29 WINTER ISLAND - BUILDING INSPECTION TR
PULICRTY
DEPART�IEN1T
KISMEY.6V DRI5COLL
MAYOR I2D WASHINCrON h rREEr 0 -
v.LEK MASSAUCHl;SkTR 01970
1FL 978-745-959S#FA]L 97&740.9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING_
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
— Property
� SaLem ,�R o/ 4�D
Property is located in a; Conservation Area Y/N AM.) Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
t..rC.�LK 1-14 o/2 -7a
Telephone: 79- 7V/ -
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing a Ya
Renovation Number of Stories Renovated a 1 3-
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
/Pc Prop/,f,o. (�•o��y �me.vr C�� ���Y
02 sVd j tf
Mail Permit to:
What is the current use of the Building? 641 d-e—
WO If dwelling, how many units?
Material of Building? g�
Will the Building Conform to Law Asbestos? �
Architect's Name
Address and Phone t
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ e7 5-OaD Permit Fee Calculation
Permit Fee$ A& - - Estimated Cost X$7/$1000 Residential
-- -- — - _ Estimated-CostX$14/$-1o0o-Commercial
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 build to the above stated
specifications. Signed under penalty of perjury X
Date / x -0 7
N
y �
v
N
� � y
1
Or owl-
r !
1
CITY OF SALEM
d. PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR
11-0 W.13HINLTON STREET♦SALEK MASSAO SEM 01970
TEL:978-745-9595• FAX:978-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location c2`/
Home Owner Address
Home Owner Telephone
Present Mailing Address
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 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 there 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 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 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
APPROVAL OF BUILDING INSPECTOR
See other side for state code
1 '9
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 —Licensing of
Construction Supervisors);provided that a Homeowner engages a person(s) for hire to do
such work, and the 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 of
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 person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities, many
communities require, as part of the Permit Application, that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.
CITY OF SAL.EM
r: PUBLIC PROPERTY
li
DEPARTMENT
KIMBERLEY DRISCOIL
01970
MAYOR l±a WtiH1N000N$7xEt-r#$.�.M.v'SACHL:SEI'IS
'lei 978-745-9595 0 FAX:978-740-984
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CUR section 111.5
Debris,oral the prov.ions of MGL c 40,S 54;
Building Petit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A. �
The debris will be transported by-.
(name of hauler)
The debris will be disposed of in :
FS Wet k S y�°
(mane of facility)
(address of facility)
signamrc of par applicant
daze
f
drbri.+l7duc
I