Xccused person as k-%v ld with
licensed Suprn s TUC bOmtM-Dtr*ding*o suptrAsor b ultltmateiy Ttipooatbk.
To cnnac that the homeowner is Billy aware of hM=nspounbllities,n=V c=ununides regtnre;as pawl
of the permit applimdM that the homeowner ecrnfy that he)she urakaurds the Tesponsibilffia ofa
supcniwr. You may cart:to amend and adopt such a forWccnhvA216at for use in your txmmtmip•
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
N A TEL. (978)745-9595 EXT. 360 -
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 Pemrit 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: �� o A T 4 5! 0-e �� �r-1 A)
Location of Facility
S' ture of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
KZ—( L tz— tM iz e✓
Name of Permit Applicant
Firm Name, if any
� Sr � L-C— Si
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.