1 WINTER ISLAND RD - BUILDING INSPECTION CITY OF $mmm
PUBLIC PROPERTY
DEPARTMENT
130 WASONG O STUMT•SAU04%&MACM serfs 01970
TU.,978•74S-959S•FAx;971.740.91N
HOMEOWNER LICENSE EXE.rIPTION
Please Print
Date 10- 3 -0 7
Job Location 1
Home Owner Address 1 t i) s ryH h, 2s Ica hrl
Home Owner Telephone 4-� k I ?)ti i �.ti+} 7
Present Mailing Address 1 I i ).Vim} )t, 7 la na
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hie 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 time 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 pennon 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 "homeowner"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 C�1t1p—QQx�CtZQ
APPROVAL OF BUILDING INSPECTOR
See other side for state code
VTTY OF SALEM
- PUBLIC PROPRERTY
DEPARTMENT
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Construcdoo Debris Disposst Aftldavit
(reyuiml for all demolition and renovation work)
In accordance with the sixth edition of dw Swe Huildinf Code.7SO CNIR section 111.5
Debris.and dw provisions of M. GL c 40.3 S*
Building Pumit 0 _ _ is issued with the condition that the debris resulting!Foal
this work shall be disposed of in a properly licensed waste disposal P.tcility as dented by%iGL c
It 1.31 SOA.
The debris will be transported by:
u m ps�
Tham a haWdd
rho&bds will be disposed of in :
(namr of fullity)-
•.err
TLIC
PARTMENT
wA%dwJLsv DRUWA)LL
�rAYDI 1301i&MON4TnMsr r•
SKti14,%rASiAO/t:ShTls 01970
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION.
DR,MOLITIOM OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR RM DING
CO SITE INFORMATION
Location Name: Building:
-- . Property Address:--------
Property Is heated in a:Corlservation Anse YIN Historic District YM
2.0 OWNERSHIP INFORMATION
2.l0wnerofLand Fo4-1' M 0.Y1n1( ✓ .
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIIdd BUILDINGS ONLY
Addition Existing
Renovation x Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate.year of ? Area per floor (sf) Renovated
construction or renovation Q
of existing building 1 `� New
8'riief Description of Proposed Work:
t� 1 kILQ-n v^e,m O
--- -- Mail Permit t0: 1 t,) , ni o r . Zs in L„na �2l Sc• - - -
What is the parent use of the Building?
Material of Building? K dwelling,how many units?
Will the Building Conform to Law? 4 eS Asbestos? --
ArchitwWa Name
Address and Phone — l
Meehanwe Name `
Address and Phone `
Construction Supervisors License 0 HIC RegisUatb(I 5
EstimatadProject iOG/l /il/ Permit FN CalculationPermit Fee i Estimated Cost X$7/111000 Residential
Es*nated CostX$}11$1006 CommsrcW--------- -
An Additional $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 Permit to b ,uildtothe above stated
specifications. Signed under penalty of Perjury ^ -L*� 1)
Date l0 -3 -U 7
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