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� OV£fl BY T�
l ��,',CT� }gp _P� 7 13E1NG GRANTED
Lr
" s IT1 OF Si, EM
No. �� y� a Date
' y it n iR c Ward
Zoning District
Is!Proparty Located In Location of
/
tf® Mlallodc District? Yes_No V Building AQ&es/
tat;Propel -Located In
i6 chore Mogn Area? Yee_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Po I,
Repair/Replace, Other._- A,Z 1✓I c-( �
bas�boarc(
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
Address & Phone . I ���fi✓�(ci1�+- '. - �( flit
) /C7Y
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
What Is the purpose of building?�//I
Material of building?rind Si c/a If a dwelling, for how many families?
T �v�
Will building conform to law? 1/,o f " _Asbestos?
Estimated cost /(ITl7/` City Ucense # State U se #
v Haas lmprovessnt
Lie. /
FF,1`1P`1ERJVRY,
lute of Applicaf
ED UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MAO 1970
TEL. (978)745-9595 EXT. 380
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 Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A.(�/
The debris will be disposed of at: di�lh J /LG)'e �� ✓��K a7
Location of Facility
ignature of Pe Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
e 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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BI DING DEPARTMENT
HOMEOWNER LICENSE E)MMITION
Please Prig
DATE
JOB LOCATION
" HOMEOWNER
ADDRESS G� �/ —7
HOMEOWNER / / � / '1- ' 6 7 0
TM—UHONE
PRESENT MAILING ADDRESS
The unrest exemption of"homeowners"was c-ncnded to include w+ner-occuupled dwcMelp o[TWO
Units or less and to allow such homeowners to engage an ire/ dual for biro wbo does not posxs a
license,pronded that the owner act as superriwr.
DEFINITION OF HOMEOWNER:
Person(s)who owns a pw=1 of land on which he/she resides or intends to rctide,on which Ohre is,Otis
intended to be,a one to two family dwelling,attached of detached structanes axessm to web One andkr
farm structwes.A person who con stmcu mart than one home in a two-year priod sball mt be considered
a homeow=. Such"homcowtrcf shall submit to the Building OfficK om a form aeecptabk to ffie
Building Official,that he/she be responsible to all such work performed wider the buil ft pamk
The undasignn ed"homeowner"assumes resporhsibility for compliance with the State Building Code and
other applicable goes by-laws,rules and rtgulatiom
The undcrsipcd"homeowner"artifice ihai he/she undavwds the City of Salon Building DepamoaR
minimum inspcnion procedures and rcyuimnents and that hlshe will comply with said ptoced=rind
rcquirtmeai
HOMEOWNER'S SIGNATUiSPECTO7R
�mL
APPROVAL OF BUILDING
See otber sde for state code
HOMEOWNER'S EXEMPTION
The code state that: "any homeowner performing work for which a building permit is required shall be
exempt front the prmisions of this section (Section 1t19.1.17 licensing of Construction Supervrsors);
Provided that is a homeowner engages a person(s)for hue to do.such work,that such bomeowner chap sa
asncryisorw
A4any bomeowrters who use this cxemption are iutawarc that they an assurning the Tesponsibifitiea of s
supervism (see Appendix Q,Rules and Regulations for Licensing Construction Supervisors,Seedw
.2.15} This lack of awareness often rcanits in serious problems,particularly when the Lomeosrner b>rei
unlicensed persom. In this case your Board cannot proceed against the unlicensed person at itwtwld wl&
licensed Supcnisor. The bomeon-oer acting as supervbor is okimatdy responsible.
To ensure that the homeowner is fully aware of hilhcr mspon_n'blHes,marry eommurities require:as part
of the permit appliczdm that the homeowner certify that hcJshe wukmm ds the responsibilities at
supcnisor. You may care to amend and adopt such a form/mrdficatim for use in your ,